Exploring the emotion regulation strategies used by adults with intellectual disabilities

Abstract

Objectives

There is a growing body of evidence revealing emotion regulation difficulties are a common factor in the development and maintenance of mental health problems in the general population, however relatively little is known of the emotion regulation strategies used by people with intellectual disabilities.

Method

A qualitative approach was used to explore the emotion regulation strategies used by adults with a mild intellectual disability in interpersonal experiences. Semi-structured interviews were conducted with 11 participants with the transcripts analyzed using Thematic Analysis.

Results

Three main-themes, each with two sub-themes were identified; regulatory talk (sub-themes of ‘self-talk’ and ‘talking about emotions in beneficial’), avoidance (sub-themes of ‘avoidance is bad’ and ‘avoidance can be good’) and cognitive strategies (sub-themes of ‘cognitive distraction’ and ‘cognitive reappraisal’).

Conclusions

The main-themes and sub-themes suggest people with intellectual disabilities can use a range of strategies in different contexts. Research and clinical implications are discussed.

Introduction

People with IDs experience more mental health problems than the general population (Cooper et al. 2007) with 10–17% of the population experiencing behavioral problems (e.g. Allen et al. 2007). Deficits in emotion regulation have been suggested as a common factor in the development and maintenance of mental health problems in the general population (Aldao et al. 2010) however this area has not been significantly researched for people with intellectual disabilities (McClure et al. 2009).

Emotion regulation has received considerable attention in an attempt to understand the commonalities that exist across mental health problems in the general population (e.g. Gross and Thompson 2007) and has been defined as ‘‘the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals’’ (Thompson 1994). A number of models of emotion regulation have been suggested (Aldao et al. 2010). Gross and colleagues have described the process model of emotion regulation (Gross and John 2003). This model suggests a number of stages in emotion regulation. Situation selection, the first point in the model, identifies that different situations can evoke different emotions and remaining or leaving a situation can be a regulatory process. Situations can be modified, situation modification, in various ways to alter the emotional impact and response. Whilst situation selection and situation modification focus on managing external variables, attentional deployment refers to the ability of individuals to attend or not to a situation in order to regulate their emotions. Cognitive change or changing how one appraises the situation can alter its emotional significance. The last potential regulatory point in the model is response modulation which refers to moderating the physiological, experiential and/or behavioral responses to any given situation (Gross and John 2003, Gross and Thompson 2007).

Different emotion regulation strategies have different potential outcomes, with some being more adaptive or beneficial than others (Kring and Sloan 2009). For example, cognitive reappraisal is an antecedent-focused strategy which involves intervening before the emotion response has been fully generated. It alters the whole emotional process and resulting consequences. In contrast, expressive suppression is a response-focused strategy occurring relatively late in the emotion-generative process which primarily modifies the behavioral aspect of the emotion response (Gross and John 2003). Studies have identified cognitive appraisal as being a more adaptive, beneficial regulatory process compared to expressive suppression (e.g. Dillon et al. 2007).

However, no single emotion regulation strategy is appropriate or beneficial for all emotions or situations. This is because the outcomes of each emotion regulation strategy have to be judged in accordance factors such as immediate and future goals, and contextual variables; outcomes can also vary according to individual differences such as age, gender, occupation, relationships, social support, previous emotion regulation experiences, and attachment (English et al. 2013).

To date, only one study has specifically investigated the emotion regulation strategies used by adults with IDs. Meule and colleagues (Meule et al. 2013) investigated the relationship between quality of life and emotion regulation (cognitive reappraisal and emotion suppression). The results suggested individuals who primarily used cognitive reappraisal as an emotion regulation strategy had higher scores on the subjective and objective quality of life measures. These findings replicate previous findings from adults in the general population (Geisler et al. 2010) suggesting emotion regulation strategies used by people with IDs and their resulting outcomes may be similar to those from the general population.

No study to date has investigated the full range of emotion regulation strategies used by adults with IDs. More specifically, there is a very limited understanding of how adults with IDs regulate their emotions and why they use such strategies. The aim of this study is to explore the emotion regulation strategies used by adults with IDs and gain an understanding of the factors which may contribute to their use.

Method

This study used a qualitative approach with semi-structured interviews conducted with participants to gather data which were analyzed using thematic analysis.

Participants were recruited through a social-care day service for people with intellectual disabilities and the study was granted ethical approval through the appropriate university ethical committee

Inclusion criteria

• (1)Individuals identified by day service staff as having a mild intellectual disability with sufficient expressive and receptive vocabulary to be approached to participate in the interview. To support staff in identifying participants they were asked to consider people who met criteria based on three questions from the Adaptive Behavior Scale (ABS RC: 2, Nihira et al. 1993); (1) talks to others about sports, family, group activities etc.; (2) sometimes use complex sentences containing ‘because’, ‘but’ etc.; and (3) answers simple questions such as ‘What is your name?’ or ‘What are you doing?
• (2)Able to provide consent.

Exclusion criteria

• (1)Individuals with an identified diagnosis of Autism Spectrum Disorder (ASD) or other syndromes which have specific social-communication difficulties.

Procedure

People who met the inclusion criteria were given more information about the study in an accessible form. Potential participants were visited approximately one week later and given the opportunity to ask any questions they had about the research at which point consent was taken to participate assessed using the accessible information sheets and consent recording forms demonstrating core capacity criteria (able to understand, retain, weigh and use and communicate a choice). The semi-structured interviews were conducted and participants were then engaged in a general conversation to check that participants were not distressed after completing the semi-structured interview.

Participants

Eleven participants (7 males, 4 females) who met the inclusion criteria were invited to participate. The participants had a mean age of 33 years and 2 (SD = 9 years 2 months; range 24 to 53 years). Seven participants lived with their families, one lived independently and three were in supported living. Table 1 shows the characteristics of the participants

Table 1. Participant features.

Name (not real name)	Age (years)	Sex	Living status
Amy	29	Female	Independent
Peter	53	Male	Supported accommodation
Nicola	42	Female	Lives with family
Nick	32	Male	Lives with family
John	42	Male	Supported accommodation
Phillip	24	Male	Supported accommodation
James	31	Male	Lives with family
Andrew	25	Male	Lives with family
Mary	24	Female	Lives with family
Ruth	32	Female	Lives with family
Luke	27	Male	Lives with family

Interview procedure

The interviews were based on the Cognitive-Emotive Behavioral Assessment Interview (CEBA; Trower et al. 1988) was used. This format has been successfully used with people with IDs in research settings (e.g. Hebblethwaite et al. 2011). It is based upon a cognitive ABC format whereby participants describe a real-life emotive interpersonal experience of which they can recall their emotional response. Participants were then encouraged to hold onto the emotions generated by this experience whilst the interviewer asked questions about their thoughts, beliefs (e.g. ‘what were you saying to yourself when this happened’) and behavior (e.g. ‘what did you do’) associated with the events. In this study, the interviewer asked questions to investigate the emotion regulation strategy they used (e.g. ‘what did you do about [the identified feeling]’/‘did you do anything to help yourself feel better’), the factors which prompted them to use that emotion regulation strategy (‘why did you do that about [the identified feeling]’), their tendency to use that specific emotion regulation strategy (‘have you done that before at other times that have been upsetting?’), their understanding of different emotion regulation strategies (‘were there other things you thought about doing?’), and the outcomes of the emotion regulation strategy they used (‘what happened in the end?’). The approach did not prompt for specific emotion regulation strategies as described by Gross and John (2003) but allowed exploration of the types of strategy used by people with intellectual disability. Follow up questions were asked to gain more detail, to clarify answers, and to cross-check the participants answers to ensure they were consistent and accurate. Interviews lasted between 35 and 55 min.

After completing the semi-structured interview 5–10 min was allocated to debriefing the participants and assessing their emotional response to the interview.

Analysis

The recorded interviews were professionally transcribed. The transcriptions were proof-read by the principal researcher whilst listening to the recorded interview a minimum of three times to ensure the spoken word and its meaning were thoroughly and accurately recorded into written word. This follows the recommended transcription process identified in Braun and Clarke (2006) for conducting thematic analysis.

Data collection and analysis followed Braun and Clarke’s (2006) six phases for conducting thematic analysis their 15 point checklist of criteria for conducting thematic analysis was adhered to. The recorded interviews were listened to several times in conjunction with reading the transcripts so that the first author was very familiar with the data. An inductive approach was used to identify themes derived from the data. Reflective notes based upon the interviews and initial interpretations, impressions and points of interest with regards to the participant’s answers were recorded in a diary and consulted during the analysis process. Equal attention was given to each transcribed interview during coding process. The coding process was achieved by attaching additional pieces of paper to the side of the transcripts on which the codes or words/phrases of interest relating to the transcripts were written. Subsequent codes, second order codes, and themes were recorded in the same manner by attaching additional pieces of paper to the side of the transcripts and writing on it. The second-order coding and the process of identifying themes aims to refine and condense the relevant points on interest in the transcripts to identify themes or patterns of information based upon a central organizing concept; first, second, and initial themes were recorded in this manner. Semantic codes based upon the semantic meanings in the data and latent codes, implicit meanings within the data were recorded. Code and theme saturation was achieved when no new descriptive or latent codes or themes emerged from the analysis (Braun and Clarke 2013).

Two transcribed interviews and their first-order codes were reviewed by the field supervisor to ensure the coding process was conducted appropriately and the codes accurately summarized points of interest in the data (Lincoln and Guba 1985).

A descriptive and constructionist style was employed in the reporting of the themes and findings (Braun and Clarke 2013) which is consistent with the critical-realist epistemological position, inductive deductive approach of this research and in-line with Braun and Clarke’s (2006) criteria for analysis and report writing. At certain points in the results reference is made to the process model of emotion to clarify how the data obtained relates to the model, which is then fully considered in the discussion.

Results

Three main-themes were identified; Regulatory talk, Avoidance, and Cognitive strategies. These main-themes and their sub-themes are presented in table 2.

Table 2. Main-themes and sub-themes.

Main-theme	Sub-theme
Regulatory Talk	Self-talk
	Talking about Emotions is Beneficial
Avoidance	Avoidance can be Good
	Avoidance is Bad
Cognitive Strategies	Cognitive Distraction
	Cognitive Appraisal

Main-theme: regulatory talk

Regulating emotions through self-talk was reported by the majority of participants in this study. This process can involve private-speech, identified here as self-talk, or expressive speech (talking to other people). The sub-theme self-talk illustrates how and when participants talked to themselves as a regulatory process whilst the sub-theme talking about emotions is beneficial, illustrates participants see the importance of discussing their emotions and the positive outcomes of doing so.

Sub-theme: self-talk

Three participants described how they used self-talk as a process to direct themselves to engage in different behaviors, and as a method of promoting emotional change. Here, Amy describes how she uses self-talk to ‘down-regulate’ (Gross 2014) her emotions when she felt they were not appropriate to the situation she was in.

I have these little things where I just start talking to myself and I would say ‘listen you’re getting too over excited now’. (Amy)

I just try to think about why, try to be professional because I’m supposed to be at work and you’re saying ‘right this is what we need to do now, you need to take a back seat and need to go back.’ I would say ‘I need to be professional, I need to take a back seat and act like were at work, not at school.’ (Amy)

John also revealed that he used self-talk as a method of regulating his emotions. He identifies that what he says to himself depends upon the situation. He also notes that he compares his emotions in this situation to previous emotions he has experienced.

Depends on the situation, if say, something goes wrong I’m like, I might witter on about, you know ‘aw come on, pull yourself together’ you know ‘you’re not usually like this’. If I am on a downer, I’ll say ‘aw come on’ and I’ll have a walk around the garden and you know I might take the dog with us. (John)

These quotes illustrate self-talk to both ‘upregulate’ and ‘down-regulate’ emotions (Gross 2014) and as a coping strategy. These quotes also identify self-talk is used adaptively with its application dependent upon other variables.

Sub-theme: Talking about Emotions is Beneficial

Five participants revealed that they felt better after talking about their emotions. Thus, the process of talking about emotions is a regulatory process. For example;

I need to talk to that person because I need to get it off my chest. (Nicola)

This suggests there is a need for participants to talk about their emotions and emotional difficulties. This could be a need to share their emotions, a need to release the burden of their emotions or a need to ensure other people are there to support them. Talking about emotions can also be beneficial in developing a greater understanding of the emotions and their causes.

Three participants highlighted that talking about emotions allowed them gain support or help with regards to their emotional difficulties.

I said to my friend I was walking away at the time and she said why don’t you go and tell the teachers about it, so I did. (Mary)

The following dialogue by Amy reveals how she communicated her needs.

I used to tell my friends at work, my boss at work. (Amy)

Did you feel better for talking to them? (Interviewer)

Yeah, sometimes it is because they can help. They might have been in the same position so you know it might help talk about it. (Amy).

Main-theme: avoidance

The construct ‘avoidance’ refers to refraining from, or escaping from, an action, person or thing. It can involve cognitive and behavioral efforts oriented towards denying or minimizing, or to avoid dealing with or experiencing negative emotions (Penley et al. 2002).This theme illustrates that using one strategy, avoidance, in different situations, with different variables can have different outcomes. Strategies need to be adapted to contextual factors, and different emotions to be beneficial. The sub-themes focus on two specific ways in which avoidance can be used and their different outcomes.

Sub-theme: avoidance can be good

The sub-theme avoidance can be good illustrates the unwillingness of participants to remain in contact with aversive events, situations or people and taking action to alter them. All of the participants in this study revealed that they frequently used avoidance as a strategy and found it to be beneficial. When James was asked what he would do in a difficult interpersonal experience he stated:

I would ignore you (the person) and walk away. (James)

Participants were questioned about their emotions after they had avoided or escaped a situation.

So you get out of the situation. What does that do when you get out of the situation? (Interviewer)

It makes me calm down a little bit. (Amy)

Luke was more descriptive in relating why he would avoid a situation.

I would leave the room first, clear my head. (Luke)

To clear your head, right. (Interviewer)

Then go back in the room and if they are still annoying me then I would go out of the room and try and find somebody that I could tell. (Luke)

So when you left the room would that make you feel better or worse? (Interviewer)

Yeah not like 100% maybe 30% (better). (Luke)

Here, Luke appears to understand the link between the situation, his cognitions and his emotions. Luke’s narrative of this process suggests he also has some understanding that by targeting or resolving the difficult thoughts he was experiencing, he can resolve his emotional difficulties. The final sentence from Luke suggests knows that emotions are not fully resolved immediately.

Avoiding situations or people is not solely a reactive process in which people engage in regulatory strategies once the negative emotions have started developing. It can also be a preventative process in which people anticipate the emotional impact they may experience and actively avoid it. This preventative strategy requires prior learning, evaluation of situations, and people and decision-making.

Sub-theme: avoidance is bad

A theme from six participants was that trying to avoid dealing with or denying emotions is not always beneficial. Participants identified that, at times, avoidance made their emotions stronger and led them to potentially engage in maladaptive methods to regulate them.

Phillip described how his negative emotions were amplified when he ‘bottled them up’.

Well, try as best I can I suppose, show them that I do, but I did bottle it up quite a lot. (Phillip)

You bottle it up? (Interviewer)

Yeah and the thing just gets worse. It gets to the point when I think right this is just too much because I can’t handle too much. I am all right with some pressure being put on but when it gets to the point of, it’s like, if you can imagine a kettle. I can imagine a kettle, and it just boils over. If you can put it this way, steam and it builds up all the time and it just, if it gets any worse it just like, well boils over and spills over the top. (Phillip)

Phillip identifies that he is aware of his emotions developing and aware that he is losing control of them, which contributes to his emotion regulation difficulties. Phillip’s difficult emotions develop to a level where he is unable to manage or regulate them anymore and they ‘boil over’ or ‘spill over the top’.

Main-theme: cognitive strategies

All of the participants used cognitive strategies to regulate emotions, with cognitive reappraisal and cognitive distraction being the most common. Cognitive reappraisal, the process of changing the meaning of the emotion eliciting situation or stimuli, was used by four participants whilst cognitive distraction, the deployment of attention away from a negative situation or stimuli to a more neutral or positive one, was used by three participants.

Sub-theme: cognitive reappraisal

Three participants described how they used cognitive skills such as analyzing, evaluating, and empathizing in negative interpersonal experiences as part of a process of understanding them differently. Mary describes how she tried to understand an uncomfortable interpersonal experience;

Maybe if someone was not being nice to me, in the past or recently they (someone else) might have not been nice to them and they’re taking it out on somebody else. (Mary)

So why were they not being nice to you? (Interviewer)

They might be feeling angry about what somebody else has done to them. It makes me think why they are doing it. I don’t understand what the person has done to them in the past, like not understanding that it is not nice and that is why I think some people copy others. To make themselves feel better. (Mary)

Here, Mary hypothesizes that the other person’s behavior could be a product of a previous difficult interpersonal experience. In this process, Mary has used complex cognitive skills to change both how she relates to the other persons behavior and the meaning of the interpersonal experience. This process is a form of cognitive reappraisal, as outlined by the process model of emotions (Gross and John 2003).

Phillip used a different cognitive method for reappraising an interpersonal experience.

I know the persons don’t get nasty, you know like don’t mean to get nasty. They probably find it hard to see that person in the situation like me. (Phillip)

In this quote, Phillip appears to empathize with the other person. He does not react to the negative behavior by the other person but appears to try and form some understanding as to why the other person behaved the way they did. This cognitive process required Phillip to resist reacting to the behavior (emotion reactivity), and think about the potential factors underlying the behavior by the other person which appears to change his relationship to the behavior and its meaning.

Sub-theme: cognitive distraction

Not focusing on items which elicit negative emotions is described by two participants. Amy discussed interactions with a peer that she had previously had upsetting interactions. She stated:

When (name) came in to talk to me, I pretended that he wasn’t there and I wasn’t. Really, he was there. I could see that he was there but couldn’t look (at him). I could just block him out because at the minute I’m focussed on you. This is what I could do. (Amy)

Here, Amy identifies that by not focusing on the situation or distracting herself, she can avoid experiencing the unwanted emotions. In this example, Amy shifted her attention by using her cognitive skills to pretend, imagine or adapt reality. Whilst pretending could be suggestive of an immature cognitive ability, Amy’s use of it here is adaptive and appears to meet her emotional needs.

Another method of cognitive distraction was illustrated by Peter.

I would put the radio on when I’m working. Listen to the music and do my work that way. (Peter)

So you would listen to the music? (Interviewer)

Yeah to keep me happy, listen to (name of radio station). (Peter)

So you would listen to music rather than listen to him? (Interviewer)

Have to put up with him. Yeah to put up with him. A sort of therapy to keep me happy. (Peter)

In this instance, Peter incorporates a radio adaptively to distract himself away from focusing on and engaging with the other person and identifies this as a successful strategy.

Discussion

This paper has used a focused interview structure and thematic analysis to explore the emotion regulation strategies of people with intellectual disabilities. Three main-themes, each with two sub-themes were identified; regulatory talk (sub-themes of ‘self-talk’ and ‘talking about emotions in beneficial’), avoidance (sub-themes of ‘avoidance is bad’ and ‘avoidance can be good’) and cognitive strategies (sub-themes of ‘cognitive distraction’ and ‘cognitive reappraisal’).

Within the main-theme Regulatory talk, the sub-theme Self-talk reveals how participants use inner-speech or private speech (collectively referred to in this study as self-talk) to regulate their thoughts and emotions. Participant statements show self-talk was used as a regulatory processes for both positive and negative emotions. It was also used to promote the up-regulation, increasing, and down-regulation, decreasing, (Gross 2014) of emotions. The use of self-talk described here is similar to evidence of self-talk use in the general population (Alderson-Day and Fernyhough 2015) and a study by McGuire et al. (1997) with adults with Down Syndrome found 80% of their participants frequently engaged in self-talk to direct emotional and behavioral responses and plan and complete daily activities. More recent research has also found that self-talk in the form of self-regulatory speech or self-instructional training is an effective learning tool for people with intellectual disabilities (e.g. Embregts 2000, 2002). The evidence in the present study that people with intellectual disabilities frequently use self-talk is not new but its use as an emotion regulation strategy has not been described before.

The sub-theme Talking about emotions is beneficial highlights the importance of engaging in meaningful interpersonal interactions, whereby people with intellectual disabilities can disclose and discuss private and difficult experiences (e.g. Buntinx and Schalock 2010). Relationships of this nature have long been suggested to serve an emotion regulation function by relieving the burden of uncomfortable emotions and as a source of containment and security (e.g. Bion 1962).

The main-theme Avoidance highlights that no one emotion regulation strategy is always advantageous or disadvantageous and that having the ability to adapt and flexibly apply emotion regulation strategies in different contexts is important (Carver and Connor-Smith 2010). ‘Emotion regulation flexibility’ has become a prominent line of research in the field of emotion regulation with evidence identifying that flexible emotion regulation skills are associated with better outcomes (e.g. Aldao and Nolen-Hoeksema 2012).

It is commonly identified in research with people without intellectual disabilities that avoiding, denying, or suppressing emotions is a maladaptive emotion regulation process associated with negative consequences in the general population (Webb et al. 2012). The sub-theme ‘Avoidance is bad’ shows that some people with IDs who have engaged in avoidance or suppression strategies also experienced negative outcomes. More specifically, participants identified an increase, or rebound, in negative emotions as a consequence of using this strategy which is consistent with results with the general population (Wegner et al. 1987). Whilst the participants in this study identified considerable negative consequences when avoiding or suppressing emotions, their statements also revealed a learning process as a result of these experiences.

Participants used a variety of cognitive skills to regulate their emotions (third main-theme; cognitive strategies). The sub-themes, cognitive distraction and cognitive appraisal identify two types of cognitive strategies employed by participants to regulate their emotions. Cognitive strategies such as these are suggested to be adaptive emotion regulation strategies (e.g. Srivastava et al. 2009). Conversely, the absence of cognitive strategies is associated with increased mental health difficulties (e.g. Gross and Jazaieri 2014).

Whilst cognitive distraction and cognitive appraisal are both antecedent emotion regulation strategies there are subtle but important differences between them. Cognitive distraction is an earlier process used to block emotional information before it is represented in the working memory for further evaluative processing. Cognitive reappraisal occurs after distraction and requires some processing of the emotional information in the working memory (Sheppes et al. 2011). With the process model of emotion (Gross and John 2003) emotions develop and gain strength over time, the slight temporal difference between these two cognitive strategies means the emotions are stronger and require more regulatory input for cognitive reappraisal (Sheppes and Gross 2011). Recent studies have identified cognitive distraction is more effective at modulating high-intensity emotions whilst cognitive reappraisal is more effective at modulating low-intensity emotions (Sheppes et al. 2009).

The statements in this study show participants used up-regulation, increasing, and down-regulation, decreasing, methods for managing their emotions (Gross 2014). In addition, they also used problem-focused and emotion-focused strategies (Baker and Berenbaum 2007) and were able to select strategies from a repertoire and adaptively apply them. Participants also illustrated how they could use individual strategies, or combine strategies when required. Having the ability to choose from a variety of strategies and apply them dynamically in this manner considerably increases the effectiveness of the strategies (Bonanno and Burton 2013).

This study is an initial exploration of the Gross and John (2003) model, Clearly the results should be interpreted with caution as it represents the experience of a small sample selected from a limited range of day service settings. The sample does not report the full range of emotional regulation strategies and stages identified by Gross and John (2003). We suggest that more specific exploration of particular stages is needed to identify if this is a product of the interview approach or represents a true absence of some regulatory approaches in this population. It would also be important to explore these issues in populations in forensic, mental health or challenging behavior settings where we would expect people with difficulties with emotion regulation to be found.

A small number of studies have demonstrated links between similar concepts such as ‘emotional development’ and challenging behavior (Sappok et al. 2014) and related aspects of executive functioning such as inhibitory control and adaptive functioning (Gligorović and Buha 2014). Understanding that individuals with IDs routinely engage in self-talk as a process of regulating their emotions and behaviors suggests more structured cognitive techniques such as self-instruction training (Meichenbaum and Goodman 1971) may have particular potential in developing emotion regulation skills. Specific interventions could focus on skills based approaches to improving the components of emotion regulation such as strategy selection, implementation, or disengagement. Focusing on the components of emotion regulation may make it easier for people with cognitive limitations to understand, store in memory and apply in the future. Once a specific emotion regulation component is mastered, interventions could focus on subsequent components. It is also possible that more generalized arousal reduction techniques will improve the ability for people with intellectual disabilities to sue the skills they already have. For example, Bouvet and Coulet (2016) found that learning relaxation skills led to an increase in the use of emotion regulation skills.

This is the first study to qualitatively investigate the emotion regulation strategies used by adults with IDs. Semi-structured interviews explored how and why participants regulated their emotions in interpersonal experiences. From these interviews, people with IDs were understood to use a variety of emotion regulation strategies. The findings in this study provide a greater understanding of emotion regulation adults with IDs from which future studies can be developed.

Conflict of interest

No potential conflict of interest was reported by the authors.

Notes on contributors

Mark Littlewood is a clinical psychologist in a private practice in New Zealand where he works with clients of all ages. He has an particular interest in developmental disorders, intellectual disabilities and trauma related issues.

Dave Dagnan is a consultant clinical psychologist and honorary chair at Lancaster University. He researches and writes about theory and practice in cognitive-behavioural therapies for people with intellectual disabilities.

Jacqui Rodgers is a senior lecturer and autism researcher in the Institute of Neuroscience, Newcastle University. She leads a programme of work which aims to advance the conceptualisation, assessment and treatment of mental health conditions in children and adults with neurodevelopmental disorders. She has a particular interest in anxiety in autism.