Affect Consciousness in children with internalizing problems: Assessment of affect integration

Abstract

Affect integration was operationalized through the Affect Consciousness (AC) construct as degrees of awareness, tolerance, nonverbal expression and conceptual expression of 11 affects. These aspects are assessed through a semi-structured Affect Consciousness Interview (ACI) and separate rating scales (Affect Consciousness Scales (ACSs)) developed for use in research and clinical work with adults with psychopathological disorders. Age-adjusted changes were made in the interview and rating system. This study explored the applicability of the adjusted ACI to a sample of 11-year-old children with internalizing problems through examining inter-rater reliability of the adjusted ACI, along with relationships between the AC aspects and aspects of mental health as symptoms of depression, symptoms of anxiety, social competence, besides general intelligence. Satisfactory inter-rater reliability was found, as well as consistent relationships between the AC aspects and the various aspects of mental health, a finding which coincides with previous research. The finding indicates that the attainment of the capacity to deal adaptively with affect is probably an important contributor to the development of adequate social competence and maybe in the prevention of psychopathology in children. The results indicate that the adjusted ACI and rating scales are useful tools in treatment planning with children at least from the age of 11 years.

Keywords

Affect Consciousness affect integration treatment planning children internalizing problems

Affect integration defined as the functional integration of affect, cognition and behaviour, is an essential aspect of mental health (Solbakken, Hansen, Havik, & Monsen, 2011). The concept refers to the capacity for utilizing the adaptive properties of discrete affects for personal adjustment. Thereby the concept reflects both processes by which affects or emotions themselves are regulated and processes by which affects serve as regulators of other domains of functioning, that is, reasoning, decision-making, goal-directed action and so on. Central aspects of affect integration can be described with reference to the concept of emotion regulation. Emotion regulation in its most common usage focuses on the processes by which affects themselves are regulated, but is not concerned with processes by which affects regulate other domains of functioning (Izard, Stark, Trentacosta, & Schultz, 2008; but see especially Gross, 2007, for a clear statement of this position). Affect integration, on the other hand, reflects both domains in equal proportion. Less mainstream perspectives on emotion regulation do include processes by which emotions regulate other functions. One example has been proposed by Cole and Deater-Deckard (2009). These alternative perspectives on emotion regulation correspond quite well conceptually with the construct domain represented by affect integration, in that both perspectives include the capacity to be aware of discrete positive and negative affects, to modulate the intensity and duration of affects, to adaptively utilize the motivational and signal properties of affects and to maintain and express affects congruently with contextual demands. These aspects have been operationalized through the Affect Consciousness (AC) construct (Monsen, Eilertsen, Melgard, & Odegard, 1996; Solbakken, Hansen, Havik, & Monsen, 2011). However, one important distinction between affect integration and emotion regulation, even when comparing with broader models of emotion regulation, is the highly differentiated nature of the affect integration construct in terms of distinguishing systematically between affects.

Affect integration as defined through the AC construct

AC is defined as the individual’s capacity to consciously perceive, tolerate, reflect upon and express the experiences of basic affective activation (Monsen et al., 1996; Solbakken, Hansen, Havik, & Monsen, 2011, p. 257). These aspects of AC are operationalized as degrees of awareness, tolerance, emotional (nonverbal) expressivity and conceptual (verbal) expressivity for discrete affects (Monsen & Monsen, 1999). For assessment of AC, a semi-structured interview was developed for use with adults (the Affect Consciousness Interview (ACI)). Interviews are transcribed and responses to the interview questions are scored by means of separate observer-based rating scales, one for each of the four integrating aspects (awareness, tolerance, emotional and conceptual expression) across various affects (the Affect Consciousness Scales (ACSs); Monsen et al., 1996). The most recent version of the ACI includes scales that propose to measure 11 affect constructs: (1) Interest/Excitement, (2) Enjoyment/Joy, (3) Fear/Panic, (4) Anger/Rage, (5) Shame/Humiliation, (6) Sadness/Despair, (7) Envy/Jealousy, (8) Contempt/Condescension, (9) Disgust/Revulsion, (10) Guilt/Remorse and (11) Tenderness/Care/Devotion.

These affects are regarded as biologically founded responses with an evolutionary basis. Variations in the subjective experience of affects presumably depend on the individual’s developmental history and formative experiences and mental representations organizing affective life. Individualized patterns of organizing one’s affective experience (scripts) gradually become automatic and operate mostly on an unconscious or preconscious level (Monsen & Monsen, 1999; Solbakken, Hansen, Havik, & Monsen, 2011; Tomkins, 1995). The ACI and ACSs assess the levels of affect integration, and hence the quality of an individual’s organization of affective experiences or scripts. This information is highly relevant for planning and evaluating treatment. The ACI and ACSs exhibit good psychometric properties in studies with adult samples (Gude, Monsen, & Hoffart, 2001; Monsen et al., 1996; Monsen & Monsen, 2000; Solbakken, Hansen, Havik, & Monsen, 2011; Waller & Scheidt, 2004).

The Affect Consciousness Interview for Children

However, there has been no prior investigation into the appropriateness and relevance of the ACI with school-age children or youth. The goal of this study is to explore whether the AC construct through an adapted version is useful in research and clinical work with children. Corresponding and related capacities to those measured in the ACI are included in some other assessment instruments for children. For example, the Kusche Affective Interview–Revised (Cook, Greenberg, & Kusche, 1994; Greenberg, Kusche, Cook, & Quamma, 1995) measures emotional understanding and experience, including ability to provide personal examples of different emotions and site cues used for recognition of emotions in oneself and others, besides ability to discuss issues regarding potential simultaneity of emotions, display rules for emotions and whether and how emotions change.

Nevertheless, to our knowledge, only the ACI is specifically designed for examining affect integration through rating the child’s own descriptions of both experiencing abilities (awareness, tolerance/reflection) and expressive abilities (emotional expressivity, conceptual expressivity) across a number of discrete affects related to the child’s descriptions of personally relevant scenes. The information gathered with an adapted version of the ACI may be highly relevant for understanding clinical phenomena, especially with respect to treatment planning at least when considering children 11 years of age or older.

Emotional development and AC

Theoretically, the ACI measures aspects of the organization of affective experience that are central for both development of psychopathology and for general emotional development, for example, the ability to distinguish emotional experiences and cognitively differentiate and integrate conflicting emotional states. In normal development through the elementary school age (6 years to 12–13 years), children attain an increased ability to identify and differentiate emotional experiences (Carroll & Steward, 1984; Harris, Olthof, & Terwogt, 1981). They also attain an increasing ability to cognitively differentiate and integrate opposite and conflicting feelings (Donaldson & Westerman, 1986; Harter & Whitesell, 1989). In turn, this increased integration generates an understanding that conflicting affects may be simultaneously present and influence each other, besides being influenced by prior experiences (Donaldson & Westerman, 1986; Harter & Buddin, 1987; Harter & Whitesell, 1989). This structure of emotional experience is presumably fundamental to affective reflective capacity, normally attained at about 10 to 11 years of age (Donaldson & Westerman, 1986; Harter & Buddin, 1987; Harter & Whitesell, 1989). These normal changes in mental capacities through elementary school age represent capacities measured by the ACI. Similarly, disturbances in these capacities in the form of ambivalent and conflicting experience, expression and behaviour that may reside outside of the child’s awareness and semantic representational world are reflected in the ACI and corresponding rating scales.

Affect integration, mental health and psychological functioning

When we intend to study AC in school-aged children and its relationship with other indicators of mental health (social competence and psychopathology, besides IQ), it is reasonable to expect similar findings as those found in previous studies. Both in studies on adults with mental disorders (Gude et al., 2001; Monsen et al., 1996; Solbakken, Hansen, Havik, & Monsen, 2011; Waller & Scheidt, 2004) and in a number of previous studies on children using other instruments (Bohlin & Hagekull, 2009; Cook et al., 1994; Penza-Clyve & Zeman, 2002; Rieffe, Oosterveld, Miers, Terwogt, & Ly, 2008; Suveg & Zeman, 2004), relationships were found between capacity for affect integration and different facets of social competence and psychopathology. However, it is not obvious how AC scores are related to intelligence, as there are no previous studies reporting on the topic. Meanwhile, there are studies on the related concept of emotional intelligence (EQ) and IQ in both youth and adults, respectively (Mayer, Salovey, Caruso, & Sitarenios, 2001), where EQ is defined as emotional perception, use of emotion to facilitate thought, understanding of emotion and managing of emotion, concluding that EQ is moderately and positively related to scores on verbal tasks (Marquez, Martin, & Brackett, 2006), but not related to scores on performance tasks or the general intelligence level (Derkson, Kramer, & Katzko, 2002). As there are significant conceptual similarities between EQ and AC, comparable findings can be expected for AC and intelligence.

Research questions

This study is a first attempt at exploring the ACI and ACSs in use with school-aged children in what we hope will be a greater research venture examining AC in samples of referred and non-referred children at different ages and in clinical samples of children with different types of mental disorders. The study aims to explore the applicability of the age-adjusted ACI to a clinical sample of 11-year-old children with internalizing problem behaviour in terms of the following questions: (a) Can the ACI and ACSs yield reliable scores when applied to children 11 years of age or older? (b) Are there clinically significant associations between AC scores and various external indicators of mental health and functioning, such as symptoms of depression and anxiety, social competencies and level of general intelligence?

Based on previous research and theoretical conjecture, we expect that AC scores on all levels of specificity will correlate positively with Social Competence scales and negatively with Symptom scales. AC and Verbal IQ (VIQ) are expected to be positively related, while General and Performance IQ (PIQ) are not expected to be systematically related to AC scores.

Method

Participants

The sample consisted of 30 children, 13 girls and 17 boys, referred to an outpatient unit for child and adolescent psychiatry. Criteria for study inclusion comprised the following: age 11 years; referred for anxiety/phobia, depression and somatic complaints; and normal intelligence (based on school-functioning and IQ scores over 70). Criteria for exclusion were externalizing problem behaviour, psychotic symptoms, attention-deficit hyperactivity disorder (ADHD)/hyper-activity, severe language deficits or lacking proficiency in the Norwegian language or severe registered somatic disease. Different types of internalizing problem behaviour were selected as inclusion criteria in part to avoid too much variation in problem types, possibly characterized by quite different patterns of affect organization, and in part to provide sufficient variability to render hypothesized relationships statistically detectable.

Besides the 30 children, 29 of the mothers, 27 of the fathers and 28 of the children’s primary teachers, of whom 25 were female, participated in the study with observer ratings of the children. The mean age of the children was 11.5 years. Seven of the children (23.3%) had anxiety disorders, one (3.3%) had a disorder of mixed compulsive thoughts and compulsive behaviour, one (3.3%) had a depressive disorder, 10 children (33,3%) had mixed anxiety disorders and depressive disorders, eight (27.7%) had other specific emotional disorders typical in childhood, two (6.7%) had other specific mixed behavioural disorders and emotional disorders, and one (3.3%) had no diagnosis on axis I according to diagnostic criteria in the International Classification of Diseases (ICD)-10 Classification of Mental and Behavioural Disorders (World Health Organization, 1992). Regarding ‘specific mixed behavioural disorders and emotional disorders’, this diagnosis is rather commonly used within the Norwegian clinical tradition to characterize emotional states and behaviour with much in common with internalizing problem behaviour and does not comprise emotional states and behaviour corresponding with externalizing conditions. A child who did not satisfy criteria for any axis I diagnosis was included on account of relatively disturbing symptoms of fear in relation to a specific frightening event. The symptoms experienced by this child were considered to be in line with the inclusion criteria. All socio-economic groups were represented; 40.4% of the mothers and 55.5% of the fathers had completed postsecondary education.

Procedure

The data collection was a cooperation between two outpatient departments for child and adolescent psychiatry. The age of 11 years was selected on basis of correspondence between the level of emotional and cognitive development normally attained at this age according to developmental research and theory (Donaldson & Westerman, 1986; Harter & Whitesell, 1989) and the demands posed by the questions in the ACI. Two trained therapists employed by the clinics and engaged in the study, included patients and parents in the project and administered the ACI and questionnaires. Assessment of intelligence was done by a psychologist licensed for using the Wechsler Abbreviated Scales of Intelligence (WASI), (Brager-Larsen, 2001). Diagnoses were generated through discussions and consensus in the psychiatric team according to the ICD-10 (World Health Organization, 1992). Participation was based on written consent from the parents. Approval for the study was given from the Regional Committee for Medical and Health Research Ethics.

Assessments and measures

The Affect Consciousness Interview for Children

The Affect Consciousness Interview for Children (ACI-C) is designed to assess integration of 10 affects (shown in Table 2). As in the ACI for adults, the interview for children explores the five aspects for each of the discrete affects: (1) Scenes, (2) Awareness, (3) Tolerance, (4) Emotional Expressiveness, and (5) Conceptual Expressiveness:

Scenes refer to the eliciting stimuli or context associated with activation of the affect in question (Tomkins, 1978).

Awareness, including attention to and recognition of the bodily and mental cues associated with becoming aware of affects.

Tolerance, referring to (a) affect impact, that is, the effects of affective activation on the individual; (b) affect coping, that is, voluntary and involuntary strategies for dealing with and managing affect; and (c) signal function, that is, the capacity for utilizing affect signals, both on a phenomenal, intentional level, and on a semantic level, as conveyers of meaningful information about the world, self and others.

Emotional (nonverbal) Expressivity, referring to capacity to (a) explicitly admit, own or acknowledge (US:avowe) and (b) display clearly nuanced expressions via bodily posture, tone, pitch of voice and facial expressions.

Conceptual (verbal) Expressivity, referring to capacity to (a) explicitly acknowledge or utter and (b) articulation of clear and nuanced, semantic descriptions of affect (Solbakken, Hansen, & Monsen, 2011, p. 488).

To explore these five integrating aspects for each affect, the respondent is first asked for a scene, in which the individual has experienced the affect in question. Second, based upon the description of a relevant scene associated with a given affect, specific questions are asked about the five integrating aspects. Whether typically developing children were able to understand the questions in the ACI was explored through the pilot study based upon a sample of 10 non-referred children at the age of 10 years. The result of this pilot study showed that the children were able to understand and respond in relevant ways to all questions about the five aspects of affect integration derived for each of the specific affects included in the ACI. The non-referred children’s response to the ACI in the pilot study formed the basis for age-related changes in the interview in accordance with the more concrete thinking in children. Changes implied altering words, including words or sentences, and changing the order of some questions.

Like the non-referred children, their referred peers were also able to understand and respond appropriately and meaningfully to the questions in the age-adapted ACI. Both for non-referred and referred children, it was most appropriate to use three sessions of 45 minutes each to carry out the ACI-C. Questions in the ACI-C with age-adapted changes are shown in Table 1.

Table 1.

Questions in the Affect Consciousness Interview for Children (ACI-C).

Scene(s):

Can you tell me about something that makes you feel (name of affect)?

Awareness:

In what way or where in your body do you notice that you are (name of affect)?

Do you notice or in what way do you notice by your thoughts that you feel (affect name)?

For all aspects: explore couplings with other affects, variations in intensity, close/distant relations.

Tolerance:

Questions about impact: When you are/feel (name of affect), does the feeling continue to be there? If ‘yes’: When you are/feel (name of affect), in what way does the feeling influence your mood/your thoughts?

Questions about affect coping: When you are/feel (name on affect), what do you do with the feeling inside of you? (Auxiliary questions: Do you let the feeling continue to be there or do you push the feeling away? If ‘yes’) Do you think something or what do you think?

(Auxiliary questions: Do you think something about yourself or about other(s), do you want to do something, to yourself or others?)

Emotional Expressivity:

Do you show the feeling to others? If ‘yes;: In what way do you show the feeling to others? In what way do you think that others can see that you are/feel (name of affect)? What is it like for you to show others that you are/feel (name of affect)?

Conceptual Expressivity:

Do you tell others that you are (affect name)? If ‘yes’: In what way do you tell others that you are (affect name)? What is it like for you telling others that you are/feel (affect name)?

The specific questions described above are important to obtain ratable answers. A score of 9 is the highest level, and a score of 1 represents the lowest, while intermediate levels of AC are represented by a score of 5. Each of the 9-point AC scales provides operationalization of scores and is presented in an abbreviated version in Appendix 1 (Monsen & Solbakken, 2009).

External criteria

The measures employed to examine criterion-referenced validity of the AC constructs were the following:

Achenbach’s System for Empirically Based Assessment (ASEBA) (Achenbach & Rescorla, 2001) comprising the Youth Self-Report (YSR) (11 to 18 years), the Child Behaviour Checklist (CBCL) (parent form) and Teacher’s Report (TRF). The Anxious/Depressed subscale (labelled the Anxiety scale in this study) and Withdrawn/Depressed subscale (labelled the Depression scale in this study) were used to assess anxiety and depression in the children. Problems during the last 6 months are rated on a three-point Likert scale from not true (0) to very true or often true (2). Acceptable reliability and validity have been reported for the ASEBA measures (Achenbach, 1991; Achenbach & Rescorla, 2001). Cronbach’s alpha for the Anxious/Depressed scales and Withdrawn/Depressed scales were .84 and .71 on YSR, .84 and .80 on CBCL, besides .86 and .81 on TRF (Achenbach & Rescorla, 2001).

The Social Skills Rating System (SSRS) (Gresham & Elliott, 1990, p. 2) includes child, parent and teacher versions. The Assertion subscale was present in all versions, the Empathy subscale in the child version only and the Responsibility subscale was in the parent version only. Social Skills scales are translated into Norwegian (Ogden, 1995) and are rated on a four-point Likert scale ranging from never (1) to sometimes (2), often (3) and very often (4). In the statistical analysis, we chose the traditional American rating system for the Social Skills Scales, by combining the categories often (3) and very often (4), thus calculating scores on a three-point Likert scale ranging from never (0) to sometimes (1), and often/very often (2) to enable comparison of findings in this study with American samples. Acceptable reliability and validity are reported for the SSRS in a number of studies (Gresham & Elliott, 1990). Cronbach’s alpha for the Assertion scales was .51 in the child version, .74 in the parent version and .86 in the teacher version. For Empathy/Responsibility, Cronbach’s alpha was .74 in the child version and .65 in the parent version, respectively.

WASI (Brager-Larsen, 2001) consists of four subtests: Vocabulary, Block Design, Similarities and Matrix Reasoning. Vocabulary and Similarities comprise the Verbal Scale, yielding VIQ, while Block Design and Matrix Reasoning constitute the Performance Scale, yielding PIQ. Acceptable psychometric properties have been consistently reported for the WASI (The Psychological Corporation, 1999).

Statistical analyses

Inter-rater reliability

The ACI-C was scored by two independent raters who were experienced and proficient in the scoring of the ACI for adults. Inter-rater reliability based upon ACI-C scores was estimated for the whole sample by using intra-class correlation coefficients (ICCs) (2,2) (Shrout & Fleiss, 1979) for the three levels of assessment: Global AC, average mean score on each of the integrating aspects and average mean score on integration of each affect.

Relationships between AC and external criteria, IQ, symptoms of Depression and Anxiety and Social Competence

Pearson’s correlation coefficients with two-tailed tests of significance were used to examine hypotheses about relationships between AC scores on different levels of specificity and scores on Symptom, Social Competence and IQ scales. For all Symptom and Social Competence scales, tests were run for the significance of differences in correlation magnitudes. Cohen’s d was used to calculate the effect size or the magnitude of differences between means on the various AC subscale scores, mean scores on symptoms of Depression and Anxiety, mean scores on Social Competence and mean IQ scores.

Results

Reliability

Inter-rater reliability of the ACI

The mean ICC coefficient for average scores given by two raters (ICC, 2,2; Shrout & Fleiss, 1979) was .88, that is, almost perfect agreement. ICC coefficients ranged from .74 to .92, that is, substantial to almost perfect agreement. The respective ICC coefficients for all scales are shown in Table 2.

Table 2.

Means, SD, range of sum scores of the ACI-C at three levels of specificity.

Variables	Mean	SD	Range	ICC
Overall mean score
Global AC	3.90	.58	2.8–5.4	.92
Integrating Aspects
Awareness	4.56	.61	3.4–5.8	.91
Tolerance	4.63	.67	2.8–5.9	.90
Emotional Exp.	3.27	.59	1.9–4.4	.86
Conceptual Exp.	3.15	.90	1.3–5.4	.92
Specific Affects
Interest/Excitement	4.49	.69	3.0–5.8	.74
Enjoyment/Joy	4.67	1.14	1.0–6.1	.91
Fear/Panic	3.48	.91	1.1–5.3	.90
Anger/Rage	4.11	.58	1.8–5.5	.84
Disgust/Contempt	4.11	.58	3.0–5.1	.84
Shame/Humiliation	3.46	.91	2.1–5.3	.85
Sadness/Despair	3.67	.87	1.9–5.8	.89
Envy/Jealousy	3.36	.89	1.0–5.8	.88
Guilt/Remorse	3.31	.95	1.0–5.3	.91
Tenderness/Care	4.71	1.03	2.4–6.6	.92

ACI-C: Affect Consciousness Interview for Children; ICC: intra-class correlation coefficients.

n = 30.

Inter-rater reliability (ICC) for the ACI-C at three levels of specificity, the ICC scores of average measures across two raters.

Descriptive statistics

ACSs

Table 2 displays mean scores, standard deviations and range of the various scale scores on the ACI-C. The scores on the negative affects (with the exception of Disgust/Contempt and Anger) represented on the group level the lower levels of AC according to the criteria specified in the ACSs, while the scores on the positive affects tended towards the intermediate levels of AC. The magnitude of the differences between the positive and the negative affects yielded a small effect size, d = .21. Also, scores representing the capacity to experience affect (Awareness and Tolerance) indicated levels in direction of intermediate levels of AC, while scores representing the capacity to express affect (Emotional Expressivity and Conceptual Expressivity) indicated lower levels of AC. The magnitude of the difference between these two domains indicated a large effect size, d = 1.60.

External domain measures: IQ, symptoms of Depression and Anxiety and Social Competence

Means and standard deviations on the IQ scales showed normal functioning on group level (Table 3). VIQ < PIQ with a magnitude of the difference showed a medium effect size, d = .57. For the Depression and Anxiety scales, normal distributions were found for all scales in children’s, mothers’, and teachers’ versions, while non-normal distributions were found for all scales in the fathers’ version. Means on the Depression and Anxiety scales were generally within ±1 SD of the mean of the American reference sample for children referred for psychiatric treatment (Achenbach & Rescorla, 2001). The magnitude of the differences between the two means (Depression and Anxiety) showed a large effect size, (d = .81), indicating that the group was substantially more bothered by symptoms of anxiety than depression. Relatively higher mean scores were common for the Social Competence scales (Assertion and Empathy/Responsibility). The scores were generally within ±1 SD of the American normal reference sample (Gresham & Elliott, 1990). The mean difference between the social competence subscales (Assertion and Empathy/Responsibility) yielded a negligible effect size, d = .16.

Table 3.

Means, SD, range of sum scores on Verbal IQ, Performance IQ, Total IQ, Symptoms of Depression and Anxiety, Social Competence: Assertion, Empathy, Responsibility.

Variables	Mean	SD	Range
IQ
Verbal IQ	95.73	13.47	73–137
Performance IQ	104.27	16.46	70–125
Total IQ	99.70	14.20	70–127
Symptoms
Depression, children	3.67	2.50	0–10
Depression, mothers	4.31	2.92	0–11
Depression, teachers	2.54	2.20	0–8
Anxiety, children	8.07	6.34	0–23
Anxiety, mothers	10.86	5.74	1–24
Anxiety, teachers	7.11	5.51	0–23
Social Competence
Assertion, children	14.60	3.05	5–19
Assertion, mothers	15.14	3.27	7–20
Assertion, teachers	12.46	4.35	4–19
Empathy, children	17.63	2.76	10–20
Responsibility, mothers	15.69	2.62	10–20

Relationships between AC and external criteria

ACI-C, VIQ and PIQ and Total IQ (WASI)

Table 4 displays the correlations between ACI-C scores and scores on VIQ, PIQ and Total IQ.

Table 4.

Pearson’s correlations for scores on Global AC, Awareness, Tolerance, Emotional Expressivity, Conceptual Expressivity and 10 specific affects in the ACI-C and scores on IQ (WASI).

Variables	Verbal IQ	Performance IQ	Total IQ
Overall mean score
Global AC	.54**	.08	.35
Integrating Aspects
Awareness	.53**	.07	.33
Tolerance	.46**	.04	.29
Emotional Exp.	.46*	.07	.30
Conceptual Exp.	.40*	.09	.27
Specific Affects
Interest/Excitement	.25	.03	.16
Enjoyment/Joy	.25	.03	.16
Fear/Panic	.12	−.02	.06
Anger/Rage	.53**	.29	.45*
Disgust/Contempt	.08	−.33	−.13
Shame/Humiliation	.65**	.22	.49**
Sadness/Despair	.50*	.18	.38*
Envy/Jealousy	.47**	−.01	.25
Guilt/Remorse	.16	−.13	.01
Tenderness/Care	.41*	−.06	.19

AC: Affect Consciousness; ACI-C: Affect Consciousness Interview for Children; WASI: Wechsler Abbreviated Scales of Intelligence.

Correlation is significant at .01 level (two-tailed); *correlation is significant at .05 level (two-tailed).

p < .05 (two-tailed correlations equal to or greater than .36 were significant at the .05 level of probability). p < .01 (two-tailed correlations equal to or greater than 0.47 were significant at .01 level).

As we expected, positive correlations were found between VIQ and Global AC, mean scores on the four integrating aspects and five specific affects (Anger/Rage, Shame/Humiliation, Sadness/Despair, Envy/Jealousy and Tenderness/Care), while no significant correlations were found between AC scores and PIQ or Total IQ (mean score across VIQ and PIQ).

ACI-C, Depression and Anxiety scales

Table 5 shows correlations between AC scores and scores on the Depression and Anxiety scales from the multi-informant perspective including children’s, mothers’ and teachers’ versions.

Table 5.

Pearson’s correlations for scores on Global AC, Awareness, Tolerance, Emotional Expressivity, Conceptual Expressivity, 10 specific affects in the ACI-C and Scales of Depression and Anxiety.

Variables	Depress. children	Depress. mothers	Depress. teachers	Anxiety children	Anxiety mothers	Anxiety teachers
Overall mean
Global AC	−.52**	−.46*	−.51**	−.26	−.36	−.32
Integrating Aspects
Awareness	−.40*	−.46*	−.30	−.17	−.30	−.18
Tolerance	−.58**	−.44*	−.66**	−.50**	−.52**	−.58**
Emotion Exp.	−.35	−.47*	−.53**	−.23	−.33	−.34
Concept Exp.	−.43*	−.28	−.30	−.04	−.15	−.07
Specific Affects
Interest/Excitement	−.41*	−.31	−.45**	−.16	−.36	−.46**
Enjoyment/Joy	−.55**	−.62**	−.59**	−.34	−.52**	−.30
Fear/Panic	−.28	−.14	−.01	−.00	.19	.37*
Anger/Rage	−.33	−.26	−.09	−.37*	−.41*	−.19
Disgust/Contempt	−.32	−.39*	−.40*	−.23	−.19	−.13
Shame/Humiliation	−.24	−.25	−.20	−.07	−.19	−.34
Sadness/Despair	−.43*	−.07	−.43*	−.25	−.11	−.23
Envy/Jealousy	−.23	−.36	−.20	−.01	−.15	−.20
Guilt/Remorse	−.11	−.28	−.36	.23	−.11	−.08
Tenderness/Care	−50**	−36	−.62**	−.49**	−.49**	−.57**

AC: Affect Consciousness; ACI-C: Affect Consciousness Interview for Children.

Correlation is significant at .01 level; *correlation is significant at .05 level (two- tailed).

For the Depression scale, significant negative correlations were found between Global AC and these scale scores in children’s, mothers’ and teachers’ versions, but not in the fathers’ version (which ratings of their children’s level of depression were unrelated to all AC scores). A similar pattern of correlations was found between three of the four integrating AC aspects (Awareness, Tolerance and Emotional Expressivity), and the Depression perspectives, though with two exceptions for Awareness and Emotional Expressivity, respectively. For integration of specific affects, the correlation pattern revealed significant negative correlations between Interest/Excitement, Enjoyment/Joy, Tenderness/Care and seven out of nine possible perspectives on the Depression scale as rated by children, mothers and teachers. Unlike the pleasant affects, the unpleasant ones showed fewer significant correlations with the Depression scales – only Sadness/Despair and Disgust/Contempt showed significant correlations as rated by children and teachers, and by the mothers and teachers, respectively.

As compared to the relationships detected between AC scores and the Depression scales, there were fewer associations with the Anxiety scales. Tolerance was the only integrating aspect showing significant correlations with the Anxiety scales, and this AC aspect was related to anxiety in children’s, mothers’ and teachers’ versions. Again, fathers’ ratings were fairly systematically unrelated to AC scores (with one exception, see below). On the specific single-affect level, Tenderness/Care was significantly associated with scores on Anxiety scales as rated by children, mothers and teachers. Among the unpleasant affects, Anger/Rage correlated significantly with the Anxiety scales in children’s, mothers’ and fathers’ versions. The remaining unpleasant affects, including Fear/Panic, were not associated with ratings on the Anxiety scales from any perspective.

All in all, results of tests of the significance of differences in correlation magnitude in all relationships showed that correlations with the fathers’ ratings in a substantial number of cases differed significantly from correlations with the ratings from the other perspectives. The smallest significant difference in correlations was between integration of Enjoyment/Joy and Anxiety in mothers’ and fathers’ perspectives, respectively, and had an absolute value of .37 (z = 1.96, df = 29, p < .05).

ACI-C and Social Competence scales: Empathy, Responsibility and Assertion

Table 6 shows correlations between AC scores and scores on the Social Competence scales from the multi-informant perspective including children’s, mothers’ and teachers’ versions.

Table 6.

Pearson’s correlations for scores on Global AC, Awareness, Tolerance, Emotional Expressivity, Conceptual Expressivity, and 10 specific affects in the ACI-C and Social Competence subscales: Empathy, Responsibility, Assertion.

Variables	Empath. children	Respons mothers	Assert. children	Assert. mothers	Assert. teachers
Overall mean
Global AC	.55**	.56**	.48**	.45**	.59**
Integrating Aspects
Awareness	.53**	.36	.37*	.28	.39*
Tolerance	.33	.76**	.28	.51**	.63**
Emotion Exp.	.48**	.65**	.41*	.54**	.51**
Concept Exp.	.53**	.25	.54**	.30	.49**
Specific Affects
Interest/Excitement	.26	.54**	.26	.35	.33
Enjoyment/Joy	.39*	.56**	.28	.52**	.44*
Fear/Panic	.22	.13	.07	−.02	.20
Anger/Rage	.34	.20	.45*	.19	.37*
Disgust/Contempt	.35	.34	.30	.39*	.32
Shame/Humiliation	.27	.27	.22	.28	.30
Sadness/Despair	.62**	.40*	.54**	.24	.67**
Envy/Jealousy	.11	.36	.11	.25	34
Guilt/Remorse	.41*	.36	.36	.41*	.30
Tenderness/Care	.53**	.57**	.49**	.44*	.64**

AC: Affect Consciousness; ACI-C: Affect Consciousness Interview for Children.

Correlation is significant at .01 level; *correlation is significant at .05 level (two-tailed).

Table 7.

The phenomenology of discrete Affects/Emotions – typical experience and typical motivation or motivational tendencies.^a.

Affect/Emotion	Typical experience	Typical motivation or motivational tendencies
Interest/Excitement	Inspired, engaged, fascinated, curious, active, alive.	A wish to examine, get involved, take in new information, seek new experiences.
Enjoyment/Joy	Vital sense of strength, confidence, competence, content, optimism.	Produces an accepting attitude toward others. Joy and interest motivate for social involvement.
Fear/Panic	Sense of insecurity, intense danger, fear/panic, high degree of tension	Mobilizes energy for self-protection through escape, flight, withdrawal.
Anger/Rage	The face gets warm, high degree of tension/impulsivity to attack the source	Mobilizes energy for self-protection through self-assertiveness and self-boundary formation
Disgust	Bad taste in the mouth, feel bad in the stomach.	Mobilizes to getting rid of or remove the self from noxious stimuli: physical or psychological.
Contempt	Experience of superiority, being better than others, self-satisfied.	Ignores or avoids given persons. Cold, distanced, arrogant attitudes toward these others.
Shame/Humiliation	Sense of incompetence, of failure. As if a wish to hide what is seen by others	Motivates for hiding, covering up, avoiding gaze of others. Wishes to correct own mistakes.
Sadness/Despair	Sense of being dejected, disappointed, lonely, isolated, unhappy, helpless.	Motivates for communicating to others what is experienced as painful or distressing.
Envy/Jealousy	Sense of being excluded when wanting to be included.	Motivates for confronting unjust lack of fidelity/attention from the other.
Guilt/Remorse	A gnawing feeling of something being wrong in relation to self or others.	Motivates for reconciliation in conflicts. Guilt complements shame in promoting responsibility.
Tenderness/Care	Experience of closeness, bonding, and attachment, personal worth.	Approach, attachment, closeness, caring for. Origin of unconditioned accepting attitude.

Mainly based on Human Emotions by Caroll E. Izard (1977) as described in Kirsti Monsen and Jon Trygve Monsen (2001).

The correlation pattern for AC scores and scores on the Empathy and Responsibility scales showed that Global AC correlated significantly with Empathy in children’s version and Responsibility in the mothers’ version. Similarly, the four integrating aspects were consistently related to Empathy and Responsibility. On the single-affect level, Enjoyment/Joy and Tenderness/Care correlated significantly with Empathy in the children’s version and Responsibility in the mothers’ version. Of the unpleasant affects, Sadness/Despair showed similar significant relationships with Empathy and Responsibility as Enjoyment/Joy and Tenderness/Care. For Guilt/Remorse, a strong relationship was found with Empathy as rated by the children, but not with the parent ratings of Responsibility.

Corresponding correlation patterns as those found between Empathy/Responsibility and Global AC, the four integrating aspects and the specific affects Tenderness/Care, Enjoyment/Joy and Sadness/Despair were found also with the Assertion scales. The relationships for Anger/Rage and the Assertion perspectives revealed a significant correlation with the children’s and teachers’ versions. Concerning Guilt/Remorse and Disgust/Contempt, a strong relationship was found only with Assertion as rated by the mothers. Overall, as for ratings of Depression and Anxiety, the multi-informant perspective for ratings of social skills in the children’s, mothers’ and teachers’ versions revealed similar patterns of correlations with AC scores, while correlations with the fathers’ versions of the scales again deviated significantly in a substantial number of cases.

Discussion

This study aimed at exploring the utility and potential usefulness of the age-adjusted ACI to a clinical sample of children 11 years of age with internalizing problem behaviour. It investigated the inter-rater reliability of the ACI-C, along with the relationships between AC scores on different levels and a number of indicators of mental health and functioning: multi-informant perspectives on symptoms of Depression and Anxiety and the Empathy/Responsibility and Assertiveness aspects of social competence, along with observer-rated levels of general intelligence.

Inter-rater reliability

Satisfactory inter-rater reliability estimates were found on all levels, indicating that the application of the scoring scales and the ACI-C afford a basis for reliable scoring. The estimates are in line with previous findings from studies of adult samples (Gude et al., 2001; Monsen et al., 1996; Monsen & Monsen, 2000; Solbakken, Hansen, Havik, & Monsen, 2011; Waller & Scheidt, 2004).

External domain measures

The mean levels and ranges of scores on IQ, symptoms of Depression, symptoms of Anxiety were all expected, given the nature of the sample. However, the Social Competence scales were unexpectedly high, both for self- and observer ratings. The elevated ratings were in line with results from previous studies from the point of view of parents (Rubin, Coplan, Fox, & Calkins, 1995; Rydell, Berlin, & Bohlin, 2003), teachers (McDowell & Parke, 2000) and from the perspective of children themselves (Strauss, Lease, Kazdin, Dulcan, & Last, 1989).

Relationships between AC and external criteria

AC and Intelligence

The distinct correlation pattern that was revealed for AC and VIQ on all levels was contrasted by the weak and non-significant correlations between AC scores and PIQ. This is in line with previous studies of the relationship between EQ and VIQ and PIQ, respectively (Derkson et al., 2002; Marquez et al., 2006).

AC and Depression

Global AC showed the expected strong, negative correlations with depression in children’s, mothers’ and teachers’ versions. Similarly, there was also a general pattern of relationships between scores on three of the four integrating aspects (Awareness, Tolerance, Emotional Expressivity) and Depression. On the single-affect level, all of the pleasant affects, along with Sadness/Despair and Disgust/Contempt showed strong relationships with Depression.

These findings clearly support the notion of a relationship between affective states that are poorly differentiated and integrated and depressive reactions among the 11-year-old children. There was a particularly consistent pattern of the strong relationship between Tolerance and the multi-informant perspectives, emphasizing the paramount importance of affect tolerance and resulting affective reflective capacity as a buffer against symptoms of depression. For the specific single affects, the adaptive motivational properties associated with Interest/Excitement, Enjoyment/Joy and Tenderness/Care clearly facilitate behaviours and experiences that are mutually exclusive from those most commonly associated with depression. It is therefore highly intuitive that strong negative relationships exist between the capacities to experience and express these pleasant affects and the severity of depressive symptoms, as is indicated by our results (Table 5).

The correlation between AC scores and the fathers’ ratings on Depression were surprisingly low for all subscales. The same low and non-significant correlations were also found between AC scores and the fathers’ ratings on Anxiety and Social Competence. However, differences between various types of informants in cross-situational assessment of children’s emotional states and functioning are common (Achenbach, McConaughy, & Howell, 1987).

AC and Anxiety

On the global AC and the integrating AC aspect score levels, only Tolerance was clearly related to the Anxiety perspectives. With respect to the single-affect level, Tenderness/Care and Anger/Rage were strongly associated with the Anxiety perspectives, while Fear/Panic, quite unexpectedly, was related to Anxiety problems in the teachers’ perspective only.

The clear relationships between the Tolerance aspect and Anxiety emphasize the specific meaning and importance of poor affect tolerance and resulting lack of reflective capacity related to anxiety problems. Also, the importance of Tenderness/Care was revealed through the strong, negative relations both with the Anxiety and Depression symptom scales. This finding may suggest that integration of Tenderness/Care may be an especially important predictor of mental health in children. For Anger/Rage, the strong relationship with the Anxiety perspective scores is a finding which is in accordance with the classic understanding of anxiety symptoms as a result of the suppression of anger, and consequent avoidant behaviour, including a general inability to acknowledge unpleasant affect and the inability of being self-assertive. Considering the relationships between Tenderness/Care, Anger/Rage and the Anxiety perspectives together, the associations indicate that adequate capacity for integrating affects associated with close attachment and greater degree of self-assertion is a protective factor related to fewer problems with anxiety.

AC and Social Competence

Strong, positive correlations were found between global AC and both Empathy/Responsibility and Self-Assertion in children’s, mothers’ and teachers’ versions. Among the Social Competence scales, Assertion was most consistently related to the integrating AC aspects. Also, empathy was strongly associated with capacities to both experience and express affect. On the specific single-affect level, there was a general pattern of relationships between Tenderness/Care, Enjoyment/Joy, Sadness/Despair and Guilt/Remorse and the Social Competence scales. Anger/Rage was correlated with Assertion from the children’s perspective.

These findings clearly point to the importance of affect integration for the development of adequate social skills. Concerning empathy, including behaviours that show concern and respect for others’ feelings and viewpoints (Gresham & Elliott, 1990, p. 2), our findings support the idea that adequate contact with and integration of affect generally is related to greater capacity for ‘putting oneself in the shoes of others’ (Eisenberg, 2005; Zahn-Waxler & Radke-Yarrow, 1990). In contrast, the strong correlations between the social competence aspects and Tenderness/Care, Enjoyment/Joy, Sadness/Despair and Guilt/Remorse indicate that problems with these affects may give rise to interpersonal problems related to empathy, responsibility and self-assertion. To our knowledge, this pattern of associations has not been reported in any previous study. One possible explanation for a pattern like this is that the capacity to deal effectively with disappointment and loss frees up affective resources so that current social challenges and circumstances can be handled more efficiently.

Correspondence with previous studies

The theoretically consistent correlations found between scores on different levels of AC and various aspects of mental health and functioning (depression, anxiety, social competence and intelligence) coincide with findings in previous studies on adults with mental disorders (Gude et al., 2001; Monsen et al., 1996; Monsen & Monsen, 2000; Solbakken, Hansen, Havik, & Monsen, 2011; Waller & Scheidt, 2004) and a number of studies on children (Bohlin & Hagekull, 2009; Cook et al., 1994; Penza-Clyve & Zeman, 2002; Rieffe et al., 2008; Suveg & Zeman, 2004), using related concepts and instruments. Our findings support the assumption that AC scores also for children with mental disorders are strongly associated with mental health and functioning.

The results offer support for the assumption that the attainment of the capacity to reflect on and adequately handle one’s own affective experiences probably is an important contributor to the development of appropriate social competence and the prevention of psychopathology in children. Findings indicate that the ACI and the corresponding child-adjusted rating scales may be valuable and useful tools in research, assessment and in treatment planning with children 11 years of age or older.

Limitations of the study and future directions

One major limitation of this study of affect integration in children with internalizing problems is lack of a reference group of non-referred children as the basis for understanding what the measure shows about affect integration and how it relates to other measures of mental health in typically developing children. It is therefore important in future research to examine the ACI-C and ACSs in samples with non-referred children at different ages. This would be important for making potential improvements in the scoring scales on an empirical basis. It is currently difficult to differentiate between those difficulties in affect integration that are expected due to limitations inherent in a normal emotional developmental trajectory, and those difficulties that are due to genuine individual differences in healthy versus unhealthy ways of experiencing and expressing affect. However, if the majority of variation in affect integration scores is due to variation in the children’s normal emotional development, we would not expect AC scores to be correlated with measures of mental health, such as symptoms of anxiety and depression. As we have seen, this was not the case. Rather, such associations were plentiful and robust.

The small sample is also a major limitation. The sample size yields limited statistical power, and can identify as statistically significant only large correlation coefficients (r > .37). As can be seen, there are a number of reported correlations that are medium to large in size that do not reach the level of statistical significance. There is thus a danger of underestimating the true relationships between AC scores and intelligence, symptoms and social competence. Also, the sample size was too small to investigate sex differences.

The analyses in this study included estimates of criterion-referenced validity (associations with measures of potentially related constructs) and reliability. However, these alone do not provide sufficient evidence for construct validity. This would demand also demonstration of a theoretically feasible internal structure of data from the ACI-C. Unfortunately, this sample was too small to conduct the necessary item and factor analyses for such demonstration. Future studies should therefore examine these issues in larger clinical and non-clinical samples.

Finally, this study is exploratory in design and examines a large number of variables searching for patterns of relations across various rater perspectives. The findings raise important questions about the potential specificity of relationships, for example, between scores on discrete affects and different outcomes as rated by the children, their caregivers or teachers, respectively. Future studies should address these issues more systematically than was possible in this article.

Conclusion

In this study, the reliability of the ACI-C was satisfactory on all levels of scores, indicating that the application of the scoring scales, ACSs and the ACI-C afford a basis for reliable scoring in children with internalizing problem behaviour 11 years of age or older. Theoretically consistent correlations found between scores on different levels of AC and various aspects of mental health and functioning coincide with findings in previous research on AC in adults with mental disorders and a number of emotion regulation studies on children. It is thus indicated that various aspects of AC, as these are measured by the ACI-C, are related to other areas of mental health and functioning such as symptoms of depression, anxiety and social competence also in children with internalizing problems. The findings indicate that the attainment of the capacity to deal adaptively with affect is an important contributor to the development of adequate social competence and may be central in the prevention of psychopathology in children. The results also indicate that the adjusted ACI and corresponding rating scales can be valuable and useful tools for both research, in assessment and for treatment planning in clinical work with children at least from the age of 11 years or older.

Footnotes

Appendix 1

A shortened version of criteria for rating Affect Consciousness (Monsen & Solbakken, 2009).

Funding

This research was supported in part by grants from The Centre for Child and Adolescent Mental Health, Eastern and Southern Norway (RBUP), The Fund for Training and Development of Service Enterprises (OU-Fund) within the Federation of commercial and service Enterprises in Norway (HSH), The Foundation Grethe Hoff and Ruth Fuglerud’s Legacy, Lovisenberg Hospital, Health South – East Hospital Trust, Department Nic Waal’s Institute, Oslo, Norway. Thanks are addressed to Lovisenberg Hospital, Health South – East Hospital Trust, Department Nic Waal’s Institute for support in organizing the study. We want to give thanks to Bjørn Christoffersen, The Inland Hospital, Health South – East Hospital Trust, The Clinic for Children and Adolescents Mental Health for his contribution in the data-collection and discussions concerning improvements of the rating scales of the Affect Consciousness Interview for children.

Author biographies

Eva Taarvig (cand.polit) is psychotherapist at Lovisenberg Hospital, Health South – East Hospital Trust, Department Nic Waal’s Institute, (Clinic for Children and Adolescents Mental Health), Norway. Her research interests are aspects of developmental psychopathology and different manifestations of affect integration or affect consciousness in children.

Ole André Solbakken (PhD) is currently associate professor of clinical psychology at the Department of Psychology, University of Oslo, Norway. He has written extensively in the fields of psychotherapy research, the psychology of emotions, and the psychometric properties of various clinical assessment instruments.

Bjorg Grova is senior lecturer emeritus in clinical child psychology at the Department of Psychology, University of Oslo, Norway. She is specialist in clinical psychology. Among her research interests are developmental psychopathology, attachment and sleep research.

Jon T Monsen is professor of clinical psychology at the Department of Psychology, University of Oslo, Norway. He has written extensively in the fields of psychotherapy research, the psychology of emotions, and the psychometric properties of various clinical assessment instruments

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