Should Adolescents Listen to Their Hearts? A Closer Look at the Associations Between Interoception,Emotional Awareness and Emotion Regulation in Adolescents

Abstract

The aim of the current study was to replicate findings from prior work among adults showing that individuals with better interoceptive skills have more emotional awareness, and show better emotion regulation abilities, in a sample of adolescents and by relying on instructions that reduce the contamination of known confound variables. A total of 102 Belgian adolescents (M_age = 14.10 years, SD_age = .63; 50 males) completed self-report questionnaires of emotional processes (FEEL-KJ and DERS) and the modified heartbeat counting task. From this task, interoceptive accuracy, interoceptive sensibility (confidence ratings), and interoceptive awareness scores (within-person correlations) were derived per participant. Results revealed no associations between the three dimensions of interoception and adolescents’ levels of emotional awareness, adaptive, and maladaptive emotion regulation. The lack of associations which contrast some prior work with adults may be due to developmental differences. However, these might also support the low validity of the heartbeat counting task, or could be attributed to the measurement of the emotion measures (i.e., self-report). Future studies should, nevertheless, also test whether these non-significant results can be explained by the developmental differences in adolescents. Longitudinal research is needed to capture interoceptive changes during adolescence, as well as to replicate the current findings using rigorous multimethod approaches that increase the validity of interoception measurement.

Keywords

Interoception adolescence emotional awareness emotion regulation heartbeat counting task

Introduction

Many theories of affect highlight the importance of bodily processes in the detection of emotions. The somatic marker hypothesis for example states that one’s subjective emotional experience is shaped by the awareness of one’s bodily signals, which is supported by ‘interoception’ (Damasio, 1996). Interoception can be defined as an individual’s ability to sense, interpret and integrate signals from within, across conscious and unconscious levels (Berntson & Khalsa, 2021; Chen et al., 2021; Desmedt, Luminet, Maurage, & Corneille, 2023; Garfinkel et al., 2015). One interoceptive process that has received great research attention is interoception related to the heart, which is typically assessed with the heartbeat counting task (HCT) (Schandry, 1981), whereby participants are instructed to count their heartbeats in the interval between two auditory signals, while their actual heartbeat is being recorded. The absolute proportional difference between actual and reported heartbeats is meant to represent an individual’s level of cardiac interoceptive accuracy (IAcc). IAcc refers to the objective detection of bodily signals and is assessed by performance-based tasks. In addition to IAcc, other dimensions of interoception have been proposed (Desmedt, Luminet, Maurage, & Corneille, 2023; Garfinkel et al., 2015; Khalsa et al., 2018), including interoceptive sensibility (IS) and awareness (IAw). IS can be described as the self-evaluation of one’s detection ability and is usually assessed with self-report questionnaires or with trial-wise confidence judgements on IAcc tasks (Garfinkel et al., 2015). IAw refers to the metacognitive beliefs of one’s own IAcc, reflecting the trial-wise correspondence between IAcc and confidence (Garfinkel et al., 2015). Although studying heartbeats has a long tradition, the contribution of bodily processes in the regulation of emotions has only recently gained attention in adolescents (De Witte et al., 2016).

Prior empirical work suggested important associations between interoception and emotional processes, including emotional awareness and emotion regulation (ER) (e.g., Tan et al., 2023). ER can be defined as a set of processes that can be used to influence the emotional experiences of individuals (Gross, 1998). The literature often distinguishes between putatively adaptive or maladaptive ER strategies (ERS) based on their overall impact on emotion, cognition, and behavior, as well as their associations with mental health outcomes (Aldao et al., 2010). Adaptive ERS, such as cognitive reappraisal, tend to have a positive impact on mental health outcomes by mitigating psychopathological symptoms and promoting psychological well-being, whereas maladaptive strategies, such as suppression, often exacerbate psychological distress and contribute to the development or worsening of mental health issues (Aldao et al., 2010; Schäfer et al., 2017). Importantly, theoretical models, such as the Adaptive Coping with Emotions model (ACE, Berking & Whitley, 2014), suggests that different skills are required in order to adaptively regulate emotions, one such process being emotional awareness (Berking & Whitley, 2014). Emotional awareness has been shown to be an important precursor to the adaptive use of ERS (Van Beveren et al., 2019), and refers to the ability to identify, explain, and understand one’s own and other’s emotional experiences (Lane & Schwartz, 1987). The period of adolescence is characterized by multiple developmental changes and challenges, which can potentially intensify negative emotional episodes (Dahl et al., 2018). Therefore, studying interoception in adolescents is vital, as it may relate to emotional awareness and adaptive ER, two processes that are crucial for coping with age-related challenges and stressors.

Recent work in adults has revealed that higher attention to bodily signals is related to more emotional awareness, which in turn leads to the flexible use of certain ERS tailored to a certain situation (Tan et al., 2023). In adolescents, no studies have been conducted relating interoception to emotional awareness. However, in pre-school children one study failed to find an association between IAcc and emotion recognition (Schaan et al., 2019). Other work examined how low interoception abilities may relate to alexithymia, a personality trait characterized by difficulties in identifying and describing emotions, as well as a concrete thinking style that avoids affect (Taylor et al., 2016). Overall, a meta-analysis concluded that there was no significant association between alexithymia and both IAcc and IS (Trevisan et al., 2019). Only few studies examined the role of IAw in alexithymia, indicating that generally higher levels of alexithymia are related to lower levels of IAw (e.g., Scarpazza et al., 2022). To conclude, current studies have revealed mixed results in adults and the relationship between interoception and emotional awareness has not been studied in healthy youth. Therefore, with the current study, we aim to study how these interoception dimensions (i.e., IAcc, IS and IAw) relate to emotional awareness in a sample of adolescents.

Research has also highlighted that the degree of interoception is related to the intensity and duration of emotional experiences, thereby also influencing ER. For example, adults with higher IAcc have been shown to use more putatively adaptive ERS (e.g., Kever et al., 2015; Pinna & Edwards, 2020), but also more maladaptive labeled ERS (Kever et al., 2015; Pinna & Edwards, 2020). Other work on the contrary failed to find any significant association between IAcc and ER, while a greater IS was linked with the use of more adaptive ER (e.g., Schuette et al., 2021). In pre-school children, studies typically found similar associations between IAcc and ER, although overall these were weaker in comparison to the ones emerged in adults, suggesting possible developmental differences (Opdensteinen et al., 2021; Schaan et al., 2019). To our knowledge, only one study was conducted in adolescents, revealing that adolescents with higher IAcc reported to use fewer maladaptive labeled ERS (De Witte et al., 2016). Both IS and IAw have not been studied in relation to ER in healthy youth.

Most of existing work has assessed IAcc using the HCT, which has been questioned to have poor validity. For example, one main concern with the HCT is that enhanced knowledge of one’s heart rate improves the performance on the task (Ring et al., 2015). This contamination by heart rate knowledge may explain previous (non-)significant findings (Murphy et al., 2018). To address this issue, modified instructions have been proposed with the goal to limit the effects of prior knowledge (Desmedt et al., 2018). With adapted instructions, it is made explicit to participants that they should only report what they feel, and not use strategies to guess their number of heartbeats. It was found that IAcc scores were significantly lower when using adapted instructions (Desmedt et al., 2018). Modifications to the HCT instructions could therefore limit the influence of prior knowledge (Desmedt et al., 2020), reducing the likelihood that results are explained by this bias.

The Present Study

Current research suggests that individual differences in interoception may relate to different emotional processes, such as emotional awareness and ER (e.g., Tan et al., 2023). However, little is known about interoception and emotion during adolescence, a period marked by profound hormonal, neurobiological, and physical changes that may affect the strength of this association (Dahl et al., 2018). Moreover, most previous studies have used the original HCT which is known to have validity issues. Therefore, the present study aimed to examine the associations between interoception, emotional awareness, and ER in adolescents by administering an adapted version of the HCT (i.e., participants were encouraged to only report felt heartbeats). This adapted version is meant to reduce the influence of guessing strategies. It was hypothesized that adolescents with higher levels of IAcc, IS, and IAw would show higher degrees of emotional awareness, more usage of adaptive ERS, and less usage of maladaptive ERS (De Witte et al., 2016; Pinna & Edwards, 2020; Tan et al., 2023).

Method

Participants

A total of 102 adolescents aged between 13 and 16 years (50 male; M_age = 14.10 years, SD_age = 0.63) participated in the current study. All participants were in their third year of secondary school (54% university track, 32% technical track, 14% vocational track). The majority of the participants lived together with both of their parents (63%). In the current sample, 48.4% of mothers and 47.3% of fathers pursued higher education.

Procedure

All procedures were approved by the Ethical Committee of Ghent University. The current data were collected as part of a larger project aimed at examining ER processes during adolescence. Adolescents provided written assent and their parents signed an informed consent form prior to the start of the study. First, self-report questionnaires were completed online at school. Second, all participants were invited for a baseline lab assessment at their school where electrocardiogram (ECG) was recorded during different tasks. During ten consecutive minutes, participants were asked to sit still and stare at a white fixation cross to allow them to acclimatize to the lab setup in order to assess ECG levels at rest (Zisner & Beauchaine, 2016). Next, participants conducted the HCT. At the end of the lab visit all electrodes were removed.

Psychophysiological Measurements

Electrocardiogram

ECG was collected at a sampling rate of 1000 hz with the Porti 16-channel-amplifier (TMSi, Twente Medical Systems International, EJ Oldenzaal, The Netherlands) and the software Polybench 1.2 (TMSi). ECG 55-mm diameter Ag/AgCl gel electrodes were placed on the right upper sternum and lowest rib on the left side (Lead-II), with the ground electrode fixed over the dorsum of the wrist by using a wristband. The ECG recordings were processed in ANSLAB (Blechert et al., 2016), a computer program written in Matlab. First, R-peaks were detected via ANSLAB, and settings to improve R-peak detection were adjusted if needed. Second, all recordings were visually inspected to correct for occasional misdetections of R-peaks and other artifacts. Heart rate was first calculated using 60-s epochs; subsequently, a total heart rate score for the baseline task was computed by averaging across 60-s epochs (to include as covariate). This resulted in an average heart rate score for the baseline period (6 minutes). Note that to increase the reliability of the baseline period only the middle 6 minutes (out of 10) were used for the analyses to ensure that participants were habituated to their surroundings and to account for possible boredom effects (M_heartrate = 82.02, SD_heartrate = 12.88, range = 57–116) (Zisner & Beauchaine, 2016). The number of heart beats was extracted for the different trials to calculate participants’ IAcc.

Interoceptive Accuracy

In line with previous work, the HCT was used as a measure of IAcc according to the mental tracking method (Schandry, 1981; Schuette et al., 2021). During this task participants were instructed to count their heartbeats in the interval between two auditory signals; while recording heart beats with ECG. Participants were explicitly instructed not to guess or count seconds, but to report what they actually felt (Desmedt et al., 2018). If they did not feel any heartbeat, they were asked to report zero. Participants completed a practice trial of 20 seconds followed by six experimental trials (25, 35, 45, 35, 45, 25 seconds). Adolescents received no information concerning the length of each trial interval. Following each trial, participants had to indicate how many heartbeats they counted. After each trial, participants received a break. Consistent with previous work (e.g., Schuette et al., 2021) IAcc was calculated as follows:

\frac{1}{6} \sum [1 - (\frac{| ECG recorded heartbeats | ‐ | participant counted heartbeats |}{ECG recorded heartbeats})]

IAcc scores range from 0 to 1, with higher scores indicating better IAcc. After completion, it was explicitly asked whether participants counted the time to guess their heartbeats; no participant reported counting the time or guessing their number of heartbeats.

Interoceptive Sensibility

At the end of each trial, participants were asked to rate how confident they were about their performance on each counting trial. This procedure has been used in prior work to calculate confidence in one’s own interoceptive capabilities, specifically related to the heart-domain of interoception (e.g., De Witte et al., 2016; Garfinkel et al., 2015). Participants had to rate their confidence for each counting trial by selecting a number on a scale of 1 (not sure at all) to 9 (very sure). IS was calculated by averaging the confidence rating across the experimental trials.

Interoceptive Awareness

IAw is related to the correspondence between IAcc and IS and can be calculated by computing the within-person correlations between IAcc and IS (Garfinkel et al., 2015). A high IAw refers to the ability of an individual to know when they are making a correct decision (Garfinkel et al., 2015). The objective (IAcc) and subjective score (IS) of interoception can correlate positively, suggesting a good correspondence between what one believes at the subjective level and the objective performance. However, they can also be negatively or poorly correlated reflecting a weak correspondence between both the subjective and objective dimension.

Questionnaires

Emotional Awareness

The “Awareness” scale of the Difficulties in ER Scale (DERS; Gratz & Roemer, 2004) was used to assess emotional awareness. This six-item subscale measures individual’s attention to and awareness of their emotional experiences (e.g., “I pay attention to how I feel”). Participants had to indicate how often each item applied to their current situation by rating a 5-point Likert scale ranging from 1 (“almost never”) to 5 (“almost always”). Higher scores indicated higher degrees of emotional awareness. The validity and reliability of the DERS emerged to be good in adolescent samples (Van Beveren et al., 2019). In the present study, Omega Total was .93.

Emotion Regulation

ERS were examined using the validated Dutch version of the FEEL-KJ (Cracco et al., 2015), a self-report measure including 15 ERS in response to anxiety, anger and sadness in youth (9–19). The questionnaire consists of 90 items, each item was rated on a five-point Likert scale ranging from 1 (“almost never”) to 5 (“almost always”). A distinction can be made between a range of putatively adaptive (e.g., distraction; I do something I enjoy), maladaptive (e.g., suppression; I keep my feelings to myself) and external ERS (e.g., social support seeking; I go to someone who might be able to help me). In the current study, the total scores of maladaptive and adaptive ERS were included in the analyses. The FEEL-KJ has good psychometric properties (e.g., Cracco et al., 2015). In the present study, Omega Total (=.97) for the total adaptive ERS, and Omega Total (=.93) for the total maladaptive ERS were excellent.

Covariates

We adjusted for a number of covariates in the main analyses, including participants’ gender (as assigned by birth), age, mean heart rate, body mass index (BMI), and pubertal status (Petersen et al., 1988). Information about weight and height was retrieved via self-report. The pubertal status of the participants was assessed using the Pubertal Development Scale (Petersen et al., 1988).

Data Analytic Approach

A priori power calculations were conducted in G-Power (Faul et al., 2007) to determine the required sample size to detect significant effects for a regression with three independent variables (i.e., IAcc, IS and IAw), assuming a medium effect (.50), power = .80, and alpha = .05. The minimum sample size was 73 participants. Participants were over-recruited to allow incomplete data, noisy ECG data, and the potential to include covariates.

First, model assumptions to conduct linear regression analyses were evaluated. To start, the skewness of the residuals was calculated and visually inspected; skewness values were acceptable, ranging from −.34 to 1.52, across difference models. Variance Inflation Factor (VIF) scores were below 10 in all cases, indicating the absence of multicollinearity (all VIF <1.51). Outliers were winzorised to 3 standard deviations above or below the mean; this resulted in the winzorisation of 2 outliers for IAw and 1 outlier for BMI. Next, descriptive statistics and correlations were calculated between the main study variables. Finally, to test the main study hypotheses, three hierarchical linear regression models were fitted, one with emotional awareness, one with adaptive ERS, and one with maladaptive ERS as dependent variable. In a first step, each model included simultaneously all three interoception dimensions as independent variables. In a second step, all covariates were added (i.e., gender, age, mean heart rate, and BMI). Covariates were entered in the second step to investigate whether the effects of the predictors held also after accounting for gender, age, mean heart rate, and BMI.

Results

Descriptive statistics and correlations

Descriptive statistics (means and standard deviations) of the main study variables are summarized in Table 1. There were no significant correlations between the interoception indexes and neither emotional awareness nor ER.

Table 1.

Descriptive Statistics (Mean and SD) and Correlational Analyses.

Variable	1	2	3	4	5	6
1. Emotional awareness	-
2. Adaptive strategies	.32**	-
3. Maladaptive strategies	.09	−.10	-
4. Accuracy (IAcc)	.08	.01	.05	-
5. Sensibility (IS)	.06	−.03	.08	.65**	-
6. Awareness (IAw)	.15	.12	−.01	−.40**	−.33**	-
M	17.18	124.18	73.56	.34	3.32	.43
SD	5.78	33.03	21.13	.27	1.82	.55

**p < .01.

Interoception, emotional awareness and emotion regulation

An overview of all linear regression models can be found in Table 2. None of the models revealed statistically significant associations between any of the interoception dimensions and emotional awareness, adaptive ERS, or maladaptive ERS. These results were unchanged after adding the study covariates (all p > .06).

Table 2.

Results of Linear Regression Models Predicting Emotional Processes by Interoception Dimensions.

	Awareness				aER				mER
	B	SE	p	R ²	B	SE	P	R ²	B	SE	p	R ²
Step 1				.03				.02				.02
IAcc	−.02	3.39	.89		−.06	18.12	.68		−.12	11.46	.38
IS	−.04	.49	.80		.01	2.64	.94		.14	1.67	.31
IAw	.14	1.39	.28		.11	7.44	.39		−.06	4.71	.63
Step 2				.13				.17				.16
IAcc	.02	3.65	.89		−.05	19.52	.76		−.07	12.44	.66
IS	.06	.52	.69		.05	2.77	.71		.25	1.77	.08
IAw	.18	1.43	.17		.12	7.65	.37		.02	4.87	.90
Gender	.21	1.52	.11		.04	8.10	.77		.31	5.16	.02
Age	−.07	1.25	.52		−.17	6.67	.14		−.05	4.25	.68
Mean HR	−.04	.05	.76		.11	.29	.40		−.01	.18	.92
BMI	−.22	.23	.08		−.31	1.24	.01		.12	.79	.32
Puberty	.25	1.23	.06		−.03	6.56	.84		.09	4.18	.50

Note. aER = Adaptive emotion regulation; mER = Maladaptive emotion regulation; IAcc = Interoceptive accuracy; IS = Interoceptive sensibility; IAw = Interoceptive awareness; HR = Heart rate; BMI = Body mass index; Gender = as assigned at birth (0 = boy, 1 = girl).

Exploratory analyses

For exploratory purposes we examined the moderating role of gender in the relationship between the interoception dimensions and emotion measures. Overall, we failed to find any significant interaction effect (all p > .14).

Discussion

Interoceptive processes have been extensively investigated in adult populations, as they may have important connections with emotional awareness, ER, and psychopathology (Garfinkel et al., 2015; Kever et al., 2015; Schuette et al., 2021; Tan et al., 2023). Yet, research on interoception in youth is still in its infancy. In the current study, three interoception dimensions (i.e., IAcc, IS and IAw), assessed with the HCT with adapted instructions, were found not to be related to adolescents’ levels of emotional awareness, adaptive, and maladaptive ERS.

The current findings are not in line with prior work demonstrating positive associations between interoception, emotional awareness, and ER both in adults as well as in one study conducted among adolescents (De Witte et al., 2016; Pinna & Edwards, 2020). However, it should be noted that more recent work in adults also failed to find associations between the accuracy and awareness interoception dimensions and emotional awareness, and ER (e.g., Schuette et al., 2021). Moreover some studies in children also failed to find statistically significant effects (Opdensteinen et al., 2021; Schaan et al., 2019). We hypothesized that these previous inconsistencies could be due to the contamination of HCT performance by guessing strategies. By relying on adapted instructions, we expected that these associations would emerge; however, our hypothesis was not confirmed.

There are several developmental differences that may explain the current null-findings. First, the prefrontal cortex, which is crucial for higher-order cognitive functions such as sustained attention, metacognition, and executive functions, continues to develop throughout adolescence (Silvers, 2022). This ongoing development affects both interoception and ER. First, specific regions of the prefrontal cortex, like the ventromedial prefrontal cortex (VMPFC), are directly involved in interoception and emotional abilities. For example, the VMPFC are activated during the evaluation of emotional and bodily states (Terasawa et al., 2013). Second, recent work has also revealed that the effectiveness of more cognitively demanding ERS, such as cognitive reappraisal, during adolescence may relate to the maturation of these prefrontal regions (Schweizer et al., 2020; Silvers, 2022). Consequently, adolescents’ ER abilities are not fully developed, impacting their capacity to manage emotional responses effectively (Sahi et al., 2023; Schweizer et al., 2020). Thus, because of this ongoing maturation and the fact that recruitment of the prefrontal regions continues to increase until late adolescence (Silvers, 2022), adolescents may have not fully developed yet their abilities to engage in complex cognitive processes, such as those involved in interoception assessments. Prior work examining Heartbeat Evoked Potentials (HEP), which is thought to reflect cortical processing of cardiac information, provided some evidence in support of this hypothesis (Kamp et al., 2021). Specifically, in older adults a stronger representation of cardiac activity was observed at rest in comparison with younger adults, suggesting a higher level of interoception in older adults (Kamp et al., 2021). Similarly, prior work with functional magnetic resonance imaging (fMRI) revealed that children and adolescents use similar brain regions when conducting the HCT (i.e., left insula, prefrontal regions), but age emerged to be associated with more activation within these brain regions (Adolfi et al., 2017; Klabunde et al., 2019).

Second, adolescents go through substantial physical bodily changes, which as a consequence can result in feelings of dissatisfaction or disconnection with the body (Bijsterbosch et al., 2023). Because of these reasons, adolescents might be less able to engage in interoception tasks. Importantly, the age range in the current study is limited to 13–16 years. We can thus not generalize the current results to other age groups and, given the relatively narrow age range, we could not test whether age was a moderator of the relationship between interoceptive abilities and ER. Future research endeavors would benefit from stratifying participants based on developmental stage or adopting longitudinal methodologies to examine age effects.

An alternative explanation for our null findings could be related to the methodology used in the current study. First, different self-report questionnaires were used to assess emotion constructs. As previous work has mainly been conducted in adult populations, we considered the replication of prior findings with self-report as a first crucial step. Self-report questionnaires can be a useful tool for collecting data on individuals’ cognitions, emotions, and behaviors, but they also suffer from response biases due to social desirability, limited insight, recall bias, and low ecological validity (Paulhus & Vazire, 2007; Podsakoff et al., 2003). Therefore, researchers should move away from the sole use of self-report questionnaires and consider complementing these with other methods to increase the validity and reliability of their assessments (e.g., physiological measures or task measures of ER; see Coifman et al., 2021). Furthermore, adopting a flexible perspective on ER, rather than a simplistic categorization of ERS as adaptive or maladaptive, seems critical to further elucidate the specific relationship between interoception and ER (Bonanno & Burton, 2013). Flexible frameworks of ER indicate that the effectiveness of ERS can vary based on situational factors and personal characteristics, highlighting the importance of a more nuanced understanding of these processes (Bonanno & Burton, 2013).

Second, we relied on cross-sectional data, which provides a snapshot of data collected at a single point in time. While cross-sectional studies offer valuable insights into associations between variables at a specific moment, they do not allow for the examination of changes or trends over time. Therefore, temporal sequences cannot be established, limiting our ability to draw definitive conclusions about the directionality of relationships between variables. Future research employing longitudinal designs would be beneficial to better understand the dynamic nature of these associations and provide stronger evidence for causal inference.

Finally, the HCT might still suffer from validity issues even under adapted instructions. First, although previous adult studies have shown that adapted instructions of the HCT were effective in reducing the influence of guessing strategies (Desmedt et al., 2020), we cannot ascertain that it was effective in our adolescent sample. Our post-task question indicates that no participants tried to guess their heart rate to perform the task, but we did not test the influence of guessing strategies through other (more objective) means (e.g., time estimation). Second, the HCT still suffers from the contamination by response bias (Corneille et al., 2020). Most participants tend to underestimate their actual number of heartbeats, so adolescents who report a higher number of heartbeats because they have a liberal response bias (vs. higher detection ability) appear to perform better. Third, HCT performance may also be contaminated by cardiac signal intensity (Corneille et al., 2020). Stronger signals are easier to detect, therefore, participants with stronger heartbeats may achieve higher HCT performance, independently of their cardiac detection capacity. Adolescence involves physiological changes, including in cardiovascular function (e.g., heart rate decreases during adolescence and body fat increases with age), that might affect cardiac signal clarity and interoceptive performance (Harteveld et al., 2021; Koenig, 2020; Yang et al., 2021). Additionally, adolescents have smaller hearts than adults due to their body size (Dallaire & Sarkola, 2018). Consequently, their cardiovascular system generates less mechanical energy compared to that of adults (Dini et al., 2013). These developmental and individual variations might influence interoceptive abilities, with stronger cardiac signals aiding ER and weaker signals potentially leading to challenges. More work is needed to study individual differences in cardiac signal intensity in adolescent samples.

These HCT validity issues may also have impacted our measures of IS and IAw which are based on this task. First, regarding IS, prior work found that when IS was assessed using a self-report questionnaire, it positively correlated with emotional awareness and ER (Schuette et al., 2021). Therefore, the absence of significant findings may also be attributed to the conceptualization of IS as a confidence rating from the HCT within this study, rather than IS assessed through a trait questionnaire. Of note is that recent work has indicated that these methods capture distinct constructs and should not be directly compared (MacCormack et al., 2023). One explanation is that confidence ratings from the HCT may represent a momentary state of IS, providing insight into how accurately an individual perceives their interoceptive signals in a specific context and at a particular time. In contrast, self-report questionnaires assess trait IS, which is a more stable and enduring characteristic of an individual’s interoceptive abilities over time and across various situations. Additionally, confidence ratings may be influenced by factors such as task difficulty perception or task novelty. For example, if participants find the HCT particularly challenging or unfamiliar, their confidence ratings may be lower, not necessarily because of poor interoceptive ability but due to these extraneous influences. Further research is warranted to assess the reliability of an IS index derived from confidence ratings (MacCormack et al., 2023). Second, regarding IAw, within-person correlations were calculated to capture IAw based on prior recommendations (Garfinkel et al., 2015). However, it has been argued that 30 observations of IAcc and IS are needed to reliably calculate within-person calculations (Fraenkel et al., 2012). Therefore, future work should study these relationships with other measures of IAw (e.g., receiver operating characteristic analysis with binary data) or within-person correlations with more data points.

Although many limitations of the HCT have been highlighted in literature, it should also be noted that a recent review of interoception tasks suggested that many new tasks also suffer from various limitations (Desmedt, Luminet, Walentynowicz, & Corneille, 2023). Specifically, some cardiac tasks seem too difficult to perform for most participants, making them poorly suited for adolescents who may still develop cognitive abilities. Given the current lack of interoception tasks with strong validity, it is crucial for future research to focus on developing novel tasks that are suitable for adolescents. This will ensure more accurate assessments of interoception.

In sum, our findings indicate no clear associations between three dimensions of interoception (IAcc, IS, IAw), trait emotional awareness, and trait ER in adolescents. The absence of significant findings in the present study urges a reassessment of the methodologies employed to investigate these constructs during adolescence. Future endeavors should prioritize enhancing measurement validity, exploring potential moderating effects, and recognizing the diverse characteristics within the adolescent population. These endeavors are essential for advancing our understanding of the complex interplay between interoception and emotional processes during this critical developmental period.

Footnotes

Author Contributions

All authors contributed to the study conception and design, as well as the material preparations. Data collection and analyses were performed by J.B. The first draft of the manuscript was written by J.B. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Jolien Braet was supported by funding from the Bijzonder Onderzoeksfonds UGent (BOF) Grant agreement No. (BOF20/DOC/015). Matteo Giletta was supported by funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation program Grant agreement No. (853517). Olivier Desmedt is a Post-Doc supported by funding from the Swiss National Science Foundation (SNSF).

Ethical Statement

ORCID iD

Jolien Braet

Data Availability Statement

Data will be made available after publication on the Open Science Framework (OSF).*

Author Biographies

Jolien Braet is a PhD candidate in the Department of Developmental, Personality, and Social Psychology at Ghent University, Belgium. Her research primarily focuses on emotion, developmental psychology, and clinical psychology.

Matteo Giletta is a Professor in the Department of Developmental, Personality, and Social Psychology at Ghent University. He earned a joint PhD in Social Sciences and Developmental Psychology from Radboud University (the Netherlands) and the University of Turin (Italy) in 2012. His research centers on adolescent peer relationships, with a particular emphasis on biological processes, such as inflammation, to better understand the link between peer experiences and youth mental and physical health.

Olivier Desmedt is a postdoctoral researcher in the Institute of Psychology at the University of Lausanne, Switzerland. He obtained his PhD in 2022 from the Université Catholique de Louvain. His main research interest lies in the field of interoception, particularly in exploring different objective measures of this construct.

Laura Wante is a Professor in the Department of Developmental, Personality, and Social Psychology at Ghent University. She received her PhD from Ghent University in 2017. Her primary research focuses on emotion, cognitive psychology, developmental psychology, and clinical psychology.

Lorenz Rapp has been working as a research assistant in the Department of Clinical and Health Psychology at Ulm University since October 2022. His research spans the fields of health psychology, biological psychology, and clinical psychology.

Olga Pollatos is a Professor and head of the Department of Clinical and Health Psychology at Ulm University. She completed her PhD in 2004 at LMU Munich, specializing in emotions and cortical functions. Her research currently focuses on emotion, health psychology, and cognitive neuroscience.

Caroline Braet is a Professor in the Department of Developmental, Personality, and Social Psychology at Ghent University. She earned her PhD in 1993, with a specialization in the psychological aspects of childhood obesity. Her research focuses on emotion, abnormal psychology, developmental psychology, and clinical psychology.

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