Hostname: page-component-586b7cd67f-t8hqh Total loading time: 0 Render date: 2024-11-29T00:28:37.312Z Has data issue: false hasContentIssue false

The longitudinal development of emotion regulation capacities in children at risk for externalizing disorders

Published online by Cambridge University Press:  30 April 2013

Sarah L. Halligan*
Affiliation:
University of Bath
Peter J. Cooper
Affiliation:
University of Reading University of Stellenbosch
Pasco Fearon
Affiliation:
University College London
Sarah L. Wheeler
Affiliation:
University of Reading
Michelle Crosby
Affiliation:
University of Reading University of Stellenbosch
Lynne Murray
Affiliation:
University of Bath
*
Address correspondence and reprint requests to: Sarah L. Halligan, Department of Psychology, 2 South, University of Bath, Bath BA2 7AY, UK; E-mail: [email protected].

Abstract

The development of emotional regulation capacities in children at high versus low risk for externalizing disorder was examined in a longitudinal study investigating: (a) whether disturbances in emotion regulation precede and predict the emergence of externalizing symptoms and (b) whether sensitive maternal behavior is a significant influence on the development of child emotion regulation. Families experiencing high (n = 58) and low (n = 63) levels of psychosocial adversity were recruited to the study during pregnancy. Direct observational assessments of child emotion regulation capacities and maternal sensitivity were completed in early infancy, at 12 and 18 months, and at 5 years. Key findings were as follows. First, high-risk children showed poorer emotion regulation capacities than their low-risk counterparts at every stage of assessment. Second, from 12 months onward, emotion regulation capacities showed a degree of stability and were associated with behavioral problems, both concurrently and prospectively. Third, maternal sensitivity was related to child emotion regulation capacities throughout development, with poorer emotion regulation in the high-risk group being associated with lower maternal sensitivity. The results are consistent with a causal role for problems in the regulation of negative emotions in the etiology of externalizing psychopathology and highlight insensitive parenting as a potentially key developmental influence.

Type
Regular Articles
Copyright
Copyright © Cambridge University Press 2013

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.Google Scholar
Allison, P. D. (2003). Missing data techniques for structural equation modeling. Journal of Abnormal Psychology, 112, 545557.CrossRefGoogle ScholarPubMed
Barkley, R. A. (1997). ADHD and the nature of self-control. New York: Guilford Press.Google Scholar
Bayley, N. (1993). Bayley Scales of Infant Development (2nd ed.). San Antonio, TX: Psychological Corporation.Google Scholar
Blair, C., Granger, D. A., Kivlighan, K. T., Mills-Koonce, R., Willoughby, M., Greenberg, M. T., et al. (2008). Maternal and child contributions to cortisol response to emotional arousal in young children from low-income, rural communities. Developmental Psychology, 44, 10951109.CrossRefGoogle ScholarPubMed
Blair, C., Granger, D., Willoughby, M., & Kivlighan, K. (2006). Maternal sensitivity is related to hypothalamic–pituitary–adrenal axis stress reactivity and regulation in response to emotion challenge in 6-month-old infants. Annals of the New York Academy of Science, 1094, 263267.Google Scholar
Blandon, A. Y., Calkins, S. D., Keane, S. P., & O'Brien, M. (2008). Individual differences in trajectories of emotion regulation processes: The effects of maternal depressive symptomatology and children's physiological regulation. Developmental Psychology, 44, 11101123.Google Scholar
Brazelton, T. B., & Nugent, J. K. (1995). The Neonatal Behavioural Assessment Scale (3rd ed.). London: MacKeith Press.Google Scholar
Bright, P., Jaldow, E., & Kopelman, M. D. (2002). The National Adult Reading Test as a measure of premorbid intelligence: A comparison with estimates derived from demographic variables. Journal of the International Neuropsychological Society, 8, 847854.Google Scholar
Buss, K. A., & Goldsmith, H. H. (1998). Fear and anger regulation in infancy: Effects on the temporal dynamics of affective expression. Child Development, 69, 359374.CrossRefGoogle ScholarPubMed
Calkins, S. D. (1994). Origins and outcomes of individual differences in emotion regulation. Monographs of the Society for Research in Child Development, 59, 5372.Google Scholar
Calkins, S. D., & Dedmon, S. E. (2000). Physiological and behavioral regulation in two-year-old children with aggressive/destructive behavior problems. Journal of Abnormal Child Psychology, 28, 103118.Google Scholar
Calkins, S. D., Graziano, P. A., Berdan, L. E., Keane, S. P., & Degnan, K. A. (2008). Predicting cardiac vagal regulation in early childhood from maternal–child relationship quality during toddlerhood. Developmental Psychobiology, 50, 751766.Google Scholar
Calkins, S. D., & Hill, A. (2007). Caregiver influences on emerging emotion regulation: Biological and environmental transactions in early development. In Gross, J. J. (Ed.), The handbook of emotion regulation (pp. 229248). New York: Guilford Press.Google Scholar
Calkins, S. D., & Johnson, M. C. (1998). Toddler regulation of distress to frustrating events: Temperamental and maternal correlates. Infant Behavior and Development, 21, 349357.CrossRefGoogle Scholar
Calkins, S. D., & Keane, S. P. (2004). Cardiac vagal regulation across the preschool period: Stability, continuity, and implications for childhood adjustment. Developmental Psychobiology, 45, 101112.CrossRefGoogle ScholarPubMed
Calkins, S. D., & Keane, S. P. (2009). Developmental origins of early antisocial behavior. Development and Psychopathology, 21, 10951109.Google Scholar
Campbell, S. B. (2002). Behavior problems in preschool children: Clinical and developmental issues. New York: Guilford Press.Google Scholar
Cassidy, J. (1994). Emotion regulation: Influences of attachment relationships. Monographs of the Society for Research in Child Development, 59, 228249.Google Scholar
Charles, S. T., & Carstensen, L. L. (2007). Emotion regulation and aging. In Gross, J. J. (Ed.), The handbook of emotion regulation (pp. 307327). New York: Guilford Press.Google Scholar
Cicchetti, D., Ackerman, B. P., & Izard, C. E. (1995). Emotions and emotion regulation in developmental psychopathology. Development and Psychopathology, 7, 110.Google Scholar
Cicchetti, D., & Pogge-Hesse, P. (1981). The relation between emotion and cognition in infant development. In Lamb, M. & Sherrod, L. (Eds.), Infant social cognition (pp. 205272). Hillsdale, NJ: Erlbaum.Google Scholar
Cole, P. M., Martin, S. E., & Dennis, T. A. (2004). Emotion regulation as a scientific construct: Methodological challenges and directions for child development research. Child Development, 75, 317333.Google Scholar
Cole, P. M., Michel, M. K., & Teti, L. O. (1994). The development of emotion regulation and dysregulation: A clinical perspective. Monographs of the Society for Research in Child Development, 59, 73100.CrossRefGoogle ScholarPubMed
Cole, P. M., Teti, L. O., & Zahn-Waxler, C. (2003). Mutual emotion regulation and the stability of conduct problems between preschool and early school age. Development and Psychopathology, 15, 118.Google Scholar
Cole, P. M., Wiggins, C. N., Radzioch, A. M., & Pearl, A. M. (2007). D.O.T.S. Emotion Coding System. Unpublished manuscript, Pennsylvania State University, Department of Psychology.Google Scholar
Cole, P. M., Zahn-Waxler, C., Fox, N. A., Usher, B. A., & Welsh, J. D. (1996). Individual differences in emotion regulation and behavior problems in preschool children. Journal of Abnormal Psychology, 105, 518529.Google Scholar
Cole, P. M., Zahn-Waxler, C., & Smith, K. D. (1994). Expressive control during a disappointment: Variations related to preschoolers' behavior problems. Developmental Psychology, 30, 835846.Google Scholar
Conradt, E., & Ablow, J. (2010). Infant physiological response to the still-face paradigm: Contributions of maternal sensitivity and infants' early regulatory behavior. Infant Behavior and Development, 33, 251265.Google Scholar
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782786.CrossRefGoogle ScholarPubMed
Cronin, A., Halligan, S. L., & Murray, L. (2008). Maternal psychosocial adversity and the longitudinal development of infant sleep. Infancy, 13, 469495.CrossRefGoogle Scholar
Dadds, M. R., Mullins, M. J., McAllister, R. A., & Atkinson, E. (2003). Attributions, affect, and behavior in abuse-risk mothers: A laboratory study. Child Abuse and Neglect, 27, 2145.Google Scholar
Deater-Deckard, K., Petrill, S. A., & Thompson, L. A. (2007). Anger/frustration, task persistence, and conduct problems in childhood: A behavioral genetic analysis. Journal of Child Psychology and Psychiatry, 48, 8087.Google Scholar
DiPietro, J. A., Hodgson, D. M., Costigan, K. A., & Johnson, T. R. (1996). Fetal antecedents of infant temperament. Child Development, 67, 25682583.Google Scholar
Dunn, J., Bretherton, I., & Munn, P. (1987). Conversations about feeling states between mothers and their young children. Developmental Psychology, 23, 132139.Google Scholar
Eisenberg, N., Fabes, R. A., Murphy, B., Maszk, P., Smith, M., & Karbon, M. (1995). The role of emotionality and regulation in children's social functioning: A longitudinal study. Child Development, 66, 13601384.Google Scholar
Eisenberg, N., Smith, C. L., Sadovsky, A., & Spinrad, T. L. (2004). Effortful control: Relations with emotion regulation, adjustment, and socialization in childhood. In Baumeister, R. F. & Vohs, K. D. (Eds.), Handbook of self-regulation: Research, theory, and applications (pp. 259282). New York: Guilford Press.Google Scholar
Eisenberg, N., Zhou, Q., Spinrad, T. L., Valiente, C., Fabes, R. A., & Liew, J. (2005). Relations among positive parenting, children's effortful control, and externalizing problems: A three-wave longitudinal study. Child Development, 76, 10551071.Google Scholar
Feng, X., Shaw, D. S., Kovacs, M., Lane, T., O'Rourke, F. E., & Alarcon, J. H. (2008). Emotion regulation in preschoolers: The roles of behavioral inhibition, maternal affective behavior, and maternal depression. Journal of Child Psychology and Psychiatry, 49, 132141.CrossRefGoogle ScholarPubMed
Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1993). Maternal smoking before and after pregnancy: Effects on behavioral outcomes in middle childhood. Pediatrics, 92, 815822.CrossRefGoogle ScholarPubMed
Fergusson, D. M., & Lynskey, M. T. (1993). Maternal age and cognitive and behavioural outcomes in middle childhood. Paediatric and Perinatal Epidemiology, 7, 7791.Google Scholar
Fergusson, D. M., & Woodward, L. J. (1999). Maternal age and educational and psychosocial outcomes in early adulthood. Journal of Child Psychology and Psychiatry, 40, 479489.Google Scholar
Field, T., Diego, M., & Hernandez-Reif, M. (2006). Prenatal depression effects on the fetus and newborn: A review. Infant Behavior and Development, 29, 445455.Google Scholar
Fried, P. A., & Makin, J. E. (1987). Neonatal behavioural correlates of prenatal exposure to marihuana, cigarettes and alcohol in a low risk population. Neurotoxicology and Teratology, 9, 17.CrossRefGoogle Scholar
Gardner, F. E., Sonuga-Barke, E. J., & Sayal, K. (1999). Parents anticipating misbehaviour: An observational study of strategies parents use to prevent conflict with behaviour problem children. Journal of Child Psychology and Psychiatry, 40, 11851196.Google Scholar
Ghodsian, M., Zajicek, E., & Wolkind, S. (1984). A longitudinal-study of maternal depression and child-behavior problems. Journal of Child Psychology and Psychiatry, 25, 91109.CrossRefGoogle Scholar
Gilliom, M., Shaw, D. S., Beck, J. E., Schonberg, M. A., & Lukon, J. L. (2002). Anger regulation in disadvantaged preschool boys: Strategies, antecedents, and the development of self-control. Developmental Psychology, 38, 222235.CrossRefGoogle ScholarPubMed
Goldsmith, H. H., Buss, K. A., & Lemery, K. S. (1997). Toddler and childhood temperament: Expanded content, stronger genetic evidence, new evidence for the importance of environment. Developmental Psychology, 33, 891905.Google Scholar
Goldsmith, H. H., & Rothbart, M. K. (1999). The Laboratory Temperament Assessment Battery: Locomotor version. Unpublished manuscript, University of Wisconsin and University of Oregon.Google Scholar
Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581586.Google Scholar
Goodman, R., Ford, T., Simmons, H., Gatward, R., & Meltzer, H. (2000). Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. British Journal of Psychiatry, 177, 534539.Google Scholar
Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review, 106, 458490.Google Scholar
Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: Conceptual foundations. In Gross, J. J. (Ed.), The handbook of emotion regulation (pp. 324). New York: Guilford Press.Google Scholar
Gunnar, M. R. (1998). Quality of early care and buffering of neuroendocrine stress reactions: Potential effects on the developing human brain. Preventive Medicine, 27, 208211.Google Scholar
Gunning, M., Conroy, S., Valoriani, V., Figueiredo, B., Kammerer, M. H., Muzik, M., et al. (2004). Measurement of mother–infant interactions and the home environment in a European setting: Preliminary results from a cross-cultural study. British Journal of Psychiatry, 46(Suppl.), s38s44.Google Scholar
Hinshaw, S. P. (2003). Impulsivity, emotion regulation, and developmental psychopathology: Specificity versus generality of linkages. Annals of the New York Academy of Science, 1008, 149159.Google Scholar
Huffman, L. C., Bryan, Y. E., del Carmen, R., Pedersen, F. A., Doussard-Roosevelt, J. A., & Porges, S. W. (1998). Infant temperament and cardiac vagal tone: Assessments at twelve weeks of age. Child Development, 69, 624635.Google Scholar
John, O. P., & Gross, J. J. (2007). Individual differences in emotion regulation. In Gross, J. J. (Ed.), The handbook of emotion regulation (pp. 351372). New York: Guilford Press.Google Scholar
Kendler, K. S., & Baker, J. H. (2007). Genetic influences on measures of the environment: A systematic review. Psychological Medicine, 37, 615626.Google Scholar
Kim, J., & Cicchetti, D. (2010). Longitudinal pathways linking child maltreatment, emotion regulation, peer relations, and psychopathology. Journal of Child Psychology and Psychiatry, 51, 706716.Google Scholar
Kochanska, G., & Knaack, A. (2003). Effortful control as a personality characteristic of young children: Antecedents, correlates, and consequences. Journal of Personality, 71, 10871112.CrossRefGoogle ScholarPubMed
Kopp, C. B. (1982). Antecedents of self-regulation: A developmental perspective. Developmental Psychology, 18, 199214.Google Scholar
Kopp, C. B. (1989). Regulation of distress and negative emotions: A developmental view. Developmental Psychology, 25, 343354.Google Scholar
Marsee, M. A., & Frick, P. J. (2007). Exploring the cognitive and emotional correlates to proactive and reactive aggression in a sample of detained girls. Journal of Abnormal Child Psychology, 35, 969981.Google Scholar
Marshall, P. J., Fox, N. A., & Henderson, H. A. (2002). Temperament as an organizer of development. Infancy, 1, 11991208.Google Scholar
Maughan, A., Cicchetti, D., Toth, S. L., & Rogosch, F. A. (2007). Early-occurring maternal depression and maternal negativity in predicting young children's emotion regulation and socioemotional difficulties. Journal of Abnormal Child Psychology, 35, 685703.CrossRefGoogle ScholarPubMed
Melnick, S. M., & Hinshaw, S. P. (2000). Emotion regulation and parenting in AD/HD and comparison boys: Linkages with social behaviors and peer preference. Journal of Abnormal Child Psychology, 28, 7386.Google Scholar
Mesman, J., van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2009). The many faces of the Still-Face Paradigm: A review and meta-analysis. Developmental Review, 29, 120162.Google Scholar
Moore, G. A., Hill-Soderlund, A. L., Propper, C. B., Calkins, S. D., Mills-Koonce, W. R., & Cox, M. J. (2009). Mother–infant vagal regulation in the face-to-face still-face paradigm is moderated by maternal sensitivity. Child Development, 80, 209223.Google Scholar
Morrell, J., & Murray, L. (2003). Parenting and the development of conduct disorder and hyperactive symptoms in childhood: A prospective longitudinal study from 2 months to 8 years. Journal of Child Psychology and Psychiatry, 44, 489508.Google Scholar
Murray, L. (1992). The impact of postnatal depression on infant development. Journal of Child Psychology and Psychiatry, 33, 543561.CrossRefGoogle ScholarPubMed
Murray, L., Fiori-Cowley, A., Hooper, R., & Cooper, P. (1996). The impact of postnatal depression and associated adversity on early mother–infant interactions and later infant outcome. Child Development, 67, 25122526.Google Scholar
Murray, L., Halligan, S. L., Goodyer, I., & Herbert, J. (2010). Disturbances in early parenting of depressed mothers and cortisol secretion in offspring: A preliminary study. Journal of Affective Disorders, 122, 218223.Google Scholar
Muthén, L. K., & Muthén, B. O. (2007). Mplus user's guide (3rd ed.). Los Angeles: Author.Google Scholar
Nelson, H., & Willison, J. (1991). National Adult Reading Test (NART) (2nd ed.) Windsor, ON: NFER-Nelson.Google Scholar
O'Connor, T. G., Deater-Deckard, K., Fulker, D., Rutter, M., & Plomin, R. (1998). Genotype–environment correlations in late childhood and early adolescence: Antisocial behavioral problems and coercive parenting. Developmental Psychology, 34, 970981.Google Scholar
Patterson, G. R. (1995). Coercion—A basis for early age of onset for arrest. In Pepler, D. J. & Rubin, K. H. (Eds.), The development and treatment of childhood aggression (pp. 81105). New York: Cambridge University Press.Google Scholar
Porges, S. W. (1996). Physiological regulation in high-risk infants: A model for assessment and potential intervention. Development and Psychopathology, 8, 4358.CrossRefGoogle Scholar
Porges, S. W., Doussard-Roosevelt, J. A., & Maiti, A. K. (1994). Vagal tone and the physiological regulation of emotion. Monographs of the Society for Research in Child Development, 59, 167186.Google Scholar
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879891.Google Scholar
Raiha, H., Lehtonen, L., Huhtala, V., Saleva, K., & Korvenranta, H. (2002). Excessively crying infant in the family: Mother–infant, father–infant and mother–father interaction. Child Care, Health and Development, 28, 419429.CrossRefGoogle ScholarPubMed
Richman, N., & Graham, P. J. (1971). A Behavioural Screening Questionnaire for use with three-year-old children: Preliminary findings. Journal of Child Psychology and Psychiatry, 12, 533.Google Scholar
Rothbart, M. K. (1989). Temperament and development. In Kohnstamm, G. A., Bates, J. A., & Rothbart, M. K. (Eds.), Temperament in childhood (pp. 187247). New York: Wiley.Google Scholar
Rothbart, M. K., & Derryberry, D. (1981). Development of individual differences in temperament. In Lamb, M. & Brown, A. (Eds.), Advances in developmental psychology (pp. 3786). Hillsdale, NJ: Erlbaum.Google Scholar
Rothbart, M. K., Ziaie, H., & O'Boyle, C. (1992). Self-regulation and emotion in infancy. In Eisenberg, N. & Fabes, R. A. (Eds.), Emotion and its regulation in early development (pp. 723). San Francisco, CA: Jossey–Bass/Pfeiffer.Google Scholar
Rutter, M., Giller, H., & Hagell, A. (1998). Antisocial behavior by young people. Cambridge: Cambridge University Press.Google Scholar
Satorra, A., & Bentler, P. M. (2001). A scaled difference chi-square test statistic for moment structure analysis. Psychometrika, 66, 507514.Google Scholar
Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7, 147177.Google Scholar
Schuetze, P., Lopez, F. A., Granger, D. A., & Eiden, R. D. (2008). The association between prenatal exposure to cigarettes and cortisol reactivity and regulation in 7-month-old infants. Developmental Psychobiology, 50, 819834.Google Scholar
Shaw, D. S., Gilliom, M., Ingoldsby, E. M., & Nagin, D. S. (2003). Trajectories leading to school-age conduct problems. Developmental Psychology, 39, 189200.Google Scholar
Shaw, D. S., Winslow, E. B., Owens, E. B., & Hood, N. (1998). Young children's adjustment to chronic family adversity: A longitudinal study of low-income families. Journal of the American Academy of Child & Adolescent Psychiatry, 37, 545553.Google Scholar
Shields, A., & Cicchetti, D. (1998). Reactive aggression among maltreated children: The contributions of attention and emotion dysregulation. Journal of Clinical Child Psychology, 27, 381395.Google Scholar
Stifter, C. A., & Braungart, J. M. (1995). The regulation of negative reactivity in infancy: Function and development. Developmental Psychology, 31, 448455.Google Scholar
Stifter, C. A., & Jain, A. (1996). Psychophysiological correlates of infant temperament: Stability of behavior and autonomic patterning from 5 to 18 months. Developmental Psychobiology, 29, 379391.Google Scholar
Talge, N. M., Neal, C., & Glover, V. (2007). Antenatal maternal stress and long-term effects on child neurodevelopment: How and why? Journal of Child Psychology and Psychiatry, 48, 245261.Google Scholar
Thompson, R. (1994). Emotion regulation: A theme in search of definition. Monographs of the Society for Research in Child Development, 59, 2552.Google Scholar
Thompson, R. A., & Meyer, S. (2007). Socialization of emotion regulation in the family. In Gross, J. J. (Ed.), The handbook of emotion regulation (pp. 249268). New York: Guilford Press.Google Scholar
Tronick, E. Z., & Gianino, A. (1986). Interactive mismatch and repair: Challenges to the coping infant. Zero to Three: Bulletin of the National Center for Clinical Infant Programs, 6, 16.Google Scholar
Van den Bergh, B. R., Mulder, E. J., Mennes, M., & Glover, V. (2005). Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: Links and possible mechanisms—A review. Neuroscience & Biobehavioral Reviews, 29, 237258.Google Scholar
van den Boom, D. C., & Hoeksma, J. B. (1994). The effect of infant irritability on mother–infant interaction: A growth curve analysis. Developmental Psychology, 30, 581590.Google Scholar
Walcott, C. M., & Landau, S. (2004). The relation between disinhibition and emotion regulation in boys with attention deficit hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 33, 772782.Google Scholar
Wechsler, D. (1989). Wechsler Preschool and Primary Scale of Intelligence—Revised. San Antonio, TX: Psychological Corporation.Google Scholar
Weissman, M. M., Pilowsky, D. J., Wickramaratne, P. J., Talati, A., Wisniewski, S. R., Fava, M., et al. (2006). Remissions in maternal depression and child psychopathology: A STAR*D-child report. Journal of the Amercian Medical Association, 295, 13891398.Google Scholar
Weitzman, M., Gortmaker, S., & Sobol, A. (1992). Maternal smoking and behavior problems of children. Pediatrics, 90, 342349.Google Scholar
Wolke, D., Skuse, D., & Mathisen, B. (1990). Behavioral style in failure-to-thrive infants: A preliminary communication. Journal of Pediatric Psychology, 15, 237254.Google Scholar
Woodward, L. J., Horwood, L. J., & Fergusson, D. M. (2001). Teenage pregnancy: Cause for concern. New Zealand Medical Journal, 114, 301303.Google Scholar
Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361370.Google Scholar