Attentional bias towards threatening stimuli in children with anxiety: A meta-analysis

Case Series of Transcranial Direct Current Stimulation as an Augmentation Strategy for Attention Bias Modification Treatment in Adolescents with Anxiety Disorders

This article presents the results of a case series to assess the feasibility, acceptability, and clinical promise of transcranial Direct Current Stimulation (tDCS) as an augmentation strategy in clinic referred adolescents. Attention Bias Modification Treatment (ABMT) is a computer-based attention-training protocol designed to reduce rapidly deployed attention orienting to threat and thereby reduce anxiety symptom severity. Studies of ABMT reveal overall small to medium effect sizes. Advances in the neural underpinnings of attention to threat and attention-training protocols suggest the potential of tDCS of the dorsolateral prefrontal cortex (dlPFC) as a novel augmentation strategy to enhance ABMT's efficacy (ABMT + tDCS). However, tDCS has never been tested in a sample of adolescents with anxiety disorders. Six adolescents with a primary anxiety disorder completed all four ABMT + tDCS sessions. Adverse effects were mild and transient. Adolescents and parents independently reported fair to excellent levels of satisfaction. Impairment ratings of the primary anxiety disorder significantly decreased. Further, electrophysiological data recorded via electroencephalography (EEG) suggested decreases in neural resources allocated to threat. These findings support the feasibility, acceptability, and clinical promise of tDCS as an augmentation strategy in adolescents with anxiety disorders, and provide the impetus for further investigation using randomized controlled designs in larger samples.

Editorial: Attention to Threat in Child Anxiety: Gazing Into the Future While Keeping Sight of the Past

Since the 1960s, cognitive theories of anxiety have prioritized attention to threat in the etiology and maintenance of anxiety and its disorders.¹ The development of computer-administered tasks in the 1980s, displaying threatening stimuli on the screen and relying on participants' clicking of keys or mouse buttons to measure reaction time, permitted experimental testing of the hypothesis that individuals with anxiety disorders show biased attention to threat.² Considerable data have since accumulated supporting this hypothesis, including in children and adolescents.^1,3 However, reaction times measured by mouse button clicks are indirect and imprecise measurements of attention.⁴ With the availability of eye-tracking in the last decade, researchers have been able to directly and precisely measure attention. Lisk et al.,⁵ in this issue of the Journal, provide a systematic review and meta-analysis of studies that used eye-tracking to measure attention to threat in children and adolescents.

Systematic Review and Meta-Analysis: Eye-Tracking of Attention to Threat in Child and Adolescent Anxiety

OBJECTIVE

Attention biases for threat may reflect an early risk marker for anxiety disorders. Yet questions remain regarding the direction and time-course of anxiety-linked biased attention patterns in youth. A meta-analysis of eye-tracking studies of biased attention for threat was used to compare the presence of an initial vigilance toward threat and a subsequent avoidance in anxious and nonanxious youths.

METHOD

PubMed, PsycARTICLES, Medline, PsychINFO, and Embase were searched using anxiety, children and adolescent, and eye-tracking-related key terms. Study inclusion criteria were as follows: studies including participants ≤18 years of age; reported anxiety using standardized measures; measured attention bias using eye tracking with a free-viewing task; comparison of attention toward threatening and neutral stimuli; and available data to allow effect size computation for at least one relevant measure. A random effects model estimated between- and within-group effects of first fixations toward threat and overall dwell time on threat.

RESULTS

Thirteen eligible studies involving 798 participants showed that neither youths with or without anxiety showed significant bias in first fixation to threat versus neutral stimuli. However anxious youths showed significantly less overall dwell time on threat versus neutral stimuli than nonanxious controls (g = -0.26).

CONCLUSION

Contrasting with adult eye-tracking data and child and adolescent data from reaction time indices of attention biases to threat, there was no vigilance bias toward threat in anxious youths. Instead, anxious youths were more avoidant of threat across the time course of stimulus viewing. Developmental differences in brain circuits contributing to attention deployment to emotional stimuli and their relationship with anxiety are discussed.

Attention to Peer Feedback Through the Eyes of Adolescents with a History of Anxiety and Healthy Adolescents

During adolescence, youth may experience heightened attention bias to socially relevant stimuli; however, it is unclear if attention bias toward social threat may be exacerbated for adolescents with a history of anxiety. This study evaluated attentional bias during the Chatroom-Interact task with 25 adolescents with a history of anxiety (18F, Mage = 13.6) and 22 healthy adolescents (13F, Mage = 13.8). In this task, participants received feedback from fictional, virtual peers who either chose them (acceptance) or rejected them (rejection). Overall, participants were faster to orient toward and spent longer time dwelling on their own picture after both rejection and acceptance compared to non-feedback cues. Social feedback was associated with greater pupillary reactivity, an index of cognitive and emotional neural processing, compared to non-feedback cues. During acceptance feedback (but not during rejection feedback), anxious youth displayed greater pupil response compared to healthy youth, suggesting that positive feedback from peers may differentially influence youth with a history of an anxiety disorder.

Change in gaze-based attention bias in adolescents with Social Anxiety Disorder

Although attention bias (AB) toward threat has been associated with Social Anxiety Disorder (SAD), concerns regarding the ability of current measures to detect change in AB following treatment exist. We sought to examine change in bias, as measured via eye-tracking, in adolescents with SAD receiving either attention-bias modification training (ABMT) or attention-control training (ACT). Gaze-based AB was associated (r = -0.361) with symptoms of social anxiety prior to treatment, whereas there was no association between bias as measured via dot probe and social anxiety. Moreover, gaze-based bias to same-age face stimuli showed change following treatment. Large effects are seen for condition (ABMT or ACT) and for time, independent of treatment condition, in gaze-based AB to same-age stimuli. Findings suggest that further research on gaze-based bias, to assess stability over time outside of treatment and sensitivity to change following intervention, is warranted.

Visual attention to emotional faces in adolescents with social anxiety disorder receiving cognitive behavioral therapy

Social anxiety disorder (SAD) is a psychiatric condition that often onsets in childhood. Cognitive models underline the role of attention in the maintenance of SAD, but studies on youth populations are few, particularly those using eye tracking to measure attention. Cognitive behavioral therapy (CBT) for SAD includes interventions targeting attention, like exposure to eye contact, but the link between CBT and attention bias is largely unexplored. This study investigated attention bias in youth with SAD and the association with outcome from CBT. Latency to attend to pictures of faces with different emotions (vigilance) and latency to disengage from social stimuli (avoidance) was examined in N = 25 adolescents (aged 13–17) with SAD in relation to treatment outcome. Vigilance was operationalized as the time it took to relocate the gaze from a central position to a peripherally appearing social stimulus. The latency to disengage from a centrally located social stimulus, when a non-social stimulus appeared in the periphery, was used as a proxy for avoidance. Attention characteristics in the SAD group were compared to non-anxious (NA) controls (N = 22). Visual attention was measured using eye tracking. Participants in both the SAD and NA groups were vigilant towards angry faces, compared to neutral and happy faces. Similarly, both groups disengaged attention faster from angry faces. Adolescents with SAD who disengaged faster from social stimuli had less social anxiety after CBT. The results indicate that anxious youth display a vigilant-avoidant attention pattern to threat. However, partly inconsistent with previous research, the same pattern was observed in the NA group.

Difficulties with emotion regulation as a transdiagnostic mechanism linking child maltreatment with the emergence of psychopathology

Childhood maltreatment is associated with increased risk for most forms of psychopathology. We examine emotion dysregulation as a transdiagnostic mechanism linking maltreatment with general psychopathology. A sample of 262 children and adolescents participated; 162 (61.8%) experienced abuse or exposure to domestic violence. We assessed four emotion regulation processes (cognitive reappraisal, attention bias to threat, expressive suppression, and rumination) and emotional reactivity. Psychopathology symptoms were assessed concurrently and at a 2-year longitudinal follow-up. A general psychopathology factor (p factor), representing co-occurrence of psychopathology symptoms across multiple internalizing and externalizing domains, was estimated using confirmatory factor analysis. Maltreatment was associated with heightened emotional reactivity and greater use of expressive suppression and rumination. The association of maltreatment with attention bias varied across development, with maltreated children exhibiting a bias toward threat and adolescents a bias away from threat. Greater emotional reactivity and engagement in rumination mediated the longitudinal association between maltreatment and increased general psychopathology over time. Emotion dysregulation following childhood maltreatment occurs at multiple stages of the emotion generation process, in some cases varies across development, and serves as a transdiagnostic mechanism linking child maltreatment with general psychopathology.

Stationary and ambulatory attention patterns are differentially associated with early temperamental risk for socioemotional problems: Preliminary evidence from a multimodal eye-tracking investigation

Behavioral Inhibition (BI) is a temperament type that predicts social withdrawal in childhood and anxiety disorders later in life. However, not all BI children develop anxiety. Attention bias (AB) may enhance the vulnerability for anxiety in BI children, and interfere with their development of effective emotion regulation. In order to fully probe attention patterns, we used traditional measures of reaction time (RT), stationary eye-tracking, and recently emerging mobile eye-tracking measures of attention in a sample of 5- to 7-year-olds characterized as BI (N = 23) or non-BI (N = 58) using parent reports. There were no BI-related differences in RT or stationary eye-tracking indices of AB in a dot-probe task. However, findings in a subsample from whom eye-tracking data were collected during a live social interaction indicated that BI children (N = 12) directed fewer gaze shifts to the stranger than non-BI children (N = 25). Moreover, the frequency of gazes toward the stranger was positively associated with stationary AB only in BI, but not in non-BI, children. Hence, BI was characterized by a consistent pattern of attention across stationary and ambulatory measures. We demonstrate the utility of mobile eye-tracking as an effective tool to extend the assessment of attention and regulation to social interactive contexts.

Attentional bias and its temporal dynamics among war veterans suffering from chronic pain: Investigating the contribution of post-traumatic stress symptoms

BACKGROUND

Cognitive models propose that attentional dysregulation, including an attentional bias towards threat, is one of the factors through which chronic pain and post-traumatic stress symptoms (PTSS) maintain and exacerbate one another. The current investigation assessed the attentional bias for painful facial expressions and its relationship with PTSS, using both traditional and variability-based attentional bias measures, among veterans with chronic pain and PTSS and controls.

METHOD

Fifty-four veterans with chronic pain and 30 age/education-matched controls participated in this investigation. Participants completed a self-report measure of PTSS and a modified version of the dot-probe task with painful, happy, and neutral facial expressions. Attention was assessed using both traditional and variability-based reaction time measures of attentional bias.

RESULTS

Veterans directed attention away from painful facial expressions (i.e., avoidance) relative to both the control group (between-subject effect) and relative to neutral faces (within-subject effect). Veterans also showed significantly elevated attentional bias variability for both happy and painful facial expressions compared to controls. Attentional bias variability for happy and painful facial expressions was correlated with PTSS among all participants.

CONCLUSION

Veterans with chronic pain and PTSS avoided pain-related stimuli and displayed an overall attentional dysregulation for emotional facial expressions. Avoidance of pain cues may be a coping strategy that these individuals develop under stressful conditions. Implications, limitations, and directions for future research are discussed.

Anxiety-Linked Attentional Bias: Is It Reliable?

There is substantial evidence that heightened anxiety vulnerability is characterized by increased selective attention to threatening information. The reliability of this anxiety-linked attentional bias has become the focus of considerable recent interest. We distinguish between the potential inconsistency of anxiety-linked attentional bias and inconsistency potentially reflecting the psychometric properties of the assessment approaches used to measure it. Though groups with heightened anxiety vulnerability often exhibit, on average, elevated attention to threat, the evidence suggests that individuals are unlikely to each display a stable, invariant attentional bias to threat. Moreover, although existing assessment approaches can differentiate between groups, they do not exhibit the internal consistency or test-retest reliability necessary to classify individuals in terms of their characteristic pattern of attentional responding to threat. We discuss the appropriate uses of existing attentional bias assessment tasks and propose strategies for enhancing classification of individuals in terms of their tendency to display an attentional bias to threat.

Online Attention Bias Modification in Combination With Cognitive-Behavioural Therapy for Children and Adolescents With Anxiety Disorders: A Randomised Controlled Trial

Attention Bias Modification (ABM) targets attention bias (AB) towards threat, which is common in youth with anxiety disorders. Previous clinical trials showed inconsistent results regarding the efficacy of ABM, and few studies have examined the effect of online ABM and its augmented effect with cognitive behavioural therapy (CBT). The aim of the current study was to examine the efficacy of online ABM combined with CBT for children and adolescents with anxiety disorders in a randomised, double-blind, placebo-controlled trial. Children (aged 8–16 years) completed nine online sessions of ABM (n= 28) or online sessions of the Attention Control Condition (ACC;n= 27) over a period of 3 weeks (modified dot-probe task with anxiety disorder-congruent stimuli), followed by CBT. Primary outcomes were clinician-reported anxiety disorder status. Secondary outcomes were patient-reported anxiety and depression symptoms and AB. Results showed a continuous decrease across time in primary and secondary outcomes (ps < .001). However, no differences across time between the ABM and ACC group were found (ps > .50). Baseline AB and age did not moderate treatment effects. Online ABM combined with CBT does not show different efficacy compared with online ACC with CBT for children and adolescents with anxiety disorders.

An integrative review of the vigilance-avoidance model in pediatric anxiety disorders: Are we looking in the wrong place?

Enduring cognitive models of anxiety posit that negative biases in information processing are implicated in the etiology, maintenance, and recurrence of anxiety disorders in youth and adults. Specifically, the vigilance-avoidance model of attention is an influential hypothesis proposed to explain anxious individuals' attentional patterns. The vigilance-avoidance model posits that anxious individuals, relative to nonanxious individuals, initially orient more quickly to threatening stimuli and then later avoid threatening stimuli. However, a large body of empirical research examining attentional mechanisms in anxious individuals uses paradigms that do not allow the measurement of the time course of attention. Furthermore, existing reviews that examine the time course of attention only include studies with adults. We systematically review in depth the literature that compares anxious and non-anxious children that takes advantage of research designs that allow the examination of the time course of attention. Across studies, there is not robust support for the vigilance-avoidance model in samples of anxious youth. Future research examining attention biases across time should employ tasks that more directly measure multiple stages of attention, in order to assess if vigilance-avoidance patterns emerge based on sample characteristics or task variables, and to inform intervention efforts.

Intergenerational transmission of attentional bias and anxiety

Earlier evidence has revealed a bi-directional causal relationship between anxiety and attention biases in adults and children. This study investigated the prospective and concurrent relations between anxiety and attentional bias in a sample of 89 families (mothers, fathers, and first-born children). Parents' and children's attentional bias was measured when children were 7.5 years old, using both a visual probe task and visual search task with angry versus happy facial expressions. Generalized and social anxiety symptoms in parents and children were measured when children were 4.5 and 7.5 years old. Anxiety in parents and children was prospectively (but not concurrently) related to their respective attentional biases to threat: All participants showed a larger attentional bias to threat in the visual search (but not in the visual probe) task if they were more anxious at the 4.5 (but not at the 7.5) year measurement. Moreover, parents' anxiety levels were prospectively predictive of the visual search attentional bias of their children after controlling for child anxiety. More anxiety in mothers at 4.5 years was related to a faster detection of angry among happy faces, while more anxiety in fathers predicted a faster detection of happy among angry faces in children at 7.5 years. We found no direct association between parental and child attentional biases. Our study contributes to the recently emerging literature on attentional biases as a potential mechanism in the intergenerational transmission of anxiety by showing that parents' anxiety rather than parents' attentional bias contributes to the intergenerational transmission of risk for child anxiety.

Dispositional negativity, cognition, and anxiety disorders: An integrative translational neuroscience framework

When extreme, anxiety can become debilitating. Anxiety disorders, which often first emerge early in development, are common and challenging to treat, yet the underlying mechanisms have only recently begun to come into focus. Here, we review new insights into the nature and biological bases of dispositional negativity, a fundamental dimension of childhood temperament and adult personality and a prominent risk factor for the development of pediatric and adult anxiety disorders. Converging lines of epidemiological, neurobiological, and mechanistic evidence suggest that dispositional negativity increases the likelihood of psychopathology via specific neurocognitive mechanisms, including attentional biases to threat and deficits in executive control. Collectively, these observations provide an integrative translational framework for understanding the development and maintenance of anxiety disorders in adults and youth and set the stage for developing improved intervention strategies.

Associations Between Attentional Bias and Interpretation Bias and Change in School Concerns and Anxiety Symptoms During the Transition from Primary to Secondary School

The transition from primary to secondary school is often associated with a period of heightened anxiety and worry. For most children, any feelings of anxiety subside relatively quickly but for a small minority, emotional difficulties can continue into the first year of secondary school and beyond. This study recruited 109 children and measured their anxiety symptoms and school concerns toward the end of primary school and again at the end of their first term of secondary school. We investigated for the first time whether pre-transition measures of attentional and interpretation bias, and the magnitude of change in attentional bias toward and away from threat stimuli were associated with pre- and post-transition measures of anxiety and school concerns, and the change in these measures over time. Over 50% of the current sample exceeded clinical levels of anxiety at pre-transition. However, anxiety symptoms and school concerns had significantly reduced by post-transition. Higher levels of pre-transition anxiety or school concerns, and a greater magnitude of change in attentional bias towards threat stimuli predicted a larger reduction in anxiety symptoms and school concerns across the transition period. A greater interpretation bias toward threat was associated with higher pre-transition anxiety symptoms and school concerns but not post-transition scores, or the change in these scores. While many children experience heightened anxiety prior to school transition, this appears to be largely temporary and self-resolves. Nonetheless, the current findings highlight the importance of monitoring children's anxiety and concerns, and related cognitive processes during this important transition period.

Problematic attention processing and fear learning in adolescent anxiety: Testing a combined cognitive and learning processes model

BACKGROUND AND OBJECTIVES

Anxiety in adolescence is characterised by disturbances in attentional processes and the overgeneralisation of fear, however, little is known about the combined and reciprocal effects of and between these factors on youth anxiety. The present study investigated whether attention (attention allocation and control) and fear generalisation processes together predict more variance on adolescent anxiety symptoms than each factor in isolation, and explored their interrelations.

METHODS

197 adolescents completed a novel conditioning task, which paired balloon cues with mildly aversive or neutral outcomes. A spatial cueing task, and self-report measures of emotional attentional control and anxiety, were also completed.

RESULTS

Threat-avoidant attention allocation biases, impaired attention control, and exaggerated fear generalisation together predicted greater variance in anxiety symptoms (55.3%), than each set of fear and attention processes in isolation. Results also provided evidence of an interplay between these factors. Individual differences in threat-avoidant attention allocation biases predicted variability in the generalisation of fear, whilst the association between heightened anxiety and the overgeneralization of fear was moderated by poor attention control.

CONCLUSIONS

This study provides unique evidence of the combined effects of attention and fear generalisation mechanisms in explaining youth anxiety, and interrelations between these factors. Importantly, results suggested that deficiencies in attention control may bring out anxiety-associated impairments in fear generalisation.

LIMITATIONS

We relied on self-reported ratings of fear during generalization and also of attention control. Thus demand effects cannot be discounted. Reaction-time measures of attention focus are also indirect assessments of attention that may lack precision.

Threat-related Attention Bias in Socioemotional Development: A Critical Review and Methodological Considerations

Cross-sectional evidence suggests that attention bias to threat is linked to anxiety disorders and anxiety vulnerability in both children and adults. However, there is a lack of developmental evidence regarding the causal mechanisms through which attention bias to threat might convey risks for socioemotional problems, such as anxiety. Gaining insights into this question demands longitudinal research to track the complex interplay between threat-related attention and socioemotional functioning. Developing and implementing reliable and valid assessments tools is essential to this line of work. This review presents theoretical accounts and empirical evidence from behavioral, eye-tracking, and neural assessments of attention to discuss our current understanding of the development of normative threat-related attention in infancy, as well as maladaptive threat-related attention patterns that may be associated with the development of anxiety. This review highlights the importance of measuring threat-related attention using multiple attention paradigms at multiple levels of analysis. In order to understand if and how threat-related attention bias in real-life, social interactive contexts can predict socioemotional development outcomes, this review proposes that future research cannot solely rely on screen-based paradigms but needs to extend the assessment of threat-related attention to naturalistic settings. Mobile eye-tracking technology provides an effective tool for capturing threat-related attention processes in vivo as children navigate fear-eliciting environments and may help us uncover more proximal bio-psycho-behavioral markers of anxiety.

Neuroticism and Frontal EEG Asymmetry Correlated With Dynamic Facial Emotional Processing in Adolescents

The aim of this research was to investigate the link between resting frontal EEG asymmetry, neuroticism and the valence of emotional face processing in adolescents. Fifty right-handed adolescents (50% male; mean age = 14.20, SD = 1.97) were selected from schools in Mashhad. In order to investigate variables, we used BFQ-C, ADFES-BIV, and EEG. All data were analyzed using SPSS 22. The results showed that neuroticism correlates with the valences of fear, disgust, sadness, and surprise, but not with happiness, anger, and neutral faces. Furthermore, it was found that N was significantly positively correlated with mid-frontal asymmetry (F3-F4), and the lateral-frontal (F7-F8), whereas no correlation was found between N and frontal pole (Fp1-Fp2). We found significant negative correlations between the valence of fear, Fp1-Fp2, F3-F4, and F7-F8. The interaction findings revealed that neuroticism∗mid-frontal asymmetry can significantly affect the valence of fear. Therefore, neuroticism and mid-frontal EEG asymmetry may serve as a risk indicator for psychopathology.

Dimension-specific symptom patterns in trajectories of broad anxiety: A longitudinal prospective study in school-aged children

Theories of maladaptive anxiety in children have suggested different developmental trajectories across age. Weems (2008) suggested that one subgroup of children demonstrates high and stable levels of broad anxiety, but shifting levels of dimension-specific symptoms in part due to related normative challenges. In a prospective longitudinal design, the current study examined patterns of dimension-specific anxiety symptoms in subgroups of children following different developmental trajectories of broad anxiety. A total of 300 children (150 girls, 150 boys) ages 8–11 at baseline, completed the Spence Children's Anxiety Scale four times over 3 years. Using latent class growth mixture modeling, we found evidence of three subgroups of children following different trajectories of broad anxiety across age: low-stable, moderate-increasing, and high-decreasing. Compared with other children, the subgroup with moderate and increasing levels of broad anxiety demonstrated an initially higher level of separation anxiety with larger improvement across time but, initially, similar levels of generalized and social anxiety with a larger increase across age. High broad anxiety was partly carried by different sets of dimension-specific symptoms at different ages, which suggests that children with high levels of broad anxiety across time may be more sensitive to normative challenges that happen in typical child development.

Maternal pre- and postnatal anxiety symptoms and infant attention disengagement from emotional faces

BACKGROUND

Biases in socio-emotional attention may be early markers of risk for self-regulation difficulties and mental illness. We examined the associations between maternal pre- and postnatal anxiety symptoms and infant attention patterns to faces, with particular focus on attentional biases to threat, across male and female infants.

METHODS

A general population, Caucasian sample of eight-month old infants (N = 362) were tested using eye-tracking and an attention disengagement (overlap) paradigm, with happy, fearful, neutral, and phase-scrambled faces and distractors. Maternal self-reported anxiety symptoms were assessed with the Symptom Checklist-90/anxiety subscale at five time points between gestational week 14 and 6 months postpartum.

RESULTS

Probability of disengagement was lowest for fearful faces in the whole sample. Maternal pre- but not postnatal anxiety symptoms associated with higher threat bias in infants, and the relation between maternal anxiety symptoms in early pregnancy and higher threat bias in infants remained significant after controlling for maternal postnatal symptoms. Maternal postnatal anxiety symptoms, in turn, associated with higher overall probability of disengagement from faces to distractors, but the effects varied by child sex.

LIMITATIONS

The small number of mothers suffering from very severe symptoms. No control for the comorbidity of depressive symptoms.

CONCLUSIONS

Maternal prenatal anxiety symptoms associate with infant's heightened attention bias for threat. Maternal postnatal anxiety symptoms, in turn, associate with infant's overall disengagement probability differently for boys and girls. Boys may show enhanced vigilance for distractors, except when viewing fearful faces, and girls enhanced vigilance for all socio-emotional stimuli. Long-term implications of these findings remain to be explored.

Attention Bias Modification Treatment for Adolescents With Social Anxiety Disorder

Social anxiety disorder (SAD) tends to emerge during the early teenage years and is particularly refractory to change even when standard evidence-based CBT treatments are delivered. Efforts have been made to develop novel, mechanistic-driven interventions for this disorder. In the present study, we examined Attention Bias Modification Treatment (ABMT) for youth with SAD. Participants were 58 adolescents (mean age = 14.29 years) who met diagnostic criteria for SAD and who were randomized to ABMT or a placebo control condition, Attention Control Training (ACT). We predicted that ABMT would result in greater changes in both threat biases and social anxiety symptoms. We also explored potential moderators of change including the severity of social anxiety symptoms, the level of threat bias at pretreatment, and the degree of temperament-defined attention control. Contrary to our hypotheses, changes in attention bias were not observed in either condition, changes in social anxiety symptoms and diagnosis were small, and significant differences were not observed between the ABMT and ACT conditions. Little support for the proposed moderators was obtained. Reasons for our failure to find support for ABMT and its potential moderators are explored and recommendations for changes in the ABMT paradigm are suggested.

Vigilant attention to threat, sleep patterns, and anxiety in peripubertal youth

BACKGROUND

Vigilant attention to threat is commonly observed in anxiety, undergoes developmental changes in early adolescence, and has been proposed to interfere with sleep initiation and maintenance. We present one of the first studies to use objective measures to examine associations between vigilant attention to threat and difficulties initiating and maintaining sleep in an early adolescent anxious sample. We also explore the moderating role of development (age, puberty) and sex.

METHODS

Participants were 66 peripubertal youth (ages 9-14) with a primary anxiety disorder and 24 healthy control subjects. A dot-probe task was used to assess attentional bias to fearful relative to neutral face stimuli. Eye-tracking indexed selective attentional bias to threat, and reaction time bias indexed action readiness to threat. Sleep was assessed via actigraphy (e.g. sleep onset delay, wake after sleep onset, etc.), parent report (Children's Sleep Habits Questionnaire), and child report (Sleep Self-Report). The Pediatric Anxiety Rating Scale assessed anxiety severity.

RESULTS

Eye-tracking initial threat fixation bias (β = .33, p = .001) and threat dwell time bias (β = .22, p = .041) were positively associated with sleep onset latency. Reaction time bias was positively associated with wake after sleep onset (β = .24, p = .026) and parent-reported sleep disturbance (β = .25, p = .019). Anxiety (severity, diagnosis) was not associated with these outcomes. Sex (β = -.32, p = .036) moderated the relation between initial threat fixation bias and sleep onset latency, with a positive association for males (p = .005), but not for females (p = .289). Age and pubertal status did not moderate effects.

CONCLUSIONS

Vigilant attention to threat is related to longer sleep onset and reduced sleep maintenance. These associations are not stronger in early adolescents with anxiety. Implications for early intervention or prevention that targets vigilant attention to threat to impact sleep disturbance, and vice versa, are discussed.

Research Review: Is anxiety associated with negative interpretations of ambiguity in children and adolescents? A systematic review and meta-analysis

BACKGROUND

The tendency to interpret ambiguity as threat (negative interpretation) has been implicated in cognitive models of anxiety. A significant body of research has examined the association between anxiety and negative interpretation, and reviews suggest there is a robust positive association in adults. However, evidence with children and adolescents has been inconsistent. This study aimed to provide a systematic quantitative assessment of the association between anxiety and negative interpretation in children and adolescents.

METHOD

Following systematic searches and screening for eligibility, 345 effects sizes from 77 studies were meta-analysed.

RESULTS

Overall a medium positive association was found between anxiety and negative interpretation in children and adolescents ( d ^  = .62). Two variables significantly moderated this effect. Specifically, the association increased in strength with increasing age and when the content of ambiguous scenarios matched the anxiety subtype under investigation.

CONCLUSIONS

Results extend findings from adult literature by demonstrating an association in children and adolescents with evidence for content specificity in the association. Age effects imply a role for development. Results raise considerations for when and for whom clinical treatments for anxiety focusing on interpretation bias are appropriate. The vast majority of studies included in the review have used correlational designs and there are a limited number of studies with young children. The results should be considered with these limitations in mind.

Preschool Executive Control and Internalizing Symptoms in Elementary School

Depression and anxiety are prevalent and impairing forms of psychopathology in children and adolescents. Deficits in early executive control (EC) may contribute to the development of these problems, but longitudinal studies with rigorous measurement across key developmental periods are limited. The current study examines EC in preschool as a predictor of subsequent depression and anxiety symptoms in elementary school in a community sample (N = 280). Child participants completed a battery of nine developmentally-appropriate tasks designed to measure major aspects of EC at age 5 years, 3 months. Children later participated in an elementary school follow-up phase, during which they completed validated norm-referenced self-report questionnaires of depression and anxiety symptoms in fourth grade. Results indicate that poorer preschool EC was significantly associated with both greater depression and anxiety symptoms in elementary school, controlling for baseline depression and anxiety symptoms in preschool and other relevant variables. These findings suggest that poor EC may be an important risk factor for the development of internalizing psychopathology in childhood. Given emerging evidence for the modifiability of EC, particularly in preschool, EC promotion interventions may hold promise as a potential target in psychopathology prevention.

Integrating high-density ERP and fMRI measures of face-elicited brain activity in 9-12-year-old children: An ERP source localization study

Social information processing is a critical mechanism underlying children's socio-emotional development. Central to this process are patterns of activation associated with one of our most salient socioemotional cues, the face. In this study, we obtained fMRI activation and high-density ERP source data evoked by parallel face dot-probe tasks from 9-to-12-year-old children. We then integrated the two modalities of data to explore the neural spatial-temporal dynamics of children's face processing. Our results showed that the tomography of the ERP sources broadly corresponded with the fMRI activation evoked by the same facial stimuli. Further, we combined complementary information from fMRI and ERP by defining fMRI activation as functional ROIs and applying them to the ERP source data. Indices of ERP source activity were extracted from these ROIs at three a priori ERP peak latencies critical for face processing. We found distinct temporal patterns among the three time points across ROIs. The observed spatial-temporal profiles converge with a dual-system neural network model for face processing: a core system (including the occipito-temporal and parietal ROIs) supports the early visual analysis of facial features, and an extended system (including the paracentral, limbic, and prefrontal ROIs) processes the socio-emotional meaning gleaned and relayed by the core system. Our results for the first time illustrate the spatial validity of high-density source localization of ERP dot-probe data in children. By directly combining the two modalities of data, our findings provide a novel approach to understanding the spatial-temporal dynamics of face processing. This approach can be applied in future research to investigate different research questions in various study populations.

Subclinically Anxious Adolescents Do Not Display Attention Biases When Processing Emotional Faces - An Eye-Tracking Study

Recent research suggests that early difficulties with emotion regulation go along with an increased risk for developing psychiatric disorders, such as anxiety disorders for example. Adolescent anxiety is often referred to as a gateway disorder, due to its high predictability for lifelong persistent mental health problems. It has been shown that clinically anxious adolescents exhibit attention biases toward negative stimuli, yet whether these biases can also be found in the subclinical range of subclinically anxious adolescents is currently unclear. In this study, we set out to investigate this question by combining an emotional Go-Nogo task with eye-tracking techniques to assess attention biases for emotional faces in a subclinical sample of 23 subclinically anxious adolescent girls. This combined approach allowed us to look at both, behavioral and covert attention biases. Using both traditional and Bayesian hypothesis testing, we found no evidence for a bias toward negative, threat-relevant stimuli in the behavioral level or eye-tracking data. We believe that the results can help close a gap in the current literature by showing that like low-anxious adolescents, subclinically anxious adolescents do not exhibit attention biases when viewing de-contextualized emotional stimuli in the Overlap task. Together with previous research findings in clinically anxious participants which have reported high levels of attention biases, our results seem to suggest that attention biases do no increase linearly as a function of individual anxiety level. Future research is now needed to explore the contribution of additional factors, such as depression for example.

Children with social anxiety disorder show blunted pupillary reactivity and altered eye contact processing in response to emotional faces: Insights from pupillometry and eye movements

Cognitive models and adult research associate social anxiety disorder (SAD) with hypervigilant-avoidant processing of social information, such as eye contact. However, processing biases in childhood SAD remain mostly unexplored. We examined 10- to 13-year-old children's eye contact processing and pupil dilation in response to happy, neutral, and angry faces in three groups: SAD (n = 31), mixed anxiety disorders (MAD; n = 30), and healthy controls (HC; n = 32). Compared to HC, SAD children showed faster first fixations on the eye region of neutral faces and shorter first fixation durations on the eye region of all faces. No differences between the two clinical groups emerged in eye movement results. SAD girls showed reduced pupil dilation in response to happy and angry faces compared to MAD and to happy faces compared to HC. SAD boys showed reduced pupil dilation in response to neutral faces compared to HC. Dimensionally, reduced pupil dilation was linked to social anxiety severity while eye movements were correlated with mixed anxiety and depressive severity. Results suggest that hypervigilant-avoidant eye contact processing and a blunted pupillary reactivity characterize children with SAD. Both transdiagnostic and disorder-specific processing biases are relevant for the understanding of childhood SAD.

Attentional Bias in Children with Asthma with and without Anxiety Disorders

Children with asthma have a high prevalence of anxiety disorders, however, very little is known about the mechanisms that confer vulnerability for anxiety in this population. This study investigated whether children with asthma and anxiety disorders display attentional biases towards threatening stimuli, similar to what has been seen in children with anxiety disorders more generally. We also examined the relationships between attentional biases and anxiety symptomatology and asthma control for children with asthma. Ninety-three children, aged 8-13, took part in the study and were recruited into one of four conditions (asthma/anxiety, asthma, anxiety, control). Asthma was medically confirmed and anxiety was assessed through clinical interview. We used self- and parent-report questionnaires to measure child asthma (ATAQ) and anxiety (SCAS, CASI) variables. Participants completed a visual dot-probe task designed to measure attentional bias towards two types of stimuli: asthma related words and general threat words, as well as tasks to assess reading ability and attentional control. Results showed that attentional biases did not differ between the groups, although children with anxiety disorders displayed poorer attentional control. A significant correlation was found between poor asthma control and an attentional bias of asthma stimuli. While we found no evidence that anxiety disorders in children with asthma were associated with threat- or asthma-related attentional biases, preliminary evidence suggested that children with poor asthma control displayed biases towards asthma-specific stimuli. Future research is needed to explore whether these attentional biases are adaptive.

Attention bias for social threat in youth with tic disorders: Links with tic severity and social anxiety

Many individuals with Tourette syndrome and chronic tic disorders (TS/CTDs) report poor social functioning and comorbid social anxiety. Yet limited research has investigated the role of cognitive factors that highlight social threats in youth with TS/CTD, and whether these biases underlie tic severity and co-occurring social anxiety. This study examined whether selective attention to social threat is enhanced young people with TS/CTDs compared to healthy controls, and whether attention biases are associated with tic severity and social anxiety. Twenty seven young people with TS/CTDs and 25 matched control participants completed an experimental measure of attention bias toward/away from threat stimuli. A clinician-rated interview measuring tic severity/impairment (YGTSS Total Score) and questionnaire measures of social anxiety were completed by participants and their parents. Young people with TS/CTD showed an attention bias to social threat words (relative to benign words) compared to controls but no such bias for social threat faces. Attention bias for social threat words was associated with increasing YGTSS Total Score and parent-reported social anxiety in the TS/CTDs group. Mediation analysis revealed a significant indirect path between YGTSS Total Score and social anxiety, via attention to social threat. Tentatively, these associations appeared to be driven by impairment rather than tic severity scores. Preliminary data suggests that youth with TS/CTD have enhanced attention to threat, compared to controls, and this is associated with impairment and social anxiety. Attention to threat could offer a cognitive mechanism connecting impairment and social anxiety, and so be a valuable trans-diagnostic treatment target.

Anxiety and Attentional Bias to Threat in Children at Increased Familial Risk for Autism Spectrum Disorder

Anxiety and threat bias were examined in 6-8-year-old children at familial-risk for Autism Spectrum Disorder (ASD) and low-risk (LR, n = 37) controls. The high-risk (HR) group was divided into those who met diagnostic criteria for ASD (HR-ASD, n = 15) and those who did not (HR-non ASD, n = 24). The HR-ASD group had highest levels of parent-reported anxiety. The HR-non ASD group exhibited increased threat bias on a spatial-cueing task, while the HR-ASD group did not. Anxiety symptoms were associated with both threat bias and ASD severity. These findings suggest that the mechanisms underlying anxiety in HR siblings without ASD are similar to those in non-ASD populations. However, among children with ASD, hypersensitivity to threat may not underlie anxiety symptoms.

The Risk Factors of the Alcohol Use Disorders-Through Review of Its Comorbidities

Alcohol use disorders (AUDs) represent a severe, world-wide problem, and are usually comorbid with psychiatric disorders, comorbidity increases the risks associated with AUDs, and results in more serious consequences for patients. However, currently the underlying mechanisms of comorbid psychiatric disorders in AUDs are not clear. Studies investigating comorbidity could help us understand the neural mechanisms of AUDs. In this review, we explore three comorbidities in AUDs, including schizophrenia, major depressive disorder (MDD), and personality disorders (PDs). They are all co-morbidities of AUDs with rate of 33.7, 28, and 50–70%, respectively. The rate is significantly higher than other diseases. Therefore we review and analyze relevant literature to explore whether these three diseases are the risk factors of AUDs, focusing on studies assessing cognitive function and those using neural imaging. We found that memory deficits, impairment of cognitive control, negative emotion, and impulsivity may increase an individual's vulnerability to AUDs. This comorbidity may indicate the neural basis of AUDs and reveal characteristics associated with different types of comorbidity, leading to further development of new treatment approaches for AUDs.

Evaluating the Effectiveness of a School-Based Cognitive Behavioural Therapy Intervention for Anxiety in Adolescents Diagnosed with Autism Spectrum Disorder

This study evaluated the effectiveness of a school-based Cognitive Behavioural Therapy (CBT) on symptoms of anxiety, social worry and social responsiveness, and indices of attentional control and attentional biases to threat in adolescents diagnosed with Autism Spectrum Disorder. Thirty-five young people (11–14 years; IQ > 70) with ASD and elevated teacher or parent reported anxiety were randomly assigned to 6 sessions of the Exploring Feelings CBT intervention (Attwood in Exploring feelings (anxiety). Future Horizons, Arlington, 2004) (n = 18) or a wait-list control group (n = 17). The intervention (compared to the wait-list control) group showed positive change for parent, teacher and self-reported anxiety symptoms, and more marginal effects of increased teacher-reported social responsiveness. The discussion highlights the potential value and limitations of school-based CBT for young people with ASD.

Cognitive Bias Modification Reduces Social Anxiety Symptoms in Socially Anxious Adolescents with Mild Intellectual Disabilities: A Randomized Controlled Trial

The goal of this study was to examine the effects of Cognitive Bias Modification training for Interpretation (CBM-I) in socially anxious adolescents with Mild Intellectual Disabilities (MID). A total of 69 socially anxious adolescents with MID were randomly assigned to either a positive or a neutral control-CMB-I-training. Training included five sessions in a 3-week period, and each session consisted of 40 training items. Adolescents in the positive training group showed a significant reduction in negative interpretation bias on the two interpretation bias tasks after training compared to adolescents in the control-training group. Furthermore, in contrast to the control-training group, adolescents in the positive training reported a significant reduction of their social anxiety symptoms 10 weeks post-training.

Neural correlates of attention bias to masked facial threat cues: Examining children at-risk for social anxiety disorder

Background

Behavioral inhibition (BI) is an early-appearing temperament trait and a robust predictor of social anxiety disorder (SAD). Both BI and anxiety may have distinct patterns of emotion processing marked by heightened neural responses to threat cues. BI and anxious children display similar frontolimbic patterns when completing an emotion-face attention bias task with supraliminal presentation. Anxious children also show a distinct neural response to the same task with subliminal face presentations, probing stimulus-driven attention networks. We do not have parallel data available for BI children, limiting our understanding of underlying affective mechanisms potentially linking early BI to the later emergence of anxiety.

Method

We examined the neural response to subliminal threat presentation during an emotion-face masked dot-probe task in children oversampled for BI (N = 67; 30 BI, 9–12 yrs).

Results

Non-BI children displayed greater activation versus BI children in several regions in response to threat faces versus neutral faces, including striatum, prefrontal and temporal lobes. When comparing congruent and incongruent trials, which require attention disengagement, BI children showed greater activation than non-BI children in the cerebellum, which is implicated in rapidly coordinating information processing, aversive conditioning, and learning the precise timing of anticipatory responses.

Conclusions

Non-BI children may more readily engage rapid coordinated frontolimbic circuitry to salient stimuli, whereas BI children may preferentially engage subcortical circuitry, in response to limbic “alarms” triggered by subliminal threat cues. These data help reveal the extent to which temperamental risk shares similar neurocircuitry previously documented in anxious adolescents and young adults in response to masked threat.

•

All children displayed amygdala activation in response to brief threat cues.

•

Non-BI children displayed activation in striatum, PFC and temporal lobes.

•

BI children showed greater activation in the cerebellum.

Association between attention bias to threat and anxiety symptoms in children and adolescents

BACKGROUND

Considerable research links threat-related attention biases to anxiety symptoms in adults, whereas extant findings on threat biases in youth are limited and mixed. Inconsistent findings may arise due to substantial methodological variability and limited sample sizes, emphasizing the need for systematic research on large samples. The aim of this report is to examine the association between threat bias and pediatric anxiety symptoms using standardized measures in a large, international, multi-site youth sample.

METHODS

A total of 1,291 children and adolescents from seven research sites worldwide completed standardized attention bias assessment task (dot-probe task) and child anxiety symptoms measure (Screen for Child Anxiety Related Emotional Disorders). Using a dimensional approach to symptomatology, we conducted regression analyses predicting overall, and disorder-specific, anxiety symptoms severity, based on threat bias scores.

RESULTS

Threat bias correlated positively with overall anxiety symptoms severity (ß = 0.078, P = .004). Furthermore, threat bias was positively associated specifically with social anxiety (ß = 0.072, P = .008) and school phobia (ß = 0.076, P = .006) symptoms severity, but not with panic, generalized anxiety, or separation anxiety symptoms. These associations were not moderated by age or gender.

CONCLUSIONS

These findings indicate associations between threat bias and pediatric anxiety symptoms, and suggest that vigilance to external threats manifests more prominently in symptoms of social anxiety and school phobia, regardless of age and gender. These findings point to the role of attention bias to threat in anxiety, with implications for translational clinical research. The significance of applying standardized methods in multi-site collaborations for overcoming challenges inherent to clinical research is discussed.

The Moderating Effect of Self-Reported State and Trait Anxiety on the Late Positive Potential to Emotional Faces in 6-11-Year-Old Children

Introduction: The emergence of anxiety during childhood is accompanied by the development of attentional biases to threat. However, the neural mechanisms underlying these biases are poorly understood. In addition, previous research has not examined whether state and trait anxiety are independently associated with threat-related biases. Methods: We compared ERP waveforms during the processing of emotional faces in a population sample of 58 6-11-year-olds who completed self-reported measures of trait and state anxiety and depression. Results: The results showed that the P1 was larger to angry than neutral faces in the left hemisphere, though early components (P1, N170) were not strongly associated with child anxiety or depression. In contrast, Late Positive Potential (LPP) amplitudes to angry (vs. neutral) faces were significantly and positively associated with symptoms of anxiety/depression. In addition, the difference between LPPs for angry (vs. neutral) faces was independently associated with state and trait anxiety symptoms. Discussion: The results showed that neural responses to facial emotion in children with elevated symptoms of anxiety and depression were most evident at later processing stages characterized as evaluative and effortful. The findings support cognitive models of threat perception in anxiety and indicate that trait elements of anxiety and more transitory fluctuations in anxious affect are important in understanding individual variation in the neural response to threat in late childhood.

Cognitive Biases in Children and Adolescents With Chronic Pain: A Review of Findings and a Call for Developmental Research

Cognitive biases that emphasize bodily harm, injury, and illness could play a role in the maintenance of chronic pain by facilitating fear and avoidance. Whereas extensive research has established attention, interpretation, and memory biases in adults with chronic pain, far less is known about these same biases in children and adolescents with pain. Studying cognitive biases in attention, interpretation, and memory in relation to pain occurring in youth is important because youth is a time when pain can first become chronic, and when relationships between cognitive biases and pain outcomes emerge and stabilize. Thus, youth potentially offers a time window for the prevention of chronic pain problems. In this article, we summarize the growing corpus of data that have measured cognitive biases in relation to pediatric pain. We conclude that although biases in attention, interpretation, and memory characterize children and adolescents with varying pain experiences, questions regarding the direction, magnitude, nature, and role of these biases remain. We call for independent extension of cognitive bias research in children and adolescents, using well powered longitudinal studies with wide age ranges and psychometrically sound experimental measures to clarify these findings and any developmental trends in the links between cognitive biases and pain outcomes.

PERSPECTIVE

This article provides a rationale for the theoretical and practical importance of studying the role of cognitive biases in children and adolescents with chronic pain, which has to date, been relatively understudied. Existing findings are reviewed critically, and recommendations for future research are offered.

Amygdala-orbitofrontal structural and functional connectivity in females with anxiety disorders, with and without a history of conduct disorder

Conduct disorder (CD) and anxiety disorders (ADs) are often comorbid and both are characterized by hyper-sensitivity to threat, and reduced structural and functional connectivity between the amygdala and orbitofrontal cortex (OFC). Previous studies of CD have not taken account of ADs nor directly compared connectivity in the two disorders. We examined three groups of young women: 23 presenting CD and lifetime AD; 30 presenting lifetime AD and not CD; and 17 with neither disorder (ND). Participants completed clinical assessments and diffusion-weighted and resting-state functional MRI scans. The uncinate fasciculus was reconstructed using tractography and manual dissection, and structural measures extracted. Correlations of resting-state activity between amygdala and OFC seeds were computed. The CD + AD and AD groups showed similarly reduced structural integrity of the left uncinate compared to ND, even after adjusting for IQ, psychiatric comorbidity, and childhood maltreatment. Uncinate integrity was associated with harm avoidance traits among AD-only women, and with the interaction of poor anger control and anxiety symptoms among CD + AD women. Groups did not differ in functional connectivity. Reduced uncinate integrity observed in CD + AD and AD-only women may reflect deficient emotion regulation in response to threat, common to both disorders, while other neural mechanisms determine the behavioral response.

The CogBIAS longitudinal study protocol: cognitive and genetic factors influencing psychological functioning in adolescence

BACKGROUND

Optimal psychological development is dependent upon a complex interplay between individual and situational factors. Investigating the development of these factors in adolescence will help to improve understanding of emotional vulnerability and resilience. The CogBIAS longitudinal study (CogBIAS-L-S) aims to combine cognitive and genetic approaches to investigate risk and protective factors associated with the development of mood and impulsivity-related outcomes in an adolescent sample.

METHODS

CogBIAS-L-S is a three-wave longitudinal study of typically developing adolescents conducted over 4 years, with data collection at age 12, 14 and 16. At each wave participants will undergo multiple assessments including a range of selective cognitive processing tasks (e.g. attention bias, interpretation bias, memory bias) and psychological self-report measures (e.g. anxiety, depression, resilience). Saliva samples will also be collected at the baseline assessment for genetic analyses. Multilevel statistical analyses will be performed to investigate the developmental trajectory of cognitive biases on psychological functioning, as well as the influence of genetic moderation on these relationships.

DISCUSSION

CogBIAS-L-S represents the first longitudinal study to assess multiple cognitive biases across adolescent development and the largest study of its kind to collect genetic data. It therefore provides a unique opportunity to understand how genes and the environment influence the development and maintenance of cognitive biases and provide insight into risk and protective factors that may be key targets for intervention.