Emotion Control Predicts Internalizing and Externalizing Behavior Problems in Boys With and Without an Autism Spectrum Disorder
Journal of Autism and Developmental Disorders
Emotion Control Predicts Internalizing and Externalizing Behavior Problems in Boys With and Without an Autism Spectrum Disorder
Marieke G. N. Bos 0 1 2 4
Sofia Diamantopoulou 0 1 2 4
Lex Stockmann 0 1 2 4
Sander Begeer 0 1 2 4
Carolien Rieffe 0 1 2 4
0 Faculty of Behavioural and Movement Sciences, Vrije Universiteit , Amsterdam , The Netherlands
1 Rivierduinen, Centre for Autism , Leiden , The Netherlands
2 Department of Developmental and Educational Psychology, Institute of Psychology, Leiden University , Wassenaarseweg 52, 2333 AK Leiden , The Netherlands
3 Marieke G. N. Bos
4 Department of Psychology and Human Development, Institute of Education, University College London , London , UK
Children and adolescents with Autism Spectrum Disorder (ASD) often show comorbid emotional and behavior problems. The aim of this longitudinal study is to examine the relation between emotion control (i.e., negative emotionality, emotion awareness, and worry/rumination) and the development of internalizing and externalizing problems. Boys with and without ASD (N = 157; age 9-15) were followed over a period of 1.5 years (3 waves). We found that baseline levels of worry/ rumination was a specific predictor of later externalizing problems for boys with ASD. Furthermore, the developmental trajectory of worry/rumination predicted the development of internalizing and externalizing problems in both groups. Our findings suggest that worry/rumination may constitute a transdiagnostic factor underlying both internalizing and externalizing problems in boys with and without ASD.
Autism Spectrum Disorders (ASD); Longitudinal study; Comorbid psychopathology; Emotion regulation; Emotional control
Autism spectrum disorders (ASD) are characterized by
social and communication difficulties and the presence of
repetitive behaviors and interests (DSM V, APA 2013). In
addition to these core impairments, up to 70% of the
children and adolescents with ASD show comorbid
psychiatric problems, like social anxiety and oppositional defiant
Foundation for the Deaf and Hard of Hearing Child,
Amsterdam, The Netherlands
(e.g., Simonoff et al. 2008)
. Recently, there is a
growing interest in the role of emotion control as a possible
underlying mechanism that may explain these internalizing
and externalizing behavior problems
(Mazefsky et al. 2013)
The ability to control emotions is essential to navigate
through daily hazards. It allows one to keep an optimal level
of arousal in order to secure both social and personal goals
(Chambers et al. 2009)
. Its development is affected by social
experiences, and modeled through social learning. Indeed,
from childhood onwards we learn how to control our
emotions in a socially and culturally accepted way
et al. 2010; Morris et al. 2007; Southam-Gerow and Kendall
. However, children and adolescents with ASD have
less access to the social learning environment and show
deficits in the ability to control emotions
(Mazefsky and White
2014; Rieffe et al. 2012; White et al. 2014)
. The aim of the
current longitudinal study is to examine the role of three
indices related to emotion control—negative emotionality,
emotion awareness and worry/rumination—on the
development of internalizing and externalizing behavior problems
in children and adolescents with ASD, as compared to a
typically developing (TD) control group.
Emotion control is an umbrella term that is used to
describe several aspects related to the ability to down
regulate emotional over-arousal in emotion-evoking situations.
Problems in emotion control can be related to impairments
in both emotion generation and in the process that relates
to the ability to deal with emotions
(Sheppes et al. 2015)
Previous cross-sectional studies have shown that different
indices of emotion control are related to internalizing and/
or externalizing behavior problems. One index of problems
in emotion control is the frequent experience of negative
emotions, like fear, anxiety, and anger. This negative
emotionality is a direct consequence of an inability to down
regulate emotional over-arousal. Heightened levels of
negative emotionality is associated with both internalizing (e.g.,
anxiety) and externalizing behavior problems (i.e., bullying
and aggression) in TD youth and in children and adolescents
(Pouw et al. 2013a; Rieffe et al. 2012; White et al.
. Another index of emotion control is emotion
awareness. Emotion awareness relates to the ability to know
how you feel and to link this feeling to an emotion-evoking
situation is critical for the experience and regulation of
(Barrett et al. 2001; Rieffe et al. 2008)
. Indeed, not
being able to differentiate between emotions and focusing
too much on bodily symptoms of an emotional experience is
related to more depressive symptoms, anxiety symptoms and
somatic complaints in TD children and children with ASD
(Rieffe and De Rooij 2012; Rieffe et al. 2008)
. In a similar
vein, several studies indicate a relation between alexithymia
and emotional problems in children and adolescents with
(for a review, see Bird and Cook 2013)
. Another index
of emotion control that is related to the (in)ability to deal
with emotional over-arousal is worry. Worry and
rumination are highly related processes that are characterized by
a chain of repetitive negative thinking, that increases the
level of emotional over-arousal
. The role of
worry/rumination in youth with ASD is relatively
understudied. This is remarkable since individuals with ASD have a
propensity to perseveration and may therefore be uniquely
susceptible to worry/rumination
(Mazefsky et al. 2012; Patel
et al. 2017)
. Worry/rumination are typically associated with
the development and maintenance of internalizing
behavior problems in TD youth
(Nolen-Hoeksema et al. 2008)
Likewise, we previously demonstrated a cross-sectional and
longitudinal relation between worry/rumination and
depressive symptoms in children and adolescents with ASD
et al. 2013b; Rieffe et al. 2014)
. Recently it has been shown
that worry/rumination is also related to aggressive behavior
in TD boys (McLaughlin et al. 2014). It is however unknown
whether worry/rumination also contributes to disruptive
behavior problems in children and adolescents with ASD.
Our knowledge of the role of emotion control on the
development of internalizing and externalizing
behavior problems in children and adolescents with ASD relies
mainly on cross-sectional data. Even though these
studies provide essential information for our understanding of
this relationship, longitudinal studies are key to advance
our knowledge on whether these relations hold over time.
Therefore, we conducted a longitudinal study to test the
relation between negative emotionality, emotion awareness,
and worry/rumination with internalizing and externalizing
behavior problems in 9–15 year old boys with and
without ASD. We focused on this age range, given that social
and emotional problems often increase during adolescence
(Kuusikko et al. 2008; Paus et al. 2008)
We investigated three clusters related to internalizing
problems: depression, anxiety, and somatic complaints, and
one general cluster of externalizing problems: disruptive
behavior. Participants and their parents filled in
questionnaires about different aspects of emotion regulation and
overall well-being at three time points (9 months in between
each wave). Specifically, we aimed to test in both groups
(1) whether emotion control contribute to the prediction of
internalizing and externalizing behavior problems 18 months
later, (2) examine the developmental trajectory of
internalizing and externalizing behavior problems over time and (3)
test the co-occurrence of the developmental trajectory of
emotion control with the developmental trajectory of
internalizing and externalizing behavior problems.
Based on the literature, we expect that negative
emotionality, poor emotion awareness, and worry/rumination are
related to more internalizing problems in both boys with
and without ASD
(Aldao et al. 2010; Barrett et al. 2001;
Rieffe et al. 2008)
. For externalizing problems, we expect
that negative emotionality and worry/rumination will have
a positive predictive value for both groups (McLaughlin
et al. 2014). Given the importance of emotion regulation
for social functioning, the ability to employ effective
emotion control is relevant for both groups. Nevertheless, the
social impairments related to ASD might leave children and
adolescents with ASD more susceptible to develop problems
with controlling their emotions for which adequate
socialization seems to be critical. Thus, the lack of social learning
opportunities may reduce their capacities to control
emotions and add to their vulnerability for developing social
and emotional problem behaviors. Hence, we expect that the
predictive relation between emotion control with
internalizing and externalizing behavior problems is stronger for boys
with ASD compared to their TD peers.
The current study was part of a larger project investigating
the social-emotional development of typically developing
children and children with less access to the social
environment (children with hearing loss and children with ASD)
(e.g., Broekhof et al. 2017; Netten et al. 2015; Pouw et al.
2013a, b; Rieffe et al. 2012, 2014)
. For the purpose of the
current study, we used the data of TD boys and boys with
ASD from whom parent-reports and self-reports were
available at least at one time point.
The high functioning ASD sample included 66 children
at T1. Inclusion criteria were: (i) ASD diagnosis on T1
according to the DSM-IV (APA 1994) based on the Autism
(Lord et al. 1994)
by a child
psychiatrist, (ii) IQ score above 80 and (iii) no additional
DSM-IV diagnoses. Participants were recruited from
specialized diagnostic and treatment center for children with
autism in the Netherlands. A group of 89 TD children was
recruited from primary and secondary schools in the
Netherlands (see Table 1 for sample characteristics). Inclusion
criteria for the control group was: (i) IQ above 80 and (ii)
no DSM-IV diagnosis. All procedures were approved by the
Ethical Committee of Leiden University and all parents
provided written informed consent.
***p < .001
aNote, we did not have information on specific diagnosis for six
participants in the ASD group
b1: no/primary education, 2: lower general secondary education, 3:
higher general secondary education, 4: college/university
c1: < €15,000, 2: €15,000–€30,000, 3: €30,000–€45,000, 4: €45,000–
€60,000, 5: > €60,000
dThe presented IQ scores are age-corrected norm scores; the grand
population mean is set to ten
Two nonverbal subtests (i.e., block design and picture
arrangement) of the Wechsler Intelligence Scale for
(WISC III; Kort et al. 2002)
to calculate a general measure of intelligence. The obtained
scores were converted into age-corrected norm scores.
The grand population mean is set to 10. The IQ subtests
were not administered in 2 ASD and 5 TD boys due to time
The mood list
(Rieffe et al. 2004)
is a self-report
questionnaire that was used to assess children’s negative mood over
the past 4 weeks. We used three subscales of the mood list:
anger, fear and sadness. Each subscale consisted of 4 items
on a 3-point rating scale (e.g., I never/sometimes/often feel
angry). We used a total score for negative mood by taking
the sum score of the negative items. Higher scores
indicated dysregulated emotion experience. Previous studies
has shown good reliability and validity of this measure, this
questionnaire was not previously administered in ASD
populations. Internal consistency in the current study was good
(0.90 ≥ α ≥ 0.79).
Children rated their awareness and understanding of their
own emotions on two subscales of the Emotion Awareness
(EAQ; Rieffe et al. 2008)
emotions and bodily awareness of emotions. The subscale
differentiating emotions contained 7 items and measured
whether children were able to differentiate between their
own emotions (e.g., “I am often confused or puzzled about
what I am feeling [reversed-scored]”). Ratings were made
on a 3-point scale ranging from 1 = (almost) not true to
3 = always true. A high score indicates good ability to
differentiate between emotions. The subscale Bodily
Awareness of Emotions measures whether children are aware of
bodily changes related to emotions and consists of 5 items
(e.g., “I don´t feel anything in my body when I am scared
or nervous”). A high score indicated low bodily awareness,
which was associated with more emotion awareness based
on factor analysis
(Rieffe et al. 2008)
. A total score of the
2 subscales were used as index for emotion awareness. The
EAQ has shown to have good reliability and validity
et al. 2011)
and has been previously administered in children
and adolescents with ASD
(Rieffe et al. 2011)
. In the current
study, internal consistency of this measure was acceptable
(0.81 > α ≥ 0.69).
The worry/rumination questionnaire for children
et al. 2005; Miers et al. 2007)
is a self-report measure, which
assess the tendency of children to dwell on a problem instead
of dealing with it in terms of solving or coping adaptively
with the emotional impact of the situation. The
questionnaire comprises 10 items and children are asked to rate the
degree to which each item (e.g., When I have a problem, I
think about it all the time) is true about them on a 3-point
scale (1 = not true, 2 = sometimes true, 3 = often true). A
high score indicates a high level of worry/rumination. This
questionnaire has good reliability and validity and was
previously administered in children and adolescents with ASD
(Rieffe et al. 2011)
. In the current study, internal consistency
was good (0.81 ≥ α ≥ 0.89).
Disruptive Behavior Problems
The Child Symptom Inventory
(CSI; Gadow and Sprafkin
1994; Dutch version by; Theunissen et al. 2012)
behavior rating-scale to assess childhood disorders based on
DSM-IV criteria. The parent-checklist was used to assess
problems related to attention deficit hyperactivity disorder
(ADHD), oppositional deviant disorder (ODD) and conduct
disorder (CD). Seventeen items assessed the symptoms of
ADHD (e.g., “Is quickly distracted”), eight items assessed
symptoms of ODD (e.g., “Does things to deliberately annoy
others”) and 15 items assessed symptoms of CD (e.g., “Has
deliberately started fires”). Parents were asked to rate each
symptom on a 4-point scale (1 = never and 4 = very often).
A higher score indicated more disruptive behavior.
Previous studies indicate that the CSI has satisfactory reliability
and validity in community and ASD samples
. In the current study, internal consistency
was high (0.93 > α ≥ 0.90).
For internalizing symptoms, three indices were taken:
anxiety, depression, and somatic complaints.
The CSI was also used to assess problems related to
generalized anxiety. Parents rated children’s generalized anxiety
symptoms in the last six months on 7 items. Ratings were
made on a 4-point scale ranging from 1 = never to 4 = very
often. We used a total score of the 7 items. A higher score
indicated more anxious feelings. Internal consistency was
sufficient (0.82 > α ≥ 0.74).
Problems related to depression were measured with an
adapted Dutch version of the Children’s Depression
(Kovacs 1985; Dutch version by; Timbremont
et al. 2002)
. This self-report questionnaire includes 27 items
that are related to specific depression symptoms (e.g., “I
am sad”). Ratings were on a three-point scale ranging from
never/hardly true (1) to very true (3). The item pertaining to
suicidal ideation was removed from the measure. In the
analyses we used the total score of the 26 items. Higher scores
on the CDI indicates higher depressive mood. CDI has good
reliability and validity and has previously been administered
in ASD populations
(Lerner et al. 2012)
consistency in the current study was sufficient (0.86> α ≥ 0.66).
Somatic complaints was measured by the Somatic
Complaint List (SCL)
(Jellesma et al. 2007)
. Children rated
the frequency with which they experience certain somatic
complaints such as a headache in the past four weeks on
a 5-point scale (1 = never to 5 = very often). The scoring
was reversed for the two positively formulated items. The
SCL consists of 21 items; a high total score indicated more
somatic complaints. Previous studies have shown that the
SCL has good reliability and validity
(Jellesma et al. 2007)
and has previously been administered in ASD populations
(Rieffe et al. 2011)
. Internal consistency in the current study
was sufficient (0.83 > α ≥ 0.72).
Children were visited three times with approximately
a 9-month time interval at home (MT1 to 2 = 8.77 months;
SDT1 to 2 = 1.27; MT2 to 3 = 9.23, SDT2 to 3 = 1.17), at school
or at their institution. As part of a larger study, children
were asked to fill in several questionnaires on a laptop
and to perform some experimental tasks. The test sessions
took approximately 1 h each. It was emphasized that their
responses would be anonymous. Parents were asked to
complete questionnaires online or with paper and pencil. All
participants were invited for the second and third wave. Nine
participants (ASD: n6; TD: n = 5; attrition rate: 7.1%) in the
second wave and 26 participants in the third wave (ASD:
n = 9; TD: n = 17; attrition rate: 16.8%) indicated that they
could not or did not want to participate anymore.
Statistical analyses were performed using the statistical
software package for social sciences version 21.0 (SPSS Inc.,
Chicago). Sample characteristics were analyzed by
independent t test. To test whether indices of emotion control at
T1 predict problem behavior at T3, we used a hierarchical
regression analyses for each problem behavior separately.
In these analyses we entered as predictors diagnostic group
(dummy coded: 1 = ASD, 0 = TD) in the first step,
negative emotionality, emotion awareness and worry/rumination
in the second step and the interaction between diagnostic
group and the indices of emotion control in the third step.
Outcome variables were indices of internalizing and
externalizing behavior. All predictors were centered to the mean
before entered in the regression analyses. Even though our
predictors were moderately correlated with one another (see
Supplementary Table 3), multicollinearity diagnostics
indicated adequate tolerance levels. Note, controlling for IQ did
not alter the results.
To analyze the developmental trajectory of behavior
problems in boys with ASD compared to TD boys, we used a
multilevel model approach
(Singer and Willett 2003)
advantage of a multilevel approach is that it allows for
hierarchy within data, such as observed in longitudinal data. In
a longitudinal data set, time points are nested within
participants and multilevel modeling can account for this data
dependency. Another advantage of multilevel modeling is
that it can handle missing data. In a multilevel model, cases
with complete data at every time point are weighted more
heavily. Importantly, as long as one time point of
measurement is available, the case is included in the estimation of
effects. In these analyses, time was treated as
within-individual variable (t) (level 1) and group was included as
betweenindividual variable (level 2). All mixed-models followed a
formal model-fitting procedure. That is, we started with
an unconditional means model that only included a fixed
and random intercept, to allow for individual differences in
Poor emotion awareness
Negative emotionality (NE)
Poor emotion awareness (PEA)
Groups × NE
Group × PEA
Group × W/R
Unstandardized β coefficients and adjusted R2 are reported
*p < .05; **p < .01; ***p < .001
starting points and account for the repeated nature of the
data. The unconditional means model was compared to
additional models that tested the grand mean trajectory of
age [centered around 9 years (age of the youngest child)].
Thereafter we included diagnostic group and the interaction
between age and diagnostic group, to examine whether the
developmental trajectory of individuals with ASD differed
from TD individuals. Preferred models had significantly
lower Akaike Information Criterion values
and Bayesian Information Criterion
Finally, we tested whether changes in indices of
emotion control could explain change in problem behavior (i.e.,
score of measurement 1–3 minus the score of measurement
1 for the indices of emotion control and problem
behavior). We used a step-wise procedure including (1) change
score of each predictor and (2) including the interactions
with diagnostic group. In the results the best fitted models
Emotion Control Predicts Internalizing and Externalizing Behavior Problems in Boys
Table 2 depicts the results of the hierarchical regression
analyses examining whether negative emotionality,
emotion awareness and worry/rumination could predict problem
behavior 18 months later. For disruptive behavior problems,
diagnostic group and the interaction between group and
worry/rumination contributed significantly to the prediction
of externalizing behavior 18 months later (T3). For boys
with ASD, high levels of worry/rumination were related to
high levels of disruptive behavior at T3 (β = 0.95, p = .03),
but not for TD boys (β = 0.28, p = .37).
For symptoms of anxiety, only negative emotionality
contributed significantly to the prediction of symptoms of
anxiety at T3. That is, higher baseline levels of negative
emotionality predicted more symptoms of anxiety at T3. For
symptoms of depression, both diagnostic group and worry/
rumination contributed to the prediction of symptoms of
depression at T3. Boys with ASD showed more symptoms
of depression at T3. Furthermore, boys—independent of
diagnostic group—with higher levels of worry/rumination
at T1 also showed more symptoms of depression at T3.
For somatic complaints, diagnostic group was not a
significant predictor. Baseline levels of negative emotionality
and worry/rumination predicted somatic complaints at T3.
Higher levels of negative emotionality and worry/rumination
was predictive for higher levels of somatic complaints at T3.
Developmental Trajectory of Internalizing and Externalizing Behavior in Boys with ASD
As can be seen in Fig. 1 and confirmed by the multilevel
analyses, boys with ASD showed in general more
disruptive behavior problems, symptoms of depression, anxiety,
and somatic complaints compared to TD boys (see
Supplementary Table 2). There was a negative linear trend
for reported disruptive behavior problems (b = − 1.03,
t = 2.18, p = .03), indicating a decrease in disruptive
behavior over time. For somatic complaints, there was a
positive linear trend (b = 0.37, t = 2.10, p = .04),
indicating an increase in reported somatic complaints over time.
The developmental trajectory of symptoms of anxiety and
depression was rather stable. So, we observed no
significant change in symptoms of anxiety and depression over
time. For all outcome measures there were no differences
between groups in developmental trajectory.
ured only once are represented by points. b, d, f, h Predicted values
for respectively internalizing, externalizing symptoms based on
optimal fitting model
Emotion Control Predicts the Developmental
Trajectory of Internalizing and Externalizing
Table 3 depicts the results of the multilevel models for the
longitudinal relation between the three indices of emotion
control and internalizing and externalizing behavior
problems. The multilevel models without interaction terms fitted
best for disruptive behavior problems, symptoms of anxiety,
and symptoms of depression. For disruptive behavior
problems, an increase in worry/rumination predicted increase in
disruptive behavior problems. Also for symptoms of anxiety
was worry/rumination a significant predictor. An increase
in worry/rumination was related to an increase in anxiety
symptoms. For symptoms of depression, both change in
worry/rumination and change in negative emotionality
predicted change in symptoms of depression. Interestingly, for
somatic complaints the multilevel model including
interaction terms with group fitted best. Change in
worry/rumination, negative emotionality, and emotion awareness predicted
change in somatic complaints. Furthermore, there was also
a significant interaction effect between diagnostic group
and worry/rumination and diagnostic group and negative
emotionality. As can be seen in Fig. 2a, increase in worry/
rumination related to increase in somatic complaints
specifically in the ASD group. In Fig. 2b, increase in negative
emotionality related to increase in somatic complaints in
both groups, but this relation was stronger in the TD group
than in the ASD group.
Many children and adolescents with ASD show emotional
and behavior problems, in addition to their core symptoms
(Gadow et al. 2012; Simonoff et al. 2008)
. It is therefore
important to investigate possible underlying mechanisms
to explain this co-occurrence of symptomatology and to
provide tools for prevention and intervention of these
problems in children and adolescents with ASD. In the
current longitudinal study we examined the predictive role
of three indices of emotion control that are assumed to
play a key role in the development of additional problem
behavior in children and adolescents with ASD. Our main
findings are: (1) baseline level of worry/rumination was a
risk factor for the development of externalizing behavior
symptoms 18 months later, yet only for boys with ASD, (2)
the developmental trajectory of internalizing and
externalizing behavior symptoms did not differ between boys with
and without ASD, (3) increase in worry/rumination over
time was related to the development of more
externalizing behavior problems in boys with and without ASD and
(4) increase in worry/rumination and increase in negative
emotionality contributed both to the development of more
internalizing behavior symptoms in boys with and without
ASD, yet the longitudinal relation between
worry/rumination and somatic complaints was specific for boys with
ASD. Below we will discuss the theoretical and clinical
implications of our findings.
Fig. 2 Longitudinal graphic representation of the interaction between
emotion control and group on somatic complaints. a Change in
worry/rumination over time predicts the developmental trajectory of
somatic complaints in children and adolescents with ASD. b Change
in negative emotionality over time predicts the trajectory of somatic
Developmental Trajectory of Internalizing and Externalizing Behavior in Both Groups
Consistent with previous studies, we found that boys with
ASD showed more internalizing and externalizing
behavior problems than boys without ASD
(Simonoff et al. 2012,
. However, the pace with which these symptoms
develop over time did not differ between groups.
Moreover, we did not find an increase in symptoms of
depression and generalized anxiety. This finding seems to be in
contrast with previous studies showing that the level of
internalizing problems increases during adolescence
Paus et al. 2008)
and are more pronounced in adolescents
(Gotham et al. 2015; Kuusikko et al. 2008)
However, other longitudinal studies reported no age effects
or even a decrease in internalizing symptoms in
adolescent and adults with ASD
(Andersen et al. 2015; Shattuck
et al. 2007; Woodman et al. 2015)
. The mixed findings in
the literature, may be explained by differences in sample
characteristics like gender distribution, level of IQ, age
range, and including individuals with or without comorbid
diagnoses. Indeed, a previous study found that the increase
in internalizing symptoms in adolescents with ASD was
driven by girls, whereas boys with ASD did not show age
effects on reported internalizing symptoms
(Gotham et al.
. Moreover, in the current study we used a
homogenous sample of high-functioning boys with ASD without
complaints in both groups, but stronger for children and adolescents
with a TD development. The graphs represent the single relation
between one emotion control index and somatic complaints, without
controlling for other variables that were included in the mixed model
a comorbid diagnosis, whereas previous studies that found
an increase in internalizing problems used heterogeneous
samples of individuals with ASD
(Gotham et al. 2015;
Kuusikko et al. 2008)
Furthermore, the current findings revealed a decrease in
externalizing behavior with age for boys with and without
ASD. This finding is in line with cross-sectional studies
reporting a negative relation between aggressive behavior
(Farmer et al. 2015; Kanne and Mazurek 2011)
yet others report a relatively stable relation of externalizing
behavior over time
(Bader and Barry 2014)
. The number of
longitudinal studies are, however, limited and essential to
assess the developmental trajectories of problem behavior.
Adolescence is a time period characterized by strong
changes in behavior and biology
. It is also a developmental period sensitive to
the emergence of psychiatric problems
(Paus et al. 2008)
Importantly, the current findings indicate that this period is
not an additional risk factor for boys with ASD to develop
comorbid symptomatology. Moreover, it seems that their
heightened sensitivity to emotional and behavior problems
that are beyond their core diagnostic symptoms already exist
during (early) childhood. Given their social and
communication difficulties, children with ASD are less able to
participate in family and social life. Speculatively, this diminished
access to a social learning environment might affect their
opportunity to practice and achieve emotion control directly
and might explain why comorbid symptomatology emerges
prior to the teenage years.
Worry/Rumination as a Risk Factor for Developing
In line with previous findings we found that boys with ASD
show more disruptive and aggressive behavior than boys
(e.g., Farmer and Aman 2011)
. As has been
noted in previous studies, boys with ASD might act out their
frustration and negative thoughts
(Patel et al. 2017)
in the current study we demonstrate that baseline levels of
worry/rumination was a risk factor for disruptive behavior
problems 18 months later, yet only for boys with ASD. This
indicates that dealing with daily problems by repetitive
negative thinking has a stronger impact for boys with ASD than
for boys without ASD. Possibly, boys with ASD
worry/ruminate about other daily problems than boys without ASD. It
is often assumed that high-functioning people with ASD
are well aware of their social problems and appear to wish
this could be different
. This awareness of
social disconnectedness might be an important source for
daily problems and worries, specifically during adolescence
when peers play an increasingly important role in daily life.
A recent cross-sectional study indeed demonstrated that
adolescents with ASD reported more anger rumination than TD
(Patel et al. 2017)
. It bears mentioning that in the
current study boys with ASD did not worry/ruminate more than
boys without ASD (see Supplementary Table 1).
Furthermore, we showed that an increase in worry/
rumination over time also contributed to the prediction of
more externalizing behavior problems over time for boys
with and without ASD. This finding is in line with a recent
large-scale longitudinal study showing that
worry/rumination in TD boys is a risk factor for later aggressive behavior
(McLaughlin et al. 2014)
and a cross-sectional study in
adolescents with ASD that showed that anger rumination was
associated with aggressive behavior
(Patel et al. 2017)
will be discussed in more detail later, this finding
emphasizes the important role of worry/rumination as an
underlying mechanism explaining the development of multiple
Emotion Control as a Risk Factor for Developing
Boys with ASD showed a heightened sensitivity to develop
internalizing behavior symptoms. In the current study,
however, we merely identified general risk factors for the
development and maintenance of internalizing problems for boys
with and without ASD.
Our findings showed that dealing with daily problems
by repeatedly and negatively thinking about these problems
increases the risk for developing internalizing behavior
problems 18 months later (i.e., symptoms of depression, somatic
complaints) in boys with and without ASD. Furthermore,
increase in frequency of worry/rumination also
contributed to the prediction of increase in internalizing symptoms
(depression, anxiety, somatic complaints). These findings
combined with the observed longitudinal relation between
worry/rumination and externalizing behavior symptoms
confirm that worry rumination is a transdiagnostic factor
underlying multiple types of psychopathology
(Aldao et al.
2010; Ehring and Watkins 2008; Nolen-Hoeksema 2000)
that are beyond the core symptoms of ASD.
It should be noted that the longitudinal relation between
worry/rumination and somatic complaints was most
apparent in the ASD group. A previous study demonstrated a
cross-sectional relation between anger related rumination
and somatic complaints in TD children
(Miers et al. 2007)
Possibly, worry/rumination is a stronger stressor for boys
with ASD than for boys without ASD. It has been argued
that preservative cognition, like worry/rumination,
moderate the relation between stressors and somatic complaints
by prolonging the stress-level (Brosschot et al. 2006). So,
repetitive negative thinking in response to daily issues might
induce and prolong the stress responses related to these daily
hazards more in boys with ASD, which in turn affect their
physiological well-being stronger. This hypothesis should
be tested in future studies.
Another risk factor for internalizing symptomatology is
a regular experience of negative emotions
(Gross and John
2003; McLaughlin et al. 2011; Moses and Barlow 2006)
In line with this, we showed that for boys with and without
ASD baseline levels of negative emotionality was a
predictor for internalizing symptoms (i.e., anxiety, somatic
complaints) 18 months later. Furthermore, we showed that an
increase in negative emotionality over time was related to
an increase in internalizing behavior problems (i.e.,
depression, somatic complaints) over time. Note that this
longitudinal relation between negative emotionality and somatic
complaints was evident for all boys, albeit stronger for TD
boys. The frequent experience of anger, fear and/or sadness
reveales a child’s inability to effectively deal with daily
emotional experiences. Maintaining a negative mood state affects
the way a child approach new situations. For example,
negative mood negatively affects basic cognitive processes, like
memory, attention and interpretation (e.g., Gendolla 2000),
which in turn, are important in regulating emotions
2013; Sheppes et al. 2015)
. In this way, a vicious circle may
emerge resulting in an increased risk to delevop and
maintain internalizing symptomatology.
Remarkably, the ability to differentiate between emotional
states and be aware of bodily changes that are accompanied
by those states did not uniquely contribute to the prediction
of internalizing and externalizing behavior problems, except
for the development of somatic complaints. This finding is
unexpected, given that understanding of one’s own
emotions is critical for the experience and regulation of emotions
(Barrett et al. 2001; Lambie and Marcel 2002; Rieffe et al.
. Moreover, alexithymia—a broader construct that also
involves emotion awareness—is associated with
internalizing problems in youth with ASD (Milosavljevic et al. 2016).
This discrepancy in results may be explained by differences
in research design. Note, that alexithymia is often examined
in isolation, whereas we investigated three indices of
emotion control. As can be seen in Supplementary Table 3, we
found correlations between emotion awareness at T1 and
depression and somatic complaints at T3.
The current study had several strengths including a
longitudinal design, an adequate sample size, and a typical
developing control group. However, the following limitations should
be considered when interpreting the current findings. First,
our sample included high functioning boys with ASD
without co-occurring psychiatric problems. Hence, the boys with
ASD in our sample may not reflect a representative sample
of boys with ASD; showing less severe problem behavior.
Yet, our selection criteria ascertains group comparisons and
thereby that the findings in this study can be attributed to
the diagnosis of ASD. Second, our results on the
developmental pattern of internalizing and externalizing behavior
problems in boys with ASD should be interpreted with
caution, given that in the study period participants with ASD
and their parents received psychoeducation on ASD. Hence,
this may have positively affected their developmental
trajectories of internalizing and externalizing behavior, showing
less severe problem behavior. Third, we focused on only
three processes related to emotion control. Given the
complex nature of emotion control and its relation to emotional
and behavioral problems, we could only clarify a small part
of this relationship. For example, we only selected worry/
rumination as a measure of cognitive emotion regulation,
but other maladaptive strategies for example
catastrophizing and self-blame may also be related to the development
of psychopathology in children and adolescents with ASD
(Mazefsky and White 2014; Rieffe et al. 2014)
. It would
be interesting to incorporate both adaptive and
maladaptive cognitive emotion regulation strategies to gain a more
detailed understanding of possible risk as well as protective
factors for the development of problem behavior. Related to
this issue, we used one measure for each construct of
emotion regulation. Given the complexity of these measures,
it is highly likely that they are contaminated by
randomand systematic-error. It is well established in the literature
that a single indicator of any given construct can rarely, if
ever, be viewed as a pure measure of the construct
. Consequently, future studies using multiple
measures of emotion control incorporating perhaps latent variable
approaches extracting common variance to these concepts
may provide a clearer picture of the relations between
different aspects of emotion control and psychopathology in
ASD. Moreover, one cannot expect a single emotion control
profile to characterize all children with ASD. Rather, just
as there are individual differences in the core ASD
symptom manifestation there ought to be individual differences
or variability in the various processes related to emotion
control. It is therefore important for future research to
determine emotion control profiles in children with ASD on an
individualized basis that are (mal)adaptive for their
development. Fourth, in the current study we assessed emotion
control with self-report questionnaires and subsequently rely
on the ability of our participants to describe their emotions.
Even though growing body of research suggests that
introspection does not form a problem for adolescents with ASD
(Bird and Cook 2013; Milosavljevic et al. 2016; Rieffe et al.
, the quality of this introspection might differ between
adolescents with ASD and their TD controls. Moreover, we
used self-report measures to index emotion control,
depression, and somatic complaints and parent-reports to measure
generalized anxiety and disruptive behavior problems. The
use of different informants for the outcome measures may
have affected the current findings. Previous studies have
shown that informant agreement is only modest
et al. 2013)
, but that informant-agreement does not differ for
children and adolescents with ASD compared to their TD
peers (Stratis and Lecavalier 2015). Possibly, modest
informant agreement has lowered our power to detect associations
between self-reported emotion control with parent-reported
symptoms of generalized anxiety and disruptive behavior
problems compared to detecting associations between
selfreported emotion control with self-reported symptoms of
depression and somatic complaints. This might be
specifically the case for the relation between emotion control and
generalized anxiety, given that it is difficult for parents to
observe and report internalizing behavior during
adolescence when children become more and more independent
from their parents.
The current longitudinal study provided important insights
on the role of emotion control in developing and maintaining
internalizing and externalizing behavior problems in boys
with and without ASD. We showed that worry/rumination is
an important risk factor for developing externalizing
behavior problems in boys with ASD 18 months later. Moreover,
increase in the frequency of this negative thinking style also
contributed to the prediction of increase in internalizing and
externalizing behavior problems over time in boys with and
without ASD. This implies that worry/rumination is a key
factor underlying the development of a broad spectrum of
psychiatric symptomatology. For clinical practice, a focus on
transdiagnostic factors, such as worry/rumination may prove
useful to include in prevention and treatment programs for
children and adolescents with ASD aimed at preventing of
the development of comorbidity
Acknowledgments We gratefully acknowledge the help and assistance
from children, families, and professionals which enabled us to bring
this project to a successful conclusion.
Author Contributions MGNB conceived of the study, participated
in the design and interpretation of the data, performed the statistical
analyses and drafted the manuscript; SD conceived of the study,
participated in the design and interpretation of the data and helped to draft the
manuscript; SB participated in the interpretation of the data and helped
to draft the manuscript; LS participated in the design, coordination of
the data collection and helped to draft the manuscript; CR conceived
of the study, participated in its coordination, design, data collection,
and interpretation of the data and helped to draft the manuscript. All
authors read and approved the final manuscript.
Funding This research was supported by the Innovational Research
Incentives Scheme (a VIDI Grant) by The Netherlands Organisation
for Scientific Research (NWO), No. 452-07-004 to Carolien Rieffe.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
Open Access This article is distributed under the terms of the
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mmons.org/licenses/by/4.0/), which permits unrestricted use,
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credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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