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

The impact of negative affect on attention patterns to threat across the first 2 years of life

The current study examined the relations between individual differences in attention to emotion faces and temperamental negative affect across the first 2 years of life. Infant studies have noted a normative pattern of preferential attention to salient cues, particularly angry faces. A parallel literature suggests that elevated attention bias to threat is associated with anxiety, particularly if coupled with temperamental risk. Examining the emerging relations between attention to threat and temperamental negative affect may help distinguish normative from at-risk patterns of attention. Infants (N = 145) ages 4 to 24 months (M = 12.93 months, SD = 5.57) completed an eye-tracking task modeled on the attention bias "dot-probe" task used with older children and adults. With age, infants spent greater time attending to emotion faces, particularly threat faces. All infants displayed slower latencies to fixate to incongruent versus congruent probes. Neither relation was moderated by temperament. Trial-by-trial analyses found that dwell time to the face was associated with latency to orient to subsequent probes, moderated by the infant's age and temperament. In young infants low in negative affect longer processing of angry faces was associated with faster subsequent fixation to probes; young infants high in negative affect displayed the opposite pattern at trend. Findings suggest that although age was directly associated with an emerging bias to threat, the impact of processing threat on subsequent orienting was associated with age and temperament. Early patterns of attention may shape how children respond to their environments, potentially via attention's gate-keeping role in framing a child's social world for processing. (PsycINFO Database Record

Cognitive bias modification: A review of meta-analyses

BACKGROUND

Cognitive bias modification (CBM) is a novel, but controversial intervention with considerable divergence amongst conclusions in individual studies and reviews. This systematic review synthesizes meta-analyses of CBM to determine whether CBM is effective, and what parameters most reliably evoke the process of CBM.

METHODS

A systematic literature search resulted in twelve meta-analyses in total, from which the published effect sizes were extracted.

RESULTS

Attention bias modification (ABM) shifted targeted biases in adults (ES = 0.24-1.16), was effective as a buffer to stressor vulnerability (ES = 0.33-0.77) and in symptom control (ES = 0.16-0.41). Cognitive bias modification for interpretation (CBM-I) modified targeted biases (ES = 0.52-0.81) but did not reliably reduce stressor vulnerability (ES = 0.01-0.24, p > .05). CBM consistently reduced anxiety symptoms, but effects on depressive symptomatology were less compelling. The long-term efficacy of CBM was only supported in addiction studies.

LIMITATIONS

The review included a single CBM-I only meta-analysis, and two meta-analyses with pooled reporting on ABM and CBM-I outcomes.

CONCLUSIONS

Overall, this synthesis shows CBM is effective in the short-term for anxiety in adults, and highlights some conditions under which CBM is most efficacious. Rather than debating the efficacy of CBM, future research should focus on developing procedures that more reliably induce bias modification and determining the most efficacious clinical applications.

Different patterns of attentional bias in antenatal and postpartum depression

BACKGROUND

Biased information processing in attention, memory, and interpretation is proposed to be central cognitive alterations in patients with major depressive disorder, but studies in women with peripartum depression are scarce. Because of the many similarities with depression in nonperipartum states as regards symptom profile and risk factors, we hypothesized that women with antenatal and postpartum depression would display attentional bias to negatively and positively valenced words.

METHODS

One hundred and seventy-seven pregnant and 157 postpartum women were included. Among these, 40 suffered from antenatal depressive disorder and 33 from postpartum depressive disorder. An emotional Stroop task with neutral, positive, negative, and negatively valenced obstetric words was used.

RESULTS

No significant difference in emotional interference scores was noted between women with antenatal depression and nondepressed pregnant women. In contrast, women with postpartum depression displayed shorter reaction times to both positive (p = .028) and negative (p = .022) stimuli, compared with neutral words. Pregnant women on antidepressant treatment displayed longer reaction times to negatively valenced obstetric words in comparison with untreated depressed women (p = .012), and a trend toward greater interference in comparison with controls (p = .061).

CONCLUSIONS

In contrast with the hypothesis, we found no evidence of attentional bias to emotionally valenced stimuli in women with untreated peripartum depression. However, the shorter reaction times to emotional stimuli in women with postpartum depression may indicate emotional numbing, which in turn, is a functional impairment that may have repercussions for child development and well-being. Our findings emphasize the need to identify and treat women with postpartum depression at the earliest possible time point to ensure swift recovery and support for the family.

Can less be more? Open trial of a stepped care approach for child and adolescent anxiety disorders

This open trial presents a stepped care treatment approach for youths with anxiety disorders. In Step 1, 124 youths (65 girls; M age=9.7years) participated in a low intensity computer administered attention bias modification (ABM) protocol. Statistically significant reductions in youth anxiety severity were found following Step 1. Youths and parents were then given the option to not continue with further treatment or step up to a higher intensity cognitive behavioral therapy (CBT) protocol (Step 2). Of 112 youths who completed Step 1, 67 (59.8%) discontinued treatment and 45 (40.2%) stepped up. Co-occurring ADHD and higher anxiety severity at baseline were significantly associated with the decision to step up. Of those youths who completed Step 2, additional statistically significant reductions in youth anxiety severity were found. Across the entire protocol, 68.6% of youths were rated as either very much improved or much improved on the Clinical Global Impressions-Improvement scale. In a hypothetical comparison in which all youths received CBT alone, the stepped care protocol resulted in approximately 50% less time in treatment sessions. These findings support the promise of initiating youth anxiety disorder treatment with low intensity treatment and then stepping up to higher intensity treatment as needed.

Attention bias to threat in mothers with emotional disorders predicts increased offspring anxiety symptoms: a joint cross-sectional and longitudinal analysis

There is convincing evidence of the transmission of anxiety and depression from parents to children; however, mechanisms by which this vulnerability is passed on are unclear. Cognitive models and a small body of cross-sectional research suggest that parental attention biases (ABs) may be one mechanism involved in transmission. Longitudinal associations of maternal and offspring ABs with offspring symptoms have been scarcely studied. Forty-three mothers-child dyads were included. All children (7-12 years old) were diagnosis-free while 24 mothers had a lifetime emotional disorder (anxiety or depression) (high risk, HR) and 19 mothers had no psychiatric diagnoses (low risk, LR). This study examined cross-sectional and longitudinal associations of maternal and child AB and child anxiety symptomology at initial and 12-month assessments. ABs were assessed using a visual-probe task with emotional faces. There was a significant cross-sectional but not longitudinal association of increased child anxiety symptoms with increased maternal threat AB for HR but not LR dyads. At the cross-sectional level, increases in HR but not LR offspring anxiety symptomology were associated with maternal threat AB. Larger longitudinal studies are required that examine the interplay between parent-child variables and include multiple time-points of assessment and measures of AB.

Attention Bias Modification (ABM): Review of Effects of Multisession ABM Training on Anxiety and Threat-Related Attention in High-Anxious Individuals

Attention bias modification (ABM) aims to reduce anxiety by reducing attention bias (AB) to threat; however, effects on anxiety and AB are variable. This review examines 34 studies assessing effects of multisession-ABM on both anxiety and AB in high-anxious individuals. Methods include ABM-threat-avoidance (promoting attention-orienting away from threat), ABM-positive-search (promoting explicit, goal-directed attention-search for positive/nonthreat targets among negative/threat distractors), and comparison conditions (e.g., control-attention training combining threat-cue exposure and attention-task practice without AB-modification). Findings indicate anxiety reduction often occurs during both ABM-threat-avoidance and control-attention training; anxiety reduction is not consistently accompanied by AB reduction; anxious individuals often show no pretraining AB in orienting toward threat; and ABM-positive-search training appears promising in reducing anxiety. Methodological and theoretical issues are discussed concerning ABM paradigms, comparison conditions, and AB assessment. ABM methods combining explicit goal-directed attention-search for nonthreat/positive information and effortful threat-distractor inhibition (promoting top-down cognitive control during threat-cue exposure) warrant further evaluation.

Young people with higher social anxiety are less likely to adopt the perspective of another: Data from the Director task

BACKGROUND AND OBJECTIVES

Young people with social anxiety display poor social functioning but it is unclear whether this is underscored by difficulties in key social cognitive abilities, such as perspective taking. Here, we examined whether increased social anxiety is associated with reduced accuracy on a perspective taking task and whether this relationship is stronger at particular periods within adolescence.

METHODS

Fifty-nine adolescents aged 11-19 years completed the computerised Director Task (DT) and the Social Anxiety Scale for Adolescence. In the DT, participants virtually move objects by following either instructions given by the 'Director' (who can see only some objects), or a simple rule to ignore certain objects.

RESULTS

Participants who scored above the clinical cut-off for social anxiety (n = 17) were less accurate when they had to take the perspective of the Director into account than those scoring below cut-off, yet performed similarly on control trials. Preliminary analysis indicated that poorer performance was most strongly associated with social anxiety in mid-adolescence (14-16.5 years).

LIMITATIONS

The DT has been used previously to measure online perspective taking but the underlying cognitive mechanisms have not been fully elucidated. Extending these findings using additional measures of perspective taking would be valuable.

CONCLUSIONS

Adolescents with higher social anxiety were less accurate at taking the perspective of a computerised character, with some suggestion that this relationship is strongest during mid-adolescence. If replicated, these findings highlight the importance of addressing specific social cognitive abilities in the assessment and treatment of adolescent social anxiety.

Gender Differences in the Difficulty in Disengaging from Threat among Children and Adolescents With Social Anxiety

There is some research showing that social anxiety is related with attentional bias to threat. However, others fail to find this relationship and propose that gender differences may play a role. The aim of this study was to investigate the gender differences in the subcomponents of attentional bias to threat (hypervigilance and difficulty in disengaging) among children and adolescents with social anxiety. Overall, 181 youngsters aged between 10 and 14 participated in the current study. Images of disgusted faces were used as threat stimuli in an Exogenous Cueing Task was used to measure the subcomponents of attentional bias. Additionally, the Social Anxiety Scale for Children was used to measure social anxiety. The repeated measures ANOVA showed that male participants with high social anxiety showed difficulty in disengaging from threat, but this was not the case for female participants. Our results indicated that social anxiety is more related with attentional bias to threat among male children and adolescents than females. These findings suggested that developing gender-specific treatments for social anxiety may improve treatment effects.

Annual Research Review: An expanded account of information-processing mechanisms in risk for child and adolescent anxiety and depression

BACKGROUND

Anxiety and depression occurring during childhood and adolescence are common and costly. While early-emerging anxiety and depression can arise through a complex interplay of 'distal' factors such as genetic and environmental influences, temperamental characteristics and brain circuitry, the more proximal mechanisms that transfer risks on symptoms are poorly delineated. Information-processing biases, which differentiate youth with and without anxiety and/or depression, could act as proximal mechanisms that mediate more distal risks on symptoms. This article reviews the literature on information-processing biases, their associations with anxiety and depression symptoms in youth and with other distal risk factors, to provide direction for further research.

METHODS

Based on strategic searches of the literature, we consider how youth with and without anxiety and/or depression vary in how they deploy attention to social-affective stimuli, discriminate between threat and safety cues, retain memories of negative events and appraise ambiguous information. We discuss how these information-processing biases are similarly or differentially expressed on anxiety and depression and whether these biases are linked to genetic and environmental factors, temperamental characteristics and patterns of brain circuitry functioning implicated in anxiety and depression.

FINDINGS

Biases in attention and appraisal characterise both youth anxiety and depression but with some differences in how these are expressed for each symptom type. Difficulties in threat-safety cue discrimination characterise anxiety and are understudied in depression, while biases in the retrieval of negative and overgeneral memories have been observed in depression but are understudied in anxiety. Information-processing biases have been studied in relation to some distal factors but not systematically, so relationships remain inconclusive.

CONCLUSIONS

Biases in attention, threat-safety cue discrimination, memory and appraisal may characterise anxiety and/or depression risk. We discuss future research directions that can more systematically test whether these biases act as proximal mechanisms that mediate other distal risk factors.

Attention allocation and social worries predict interpretations of peer-related social cues in adolescents

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Across scenes, increasing social anxiety was associated with greater endorsement of negative interpretations.

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Greater attentional deployment to peers predicted increased endorsements of negative interpretations.

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Self-relevant scenes yielded more negative interpretations.

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Older adolescents selected more benign interpretations.

Adolescence is a sensitive period for increases in normative but also debilitating social fears and worries. As the interpretation of interpersonal cues is pertinent to social anxiety, investigating mechanisms that may underlie biases in social cue appraisal is important.

Fifty-one adolescents from the community aged 14–19 were presented with self- and other-relevant naturalistic social scenes for 5 s and then required to rate either a negative or a positive interpretation of the scene. Eye-tracking data were collected during the free viewing period to index attentional deployment. Individual differences in social worries were measured via self-report.

Social anxiety levels significantly predicted biases in interpretation ratings across scenes. Additionally, cumulative attentional deployment to peer cues also predicted these interpretation biases: participants who spent more time on facial displays perceived more threat, i.e. endorsed more negative and less positive interpretations. Self-relevant scenes yielded greater tendencies to draw negative interpretations. Finally, older adolescents also selected more benign interpretations.

Social anxiety is associated with a bias in interpreting social cues; a cognitive bias that is also influenced by attentional deployment. This study contributes to our understanding of the possible attention mechanisms that shape cognitions relevant to social anxiety in this at-risk age group.

Sustained visual attention for competing emotional stimuli in social anxiety: An eye tracking study

BACKGROUND AND OBJECTIVES

Numerous studies have supported attentional biases toward social threats in socially anxious individuals. The aim of the present study was to investigate the time-course of sustained attention for multiple emotional stimuli using a free-viewing paradigm in social anxiety.

METHODS

Thirty-two socially anxious (SA) and 30 non-anxious (NA) participants completed the free-viewing task. Participants were presented with a face array composed of angry, sad, happy and neutral faces for 10 s in each trial. Eye movements were recorded throughout the trial to assess the time-course of attentional processing.

RESULTS

Although SA participants did not exhibit initial orienting bias, they had higher fixation probability for angry faces during the 250-1000 ms time intervals, relative to NA participants. SA participants also maintained their attention longer than NA participants did when angry faces were initially fixated upon. Moreover, NA participants showed higher fixation probability for happy faces during the 6-8 s after stimulus onset. We failed to observe attentional avoidance of threat in SA participants.

LIMITATIONS

First, this study used a non-clinical sample. Second, the stimuli used in this study were static.

CONCLUSIONS

The present findings suggest that, relative to non-anxious individuals, socially anxious individuals are characterized by enhanced engagement with social threat at an early stage of processing and difficulty in disengaging from social threat once their initial attention is located on it. Conversely, non-anxious individuals are characterized by enhanced engagement with positive stimuli at a later stage of processing.

Hypervigilance-avoidance in children with anxiety disorders: magnetoencephalographic evidence

BACKGROUND

An altered pattern of threat processing is deemed critical for the development of anxiety disorders (AD). According to the hypervigilance-avoidance hypothesis, AD patients show hypervigilance to threat cues at early stages of processing but avoid threat cues at later stages of processing. Consistently, adults with AD show enhanced neurophysiological responses to threat in early time windows and reduced responses to threat in late time windows. The presence of such a hypervigilance-avoidance effect and its underlying neural sources remain to be determined in clinically anxious children.

METHODS

Twenty-three children diagnosed with an AD and 23 healthy control children aged 8-14 years saw faces with angry and neutral expressions while whole-head magnetoencephalography (MEG) was recorded. Neural sources were estimated based on L2-Minimum Norm inverse source modeling and analyzed in early, midlatency, and late time windows.

RESULTS

In visual cortical regions, early threat processing was relatively enhanced in patients compared to controls, whereas this relation was inverted in a late interval. Consistent with the idea of affective regulation, the right dorsolateral prefrontal cortex revealed relatively reduced inhibition of early threat processing but revealed enhanced inhibition at a late interval in patients. Both visual-sensory and prefrontal effects were correlated with individual trait anxiety.

CONCLUSIONS

These results support the hypothesis of early sensory hypervigilance followed by later avoidance of threat in anxiety disordered children, presumably modulated by early reduced and later enhanced prefrontal inhibition. This neuronal hypervigilance-avoidance pattern unfolds gradually with increasing trait anxiety, reflecting a progressively biased allocation of attention to threat.

A developmental neuroscience perspective on affect-biased attention

There is growing interest regarding the impact of affect-biased attention on psychopathology. However, most of the research to date lacks a developmental approach. In the present review, we examine the role affect-biased attention plays in shaping socioemotional trajectories within a developmental neuroscience framework. We propose that affect-biased attention, particularly if stable and entrenched, acts as a developmental tether that helps sustain early socioemotional and behavioral profiles over time, placing some individuals on maladaptive developmental trajectories. Although most of the evidence is found in the anxiety literature, we suggest that these relations may operate across multiple domains of interest, including positive affect, externalizing behaviors, drug use, and eating behaviors. We also review the general mechanisms and neural correlates of affect-biased attention, as well as the current evidence for the co-development of attention and affect. Based on the reviewed literature, we propose a model that may help us better understand the nuances of affect-biased attention across development. The model may serve as a strong foundation for ongoing attempts to identify neurocognitive mechanisms and intervene with individuals at risk. Finally, we discuss open issues for future research that may help bridge existing gaps in the literature.

Slope climbing challenges, fear of heights, anxiety and time of the day

When exposed to an unfamiliar open space, animals experience fear and attempt to find an escape route. Anxiety emerges when animals are confronted with a challenging obstacle to this fear motivated escape. High anxiety animals do not take risks; they avoid the challenge. The present experiments investigated this risk avoidant behavior in mice. In experiment 1, BALB/c, C57BL/6J and CD-1 mice were exposed to a large platform with downward inclined steep slopes attached on two opposite sides. The platform was elevated 75 and 100cm from the ground, in a standard (SPDS) and in a raised (RPDS) configuration, respectively. In experiment 2, the platform was elevated 75cm from the ground. Mice had to climb onto a stand at the top of upward inclined slopes (SPUS). In experiment 3, BALB/c mice were exposed to SPDS with steep or shallow slopes either in early morning or in late afternoon. In all 3 test configurations, mice spent more time in the areas adjacent to the slopes than in the areas adjacent to void, however only C57BL/6J and CD-1 crossed onto the slopes in SPDS, and crossed onto the stands in SPUS whereas BALB/c remained on the platform in SPDS and explored the slopes in SPUS. Elevation of the platform from the ground reduced the crossings onto the slopes in C57BL/6J and CD-1, and no differences were observed between BALB/c and C57BL/6J. BALB/c mice demonstrated no difference in anxiety when tested early morning or late afternoon; they crossed onto shallow slopes and avoided the steep one.

Attention bias in the developmental unfolding of post-traumatic stress symptoms in young children at risk

BACKGROUND

Threat-related attention bias relates to anxiety and posttraumatic stress symptoms in adults and adolescents, but few longitudinal studies examine such associations in young children. This study examines prospective relations among attention bias, trauma exposure, and anxiety and trauma symptoms in a sample previously reported to manifest cross-sectional associations between attention bias and observed anxiety at preschool age.

METHODS

Young children [mean (MN) = 5.0, ±0.7 years, n = 208] from a community-based sample completed the dot-probe task to assess their attention biases in response to angry faces. At baseline (T1) and at follow-up approximately 9 months later (T2), anxiety and trauma exposure (i.e. violent and noninterpersonal events) and symptoms were assessed by maternal report.

RESULTS

Neither attention bias nor baseline or recent trauma exposure predicted later anxiety. In contrast, attention bias toward threat and recent trauma exposure significantly predicted later trauma symptoms. There was evidence of symptom specificity such that attention bias toward threat significantly predicted hyperarousal and dissociation, but not avoidance or re-experiencing symptoms. Finally, moderation analyses indicated that the relationship between attention bias and trauma symptoms may differ according to children's experiences of probable abuse.

CONCLUSIONS

Attention profiles and trauma exposure may increase the risk that young children will develop trauma symptoms. Individual differences in these attentional patterns and children's exposure history may impact outcomes among high-risk children with potential implications for intervention.

Early maltreatment effects on adolescent attention control to non-emotional and emotional distractors

Objective

Early maltreatment increases lifetime risk of psychopathology. Emerging models suggest that exposure to maltreatment leads to changes in cognitive processes associated with the processing of threat, including processes of selective attention. Existing data may be interpreted to suggest that maltreatment is associated with an automatic attentional engagement with threatening cues, or that maltreatment is associated with generally poorer attention control. Using a pair of attention tasks, this study sought to examine whether maltreatment was associated with threat‐related interference on attention processing and if this could be explained by poorer attentional control capacity.

Method

Fifty‐one maltreated adolescents from an out‐of‐home care sample in New South Wales, Australia were recruited to complete two attention tasks. Data from 24 of these participants were compared with that of a sample of non‐maltreated peers matched on gender, age, cognitive ability, and household income to identify maltreatment‐associated group differences. Data from all participants were then used to explore the degree to which attention variables correlated with continuous measures of internalising symptoms, subtypes, and severity of maltreatment.

Results

On the first task, maltreated adolescents showed significant interference from an irrelevant but non‐emotional distractor on reaction times when completing a central letter identification task under low perceptual task conditions. On the second task, maltreated adolescents also showed similar interference on a probe‐identification task that involved ignoring threatening (angry face) distractors, again under low perceptual load.

Conclusions

These data may suggest difficulties exercising attention control following early maltreatment. These may contribute to the emergence of psychiatric disorders and other difficulties for those exposed to maltreatment.

Looking at the self in front of others: Neural correlates of attentional bias in social anxiety

In social anxiety disorder (SAD), anxiety reactions are triggered by attentional bias to social threats that automatically appear in social situations. The present study aimed to investigate the neural basis and underlying resting-state pathology of attentional bias toward internal and external social threats as a core element of SAD. Twenty-two patients with SAD and 20 control subjects scanned functional magnetic resonance imaging during resting-state and while performing the visual search task. During the task, participants were exposed to internal threat (hearing participants' own pulse-sounds) and external threat (crowds in facial matrices). Patients showed activations in the lateral orbitofrontal cortex, rostral anterior cingulate cortex and insula in response to internal threat and activations in the posterior cingulate cortex and middle temporal gyrus in response to external threat. In patients, neural activity related to combined internal and external threats in the posterior cingulate cortex was inversely correlated with the functional connectivity strengths with the default mode network during resting-state. These findings suggest that attentional bias may stem from limbic and paralimbic pathology, and the interactive process of internally- and externally-focused attentional bias in SAD is associated with the self-referential function of resting-state.

Working Memory Training and CBT Reduces Anxiety Symptoms and Attentional Biases to Threat: A Preliminary Study

Research indicates that cognitive processes linked to the detection of threat stimuli are associated with poor attentional control, placing children and adolescents at increased risk for the development of anxious affect. The current study aimed to provide preliminary data to assess whether an intervention designed to improve attentional control (via working memory; WM) would lead to better performance in tests of WM and would be associated with positive changes in symptoms of trait and test anxiety, increased inhibitory control and reduced attention to threat. Forty adolescents aged 11-14 years who reported elevated anxiety and low attentional control were randomly allocated to a WM training or an active cognitive behavioural therapy (CBT) control group. Post intervention, WM training was associated with greater improvements (versus. CBT) in trained WM tasks. Both groups, however, reported fewer anxiety symptoms, demonstrated increased inhibitory control and a reduction in attentional biases to threat post intervention and these results were maintained at follow up. The study provides indicative evidence which suggests that WM training has similar benefits to a more traditional CBT intervention on reduced anxiety and attentional biases for threat. Future research should aim to replicate the findings in a large sample size and explore the broader impact of training on day-to-day functioning. In addition, further research is needed to identify which participants benefit most from different interventions (using baseline characteristics) on treatment compliance and outcome.

The neurobiology of dispositional negativity and attentional biases to threat: Implications for understanding anxiety disorders in adults and youth

When extreme, anxiety can become debilitating. Anxiety disorders, which often first emerge early in development, are common and challenging to treat, yet the neurocognitive mechanisms that confer increased risk have only recently begun to come into focus. Here we review recent work highlighting the importance of neural circuits centered on the amygdala. We begin by describing dispositional negativity, a core dimension of childhood temperament and adult personality and an important risk factor for the development of anxiety disorders and other kinds of stress-sensitive psychopathology. Converging lines of epidemiological, neurophysiological, and mechanistic evidence indicate that the amygdala supports stable individual differences in dispositional negativity across the lifespan and contributes to the etiology of anxiety disorders in adults and youth. Hyper-vigilance and attentional biases to threat are prominent features of the anxious phenotype and there is growing evidence that they contribute to the development of psychopathology. Anatomical studies show that the amygdala is a hub, poised to govern attention to threat via projections to sensory cortex and ascending neuromodulatory systems. Imaging and lesion studies demonstrate that the amygdala plays a key role in selecting and prioritizing the processing of threat-related cues. Collectively, these observations provide a neurobiologically-grounded framework for understanding the development and maintenance of anxiety disorders in adults and youth and set the stage for developing improved intervention strategies.