Moderating effects of emotion regulation strategies on borderline personality symptoms in young adults with adverse childhood experiences

ABSTRACT

Young adults who have experienced adverse childhood experiences (ACE) are at increased risk for developing symptoms of borderline personality disorder (BPD), yet many young adults with ACE exposures do not develop BPD symptoms. As emotion regulation strategies are implicated in BPD symptoms, this study aims to understand the moderating effects of two emotion regulation strategies, cognitive reappraisal and expressive suppression, regarding the association between ACEs and BPD. Linear regression analyses examined both self-reported cognitive reappraisal and expressive suppression as moderators in the relationship between ACEs and BPD symptoms in a community-based sample of young adults aged 18–25 years old (n = 172). Childhood adversity was examined at different levels of exposure, in terms of no exposure, exposure to a single ACE, and exposure to multiple ACEs. There was no significant moderation by expressive suppression; however, a significant moderation effect was observed between multiple exposures and cognitive reappraisal. The relationship between multiple exposures to ACEs and BPD symptoms was significant at low levels of reappraisal, with the severity of BPD symptoms significantly decreasing at average and higher levels of reappraisal. These results indicate that cognitive reappraisal may act as a protective strategy against experiencing BPD symptoms despite multiple ACE exposures.

KEYWORDS:

• Borderline personality disorder
• adverse childhood experiences
• emotion regulation
• childhood trauma
• young adults

For young adults, who are individuals generally between the ages of 18–25, symptoms of borderline personality disorder (BPD) can create significant impairment in psychosocial functioning during a crucial development period generally marked by transition, identity exploration, and consolidation (Arnett, 2007; Erikson, 1968; Fadjukoff et al., 2007). Further, without early intervention, symptoms of BPD during young adulthood can lead to significant impairment during later adulthood in domains such as academic challenges, peer relationships, and risk a greater likelihood of developing substance use disorders (Chanen et al., 2020; Patel et al., 2007; Schulenberg & Zarrett, 2006). Adverse childhood experiences (ACEs) have been strongly associated with later BPD symptoms (Estric et al., 2022; Gaher et al., 2013; Keinanen et al., 2012; Mersky et al., 2013). Yet, this relationship is not universal; many young adults who experience ACEs do not go on to develop BPD symptoms (Ball & Links, 2009). While both BPD and ACEs have been associated with poor emotion regulation (Fossati et al., 2016; Neacsiu et al., 2014; Rosenstein et al., 2018), some emotion regulation strategies may be protective for young adults who experience ACEs. One such strategy, cognitive reappraisal, may buffer emotionally charged situations and stimuli, by reframing or modifying a thought in a way that lessens the emotional impact (Gross & John, 2003). Yet, other emotion regulation strategies, such as expressive suppression- wherein emotion expression is inhibited, might potentiate the ACEs-BPD symptom link. Given the risk for developing BPD symptoms among ACE-exposed young adults (Chanen & Kaess, 2012; Schulenberg & Zarrett, 2006), it is important to inform prevention and intervention efforts with knowledge of the potential buffering or exacerbating roles of emotion regulation strategies regarding adversity exposure and BPD symptoms. Thus, while previous research has addressed emotion regulation strategies as a mediator between ACEs and BPD symptoms (Carvhalo Fernando et al., 2014; Rosenstein et al., 2018), the present study examines cognitive reappraisal and expressive suppression as moderators between exposure to ACEs and BPD symptoms among young adults. Examining emotion regulation strategies as a moderator may demonstrate contextual effects for why some young adults with ACE exposures go on to develop BPD whereas some do not.

Adverse childhood experiences

Trauma experienced in childhood can have longstanding and grievous effects into adulthood, which is encapsulated in research that examines ACEs (Felitti et al., 1998; Schilling et al., 2007). ACEs are incidences occurring during childhood and adolescence that either directly harm the child (e.g., abuse and neglect) or indirectly harm the child through the environment (e.g., parental substance abuse and domestic violence) (Merrick et al., 2017). These incidences are an unfortunately worldwide experience for many children (Stoltenborgh et al., 2012). Exposure to ACEs elevates the risk for the development of psychiatric difficulties, such as symptoms of BPD, which can begin to appear in early adulthood (Mersky et al., 2013; Schilling et al., 2007). In community samples, ACE prevalence was strongly associated with poorer psychiatric outcomes among young adults (Schilling et al., 2007).

Borderline personality disorder

BPD is primarily marked by emotional instability, interpersonal difficulties, identity diffusion and dysphoria, and increased suicidality and non-suicidal self-injurious behaviours (American Psychiatric Association, 2013). BPD symptoms typically emerge during or begin to cause great distress by young adulthood (Chanen & Kaess, 2012; Meaney et al., 2016; Stepp et al., 2013). For young adults, symptoms of BPD can be severe and debilitating, creating significant suffering and dysfunction during a crucial period of integration into society as independent adults (Chanen & Kaess, 2012; Chanen et al., 2020). If these symptoms remain unmitigated, individuals with features of BPD face increasing social and mental health impairment (Linehan et al., 2000). Many BPD researchers consider emotion dysregulation an underlying mechanism, which leads to other symptoms and behaviours (Hope & Chapman, 2019; Lang et al., 2012; Linehan, 1993; Sanislow et al., 2002). However, emotion regulation might act conditionally as well. For instance, emotion dysregulation can change interpersonal reactivity and disrupt attachment styles via poor social interaction patterns, which then inhibit meaningful relationships during a period when young adults are attempting to create new, non-familial bonds (Euler et al., 2021; Miano et al., 2017; Neumann, 2017). Emotion dysregulation might exert a conditional effect where exposure to ACEs, in combination with maladaptive emotion regulation, might instigate or exacerbate BPD symptoms.

Research has consistently pointed out psychosocial factors, such as early childhood maltreatment and attachment insecurity, as posing considerable risks for developing BPD symptoms (Clarkin et al., 2007; Estric et al., 2022; Ibrahim et al., 2018; Keinanen et al., 2012; Linehan, 1993). For instance, positive associations between childhood emotional neglect and symptom distress related to BPD (Kealy et al., 2016; Kuo et al., 2015) demonstrate the effects of ACE exposure yet the relatively limited investigation of moderation by emotion regulation makes it difficult to discern for whom the relationship is strongest. Greater exploration of how early childhood environments interact with psychological variables like emotion regulation strategies via buffering or facilitating can increase the understanding of the complexities in the development, symptom severity, and persistent nature of BPD.

Emotion regulation

Broadly, emotion regulation often comes in the form of conscious and unconscious strategies to help individuals experience and express emotions, aid in interpersonal functioning, and increase personal well-being (Gross & John, 2003). Emotion regulation strategies can be broadly delineated into two category types: antecedent-focused and response-focused (Gross, 2014). Antecedent-focused emotion regulation strategies are ways in which behaviours and physiological responses to emotions are modulated before full-activation, such as cognitive reappraisal. Cognitive reappraisal is the act of changing assumptions made in response to moments that elicit emotions to reduce the emotional impact (Gross & John, 2003). Colloquially, it may be the ability the see the silver lining. It can also be used to normalize an unpleasant event (McRae et al., 2012). Cognitive reappraisal can be used to down regulate negative emotions by re-construing a potentially intense emotional experience into a more manageable one (Gross & John, 2003). For instance, one could feel embarrassed after another person points out a mistake. A cognitive reappraisal of the event may lessen these intense feelings if the embarrassed person feels gratitude that they were able to correct their mistake before the mistake led to a bad outcome.

Cognitive reappraisal is generally successful in reducing negative emotional experiences and boosting positive emotions (Gross, 2014; Webb et al., 2012). By employing reappraisal, individuals must directly confront negative stimuli (Sheppes et al., 2015). Cognitive reappraisal strategies have been noted to be of particular importance for individuals experiencing psychological distress (A. R. Daros et al., 2020), such as buffering the relationship between psychological distress and non-suicidal self-injury in young adults (Richmond et al., 2017), moderating the effects of stress and anxiety on depressive symptoms (Troy et al., 2010), and lessening distress in cases of intimate partner violence (Kraaij et al., 2007). While all genders do engage in the use of cognitive reappraisal, some research suggests that female-identifying are more likely to utilize this strategy than male-identifying, although research is limited and mixed (Anderson et al., 2016; Nolen-Hoeksema, 2012; Rogier et al., 2019).

Response-focused strategies, such as expressive suppression, work when the emotion is already felt (Gross & John, 2003). Expressive suppression relies on the inhibition of an ongoing emotionally expressive behaviour, such as stifling laughter or tears. Individuals often employ response-focused strategies (i.e., suppression, distraction, or avoidance) when the ability to attend to high intensity emotional stimuli is overwhelming. This can be an adaptive strategy for initial emotion regulation (Bonanno et al., 2004). However, overreliance on expressive suppression has been implicated in increasing symptoms of anxiety, depression, overall emotional distress, and BPD (Cheavens & Heiy, 2011; Dryman & Heimberg, 2018; Richmond et al., 2017). Longitudinal evidence suggests that among young adults, expressive suppression increases internalizing symptoms, thus increasing the risk of psychological distress (Zahniser & Conley, 2018). However, findings have been mixed; for instance, increased expressive suppression in depressed individuals was linked with greater endorsement of suicidal ideation (Forkman et al., 2014), yet among a Chinese sample, expressive suppression was found to exert no effect on depressive symptoms (Soto et al., 2011). Expressive suppression’s relationship to overall psychological distress has been noted as differing depending on the cultural context (Ford & Mauss, 2015). Culture-specific behaviours are socially rewarded, which can increase a person’s psychological wellbeing. Therefore, suppression may be encouraged and adaptive in one culture while discouraged in another. Further, while earlier research notes no gender differences regarding the use of expressive suppression (Nolen-Hoeksema, 2012), there is some suggestion that expressive suppression may be adaptive for male-identifying individuals, when they are able to use other emotion regulation strategies in different contexts (Rogier et al., 2019). While cognitive reappraisal may be helpful in reducing overall psychological distress, expressive suppression may increase psychological distress, particularly among individuals showing symptoms of BPD. Gross and John (2003) argued that while emotion regulation strategies are often automatic and unconscious, they can also be learned, including through clinical intervention.

Emotion regulation strategies are often learned from a young age and often through modeling, observation, and familial dynamics via at least one important childhood figure (Sharp et al., 2011; van Dijke et al., 2013). In an environment where there are multiple ACEs present, there may be a lack of consistent important childhood figures, which can lead to deficits in overall emotion regulation development (Lawrence et al., 2011; Luyten et al., 2020; Shaw et al., 2004). However, despite exposure to ACEs, some individuals may be able to develop and make use of adaptive emotion regulation strategies learned from ancillary supports such as educators, neighbors, and grandparents. For instance, reappraisal might help re-conceptualize these adverse events to help a child understand that the event is not a reflection of their own deficiencies or value, while expressive suppression might aid in managing emotions when the environment does not enable emotions to be safely expressed. Moreover, despite the association between ACEs and BPD, not all young adults who experience early trauma go on to develop BPD. Other moderators, such as trait-based resilience (Hong et al., 2018) and social support (McLaughlin et al., 2020), play important roles in overcoming exposures to ACEs. Exploration of the use of particular emotion regulation strategies, such as cognitive reappraisal, as a moderator of BPD symptoms may help inform future prevention and intervention work in young adults.

This study seeks to explore how the associations between exposure to early childhood trauma to developing BPD symptoms may be modified by two types of emotion regulation strategies. In the present study, we examine the association between exposure to early adversity and the severity of BPD symptoms among young adults, and how cognitive reappraisal and expressive suppression influence the strength of this association. In other words, emotion regulation strategies may act conditionally in a way that either makes exposure to early adversity more or less related to symptoms of BPD. We hypothesize that expressive suppression (H1) will moderate the association between ACEs and BPD symptoms, such that exposure to greater adversity will be associated with greater BPD symptom endorsement at higher levels of suppression. Further, cognitive reappraisal (H2) use will moderate the association between ACEs and BPD symptoms, such that exposure to greater adversity will be associated with greater BPD symptom endorsement at lower levels of cognitive reappraisal.

Methods

Participants (n = 172) were young adults recruited through community advertising to participate in a study on emotional wellbeing. Participants were between 18–25 years old with a mean age of 20.99 and predominately identified as cis-female (72.7%) with the remainder identifying as cis-male (26.6%) or non-binary (0.6%). A majority (59.3%) of individuals identified having a non-white ethnicity, including 42.4% identifying as Asian and 17.1% identifying as biracial or other ethnicity, whereas a total of 40.7% of individuals identified as white. Further, 89% of participants reported attending post-secondary education at the time of data collection. See Table 1 for additional sociodemographic characteristics. The data collection occurred between January and November 2017 in Vancouver, Canada. All participants met with a research assistant in a university research lab to provide informed consent and then completed a battery of assessments independently in a quiet office space. Participants were debriefed by research staff following completion. Participants who indicated serious psychological distress were provided with information regarding available mental health services. A nominal honorarium was given to all participants. Ethics approval from the University of British Columbia’s Human Research Ethics Board (certificate number: UBC/H16–02673) was given prior to data collection.

Table 1. Sociodemographic Information, frequencies, and means

Characteristics	n	%
Gender
Cis-female	125	72.7
Cis-male	46	26.6
Non-binary	1	0.6
Ethnicity
Asian	73	42.4
White	70	40.7
Biracial	15	8.7
Other	14	8.2
Highest level of education
Less than high school	2	1.2
High school or equivalent	70	40.7
Some college, technical/trade qualification	60	34.9
Undergraduate degree	36	20.9
Graduate Degree	4	2.3
Relationship Status
Single or casual dating	97	56.4
Committed relationship	72	41.9
Married	2	1.2
Sexual Orientation
Heterosexual	146	84.9
Lesbian, Gay, Bisexual, Pansexual, Queer	24	13.5
Asexual	2	1.2
Currently enrolled in post-secondary education	153	89
Mean Age (SD)	20.99	(2.04)
Age Range in Years	18–25
Frequencies for ACE categories	n	%
No ACEs reported	70	40.7
One ACE	43	25.0
Two or more ACEs	59	34.3
Means and Standard Deviations	M	SD
ERQ—Suppression	13.60	5.14
ERQ—Cognitive Reappraisal	28.48	6.53
BSL-23	17.63	14.31

Abbreviations: Adverse Childhood Experience (ACE; Dong et al., 2004); Emotion Regulation Questionnaire (ERQ; Gross & John, 2003); Borderline Symptoms List (BSL-23; Bohus et al., 2009).

Measures

Borderline personality disorder symptoms

The Borderline Symptom List (BSL-23; Bohus et al., 2009) is an abbreviated, self-rating instrument for the assessment of specific borderline-typical personality symptoms. It consists of 23 Likert-scaled statements between zero (not at all) to four (very strong) that correspond to DSM-IV criteria for BPD wherein higher scores correlate with greater symptom severity. The BSL-23 asks about the degree to which symptoms related to BPD have been experienced within the previous week (e.g., “I didn’t trust other people; I felt as if I was far away from myself”). The BSL-23 has been used to discriminate between individuals with BPD and those with post-traumatic stress disorder in clinical populations, despite overlapping symptoms (Bohus et al., 2009). Convergent validity showed moderate to high correlations with measures of depression and general psychopathology, and a moderate negative correlation with a measure of global well-being (Bohus et al., 2009). Previous research on the BSL-23 has established a severity grading to identify high to extremely high levels of BPD symptoms in treatment-seeking individuals as compared to healthy and clinical controls (Kleindienst et al., 2020). These severity grades were validated by comparing several well-established assessments of psychopathology. The BSL-23 demonstrated good internal consistency in the present sample, with an alpha coefficient of .92.

Emotion regulation strategies

The Emotion Regulation Questionnaire (ERQ; Gross & John, 2003) measures two emotion regulation strategies: expressive suppression and cognitive reappraisal. The ERQ uses Likert-scale responses between one (strongly disagree) and seven (strongly agree) about general trait level emotion regulation strategy endorsement (sample items: “When I want to feel less negative emotion, I change what I’m thinking about” and “I control my emotions by not expressing them”). Items for each strategy, reappraisal and suppression, are individually summed within corresponding subscales with higher scores signifying higher use of each strategy. Convergent validity was demonstrated using the Trait Meta-Mood Scales (Salovey et al., 1995), a measure of emotional reflectivity, in that reappraisal was associated with greater use of mood repair whereas suppression was associated with shutting down attention to emotion. Discriminant validity was determined by scale developers using a measure of Big Five personality traits (Gross & John, 2003). In this study, alpha reliabilities were .85 for reappraisal and .78 for suppression.

Adverse childhood experiences

The Adverse Childhood Experiences Questionnaire (ACE; Dong et al., 2004) was adapted from other childhood trauma measures (Straus & Gelles, 1990; Wyatt, 1985) to assess general adverse childhood experiences occurring within the first 18 years of life including childhood neglect (“Did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?”), childhood abuse (psychological, physical, and sexual; e.g., “Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you?”) and household dysfunction (mental illness, witnessing domestic violence, substance abuse, and criminal behaviour in the home; e.g., “Did a household member go to prison?”) within the first 18 years of life (Dong et al., 2004). The ACE is a 10-item questionnaire with yes or no response options, where the number of yes responses are summed to create a total score. Higher scores indicate a greater number of ACEs experienced. The ACE shows good to excellent test-retest reliability (Dube et al., 2003) and its use has been supported across diverse populations (Mersky & Janczewski, 2018). As ACEs are not a truly continuous variable, we trichotomized responses into three groups: no ACEs, one ACE, and multiple ACEs.

Analysis

Pearson correlations were used to examine the associations between adverse childhood experiences, which were used as a continuous variable, cognitive reappraisal, expressive suppression, and BPD symptoms without controlling for any other influence (Cohen et al., 2013). Potential confounding variables of ethnicity and gender regarding BPD symptoms were examined. Ethnicity was examined using one-way analysis of variance (ANOVA). Due to previous research controlling for gender, gender was dummy coded (1 = cis-female and non-binary individuals, 0 = cis-males) and a bivariate analysis was run to check for association. Moderation is useful for exploring the interaction effect or boundary conditions of a variable (w) on another variable’s (x) effect on a third variable (y) (Hayes, 2018). Therefore, moderation models were run using ordinary least squares regression with the PROCESS macro version 3.5 (Hayes, 2018; model 2 and model 1) in the Statistical Package for the Social Sciences (SPSS) version 26 to evaluate interactions between exposure to ACEs and emotion regulation strategies on BPD symptoms. The three ACE exposure categories of no exposure, one exposure, and multiple exposures were categorical independent variables. No exposure to ACEs was set as the reference group for the independent variable (Hayes, 2018). Cognitive reappraisal and expressive suppression were included as independent variables in the same model. BPD symptoms were the dependent variable. We examined the interactions between the two dummy-coded ACE variables and expressive suppression as well as cognitive reappraisal (four interactions in total).

Results

Preliminary analyses

Table 1 presents descriptive statistics for all variables in the study. Zero order correlations demonstrated a significant association for study variables in expected directions in that expressive suppression was positive associated with BPD symptoms and cognitive reappraisal was negatively associated with BPD symptoms (Table 2). Preliminary analyses showed no significant relationships for the potential covariates of ethnicity and gender with BPD symptoms and therefore, they were not included in the moderation analyses.

Table 2. Zero-order correlations between adverse childhood experiences, emotion regulation strategy endorsement and borderline personality symptoms

	ACE	ERQ—Suppression	ERQ—Reappraisal
ERQ—Suppression	0.021
ERQ—Reappraisal	−0.034	0.035
BSL − 23	0.239**	0.253**	− 0.364**

**p < 0.01.

Abbreviations: Adverse Childhood Experiences Questionnaire (ACE; Dong et al., 2004); Emotion Regulation Questionnaire (ERQ; Gross & John, 2003); Borderline Symptoms List (BSL-23; Bohus et al., 2009).

Moderation analyses

Linear regression analyses were conducted to assess the potential moderating effects of emotion regulation strategies on exposure to childhood trauma in predicting BPD symptoms. Results of the multiple linear regression indicated an overall significant model between exposure to ACEs, both emotion regulation strategies, and BPD symptoms, (F (8, 163) = 9.42, p < .001 R² = .32). However, only the interaction between multiple ACEs and cognitive reappraisal was significant (Table 3). As expressive suppression was not significant, a second model was rerun using only cognitive reappraisal as a moderator. The final model testing moderation by cognitive reappraisal achieved omnibus significance, F (5, 166) = 11.53, p < .000, R² = .26. As in the initial model, the interaction between cognitive reappraisal and one exposure to an ACE was non-significant. However, the interaction term of multiple exposures to ACEs × cognitive reappraisal was statistically significant, indicating a significant moderation effect (Figure 1).

Figure 1. Moderation model depicting cognitive reappraisal as a moderator.

Table 3. Standardized coefficients for regression analyses examining cognitive reappraisal between ACEs and BPD symptoms

	R^2	b	SE	t	p
Overall model	.26
Constant		26.51	7.30	3.63	.00**
One ACE		−1.80	11.40	−0.16	.88
Multiple ACEs		38.71	10.27	3.77	.00**
Cognitive Reappraisal with one ACE		0.11	0.37	0.31	.76
Cognitive Reappraisal with Multiple ACEs		−1.04	0.34	−3.04	.00**
Simple Slopes predicting BPD symptoms		b	SE	t	p
One ACE exposure at −1 SD Cognitive Reappraisal		0.83	3.54	0.23	.81
Multiple ACE exposures at −1 SD Cognitive Reappraisal		14.82	3.10	4.78	.00**
One ACE exposure at mean of Cognitive Reappraisal		1.58	2.43	0.65	.52
Multiple ACE exposures at mean of Cognitive Reappraisal		8.02	2.22	3.62	.00**
One ACE exposure at + 1 SD Cognitive Reappraisal		2.33	3.34	0.70	.49
Multiple ACE exposures at + 1 SD Cognitive Reappraisal		1.23	3.20	0.38	.70

**p < 0.01.

Simple slopes analysis demonstrated how ACE exposure interacted with cognitive reappraisal at −1 SD, mean, and + 1 SD in relation with BPD symptoms (Table 3; Figure 2). The association between multiple ACEs and BPD symptoms decreased from low cognitive reappraisal (b = 14.82, p < .01), to mean reappraisal (b = 8.02, p < .01), to high reappraisal (b = 1.23, p = .70). This finding provides support for our second hypothesis: cognitive reappraisal buffers the association between ACEs and BPD symptom.

Figure 2. Cognitive reappraisal as moderator of adverse childhood experiences (ACEs) and borderline personality disorder symptoms.

Discussion

The goal of this paper was to examine the role of two emotion regulation strategies as moderators in the relationship between ACEs and BPD symptoms in young adults. We hypothesized that for young adults who were exposed to ACEs, endorsement of BPD symptoms would be higher if there was higher endorsement of expressive suppression, whereas lower cognitive reappraisal endorsement would demonstrate heightened BPD symptoms. Contrary to our first hypothesis, expressive suppression was not a significant moderator of exposure to ACEs. However, consistent with our second hypothesis, cognitive reappraisal moderated the association between multiple ACEs and BPD symptoms, indicating that cognitive reappraisal buffered the effects of ACEs on BPD symptoms.

Consistent with previous research (Fonagy & Bateman, 2008; Gaher et al., 2013; Keinanen et al., 2012), exposure to multiple ACEs was significantly associated with BPD symptoms, however, this association was conditioned on participants’ emotion regulation capacity. Low cognitive reappraisal appears to make a considerable difference for individuals who had multiple ACE exposures and may make young adults more vulnerable to experiencing BPD symptoms. The decreased use of reappraisal skills may be due in some part to childhood environments that over-emphasized the use of less adaptive regulation skills such as suppression (Aldao et al., 2010; Lawrence et al., 2011; van Dijke et al., 2013). This deficit of reappraisal may increase the risk of developing BPD symptoms as a young adult. While expressive suppression did not show a significant interaction with exposure to ACEs on BPD symptoms in this study, more research is needed to better understand the possible associations between these variables. There may be different underlying mechanisms that account for the use of expressive suppression (Cheavens & Heiy, 2011; Zahniser & Conley, 2018) such as maladaptive schemas (Lawrence et al., 2011), cultural effects (Ford & Mauss, 2015), neurocognitive issues (Estric et al., 2022), or developmental processes such as mentalization ability (Luyten et al., 2020). Further, while there is evidence of suppression acting as a mediator between ACEs and BPD symptoms (see Carvhalo Fernando et al., 2014), use of expressive suppression can be adaptive, particularly when individuals are experiencing intense emotions (A. Daros & Williams, 2019).

Given the present findings, cognitive reappraisal may be an emotion regulation strategy of particular importance for young adults who have experienced multiple ACEs. Fortunately, cognitive reappraisal can be targeted in interventions for young adults (Denny & Ochsner, 2014; Linehan, 2015). As young adults with multiple ACEs who have low cognitive reappraisal may be at higher risk of developing BPD, a potentially beneficial and feasible strategy might involve teaching cognitive reappraisal skills to prevent or reduce BPD symptoms. Indeed, teaching cognitive reappraisal strategies may be worth investigating as an early intervention effort targeting adolescents and young adults, particularly if there has been exposure to multiple ACEs. There may be many avenues for learning and practicing cognitive reappraisal skills, including utilizing relationships with mental health professionals in psychotherapy settings (Frederickson et al., 2018; Troy et al., 2013). For example, interpretations provided by a therapist can be considered form of cognitive reappraisal if the result is a downshifting of an emotion. Dialectical behavioural therapy (DBT) has strong evidence for improvement of emotion regulation skills in individual and group therapeutic settings (Lenz et al., 2016; Linehan, 2015). A school-based program using DBT skills to enhance emotion problem solving, which includes reappraisal, is one such program that might be beneficial in increasing adaptive emotion regulation strategy use (Martinez et al., 2022; Mazza et al., 2016). Future research could examine if these skills could be adapted to be taught in brief treatments or single sessions (e.g., McLachlan et al., 2022), or adapted in culturally appropriate ways for specific populations. Previous studies have utilized group therapy and online module formats as a cost-effective and efficacious way to transmit skills (e.g., Lin et al., 2019; Ranney et al., 2017). Using cognitive reappraisal as a target for intervention can also be utilized in non-mental health settings and informal contexts; peer to peer interventions (Morris et al., 2015), classroom based skill teaching (Volkaert et al., 2020), and non-human interfaces such as gaming applications (McLachlan et al., 2022; Porat et al., 2020) have been found to increase cognitive reappraisal strategy use, overall emotion regulation abilities, and to reduce distress. Accessible and available early intervention during adolescence or younger could potentially prevent BPD symptoms from causing mental health difficulties during young adulthood. Future research could examine who may benefit most from interventions that encourage cognitive reappraisal and how younger populations and individuals at risk of developing BPD can foster adaptive emotion regulation skills via these interventions.

Limitations

There are several limitations in this study. The smaller sample size limited overall generalizability. Assessment of other forms of adversity, beyond those listed in the ACE self-report measure, such as systemic racism, were not included. While ethnicity and gender were explored as potential covariates in the design in preliminary analyses, the smaller sample size likely limited the statistical power required to understand how various socio-demographic variables might have affected the model. As the design was cross-sectional, inferences regarding the causality or directionality of this moderation model are limited. Self-reported data is also a limiting aspect of this study however previous evidence suggests that individuals with trauma histories can validly report their histories (Fadnes et al., 2009). Still, self-report data related to reappraisal and suppression may not accurately describe individuals’ actual experiences of emotion regulation and may require reports from outside sources such as family or professional report to substantiate (A. R. Daros et al., 2020). Further, the sample was community based and non-clinical, which may limit the generalizability to help-seeking populations who may demonstrate different relationships to emotion regulation strategies. Future research could utilize larger sample sizes to parse out differences between types of ACE exposures and further explore the interaction between ACEs and emotion regulation strategies like expressive suppression. Additionally, there is a need for continued exploration of potential moderators between exposure to ACEs and BPD symptoms. Some literature suggests that emotion regulation difficulties co-occur in populations with both BPD and complex post-traumatic stress disorder (CPTSD; Ford & Courtois, 2021) and therefore, future research is required to understand the relationships between emotion regulation, ACEs, BPD, and CPTSD. Similarly, we echo the call for future research to understand how different populations of individuals, such as those with differing genders, ethnicities, and socioeconomic statuses, who experience BPD symptoms, make choices regarding emotion regulation strategies (Nolen-Hoeksema, 2012).

Conclusion

Despite the limitations described above, these results suggest that cognitive reappraisal is a crucial emotion regulation strategy for young adults who have experienced multiple childhood traumas. Using moderation analysis of these relations is unique to the present study, as previous studies have examined emotion regulation abilities as a mediator (e.g., Fossati et al., 2016). For young adults who have experienced multiple childhood traumas, developing cognitive reappraisal strategies may buffer against BPD symptoms and potentially alter their mental health trajectory for the better.

Data sharing statement

Data is available from the corresponding author upon reasonable request.

Funding

The authors report that there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).