Vigilance and Avoidance of Threat in the Eye Movements of Children with Separation Anxiety Disorder

To Leave is to Die a Little: Assessing the Symptom Structure of Separation Anxiety Disorder in Left-Behind Emerging Adults

The literature on separation anxiety disorder (SAD) presented two contentious issues relating to its assessment. First, studies are scarce in assessing the symptom structure of DSM-5 SAD among the adult population. Second, the accuracy in assessing the severity of SAD through measuring the intensity of disturbance and the frequency of occurrence of symptoms is yet to be studied. To address these limitations, the present study aimed to: (1) examine the latent factor structure of the newly developed separation anxiety disorder symptom severity inventory (SADSSI); (2) evaluate the necessity of using frequency or intensity formats through comparison of differences in the latent level; and (3) investigate SAD latent class analysis. Utilizing 425 left-behind emerging adults (LBA), the findings showed that a general factor with two dimensions (i.e., response formats) measuring frequency and intensity symptom severity separately has excellent fit and good reliability. Finally, the latent class analysis yielded a three-class solution best fitting to the data. Overall, the data provided evidence for the psychometric soundness of SADSSI as an assessment tool for separation anxiety symptoms among LBA.

Attention allocation in OCD: A systematic review and meta-analysis of eye-tracking-based research

INTRODUCTION

Cognitive models of obsessive-compulsive disorder (OCD) implicate heightened attention allocation to stimuli related to one's obsessions in the disorder. Recently, to overcome several limitations of reaction time-based measures, eye-tracking methodology has been increasingly used in attentional research.

METHODS

A meta-analysis of studies examining attention allocation towards OCD-related vs. neutral stimuli, using eye-tracking methodology and a group-comparison design, was conducted conforming to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Separate meta-analyses were performed for attentional vigilance (both latency and location of first fixations) and maintenance (total dwell time and total fixation count, conjointly). Each meta-analysis was conducted twice - once including all studies (main analysis) and once only including studies using the free-viewing paradigm (secondary analysis).

RESULTS

The systematic search yielded a total of nine studies. Of those, eight provided the needed data to be included in the meta-analysis. No evidence emerged for vigilance via latency to first fixation. Vigilance reflected via first fixation location emerged in the main analysis, but not in the secondary one. Evidence for attentional maintenance was found only when analyzing free-viewing studies exclusively (the secondary analysis).

LIMITATIONS

To increase the accuracy of the research question, correlational studies were excluded, resulting in a small number of available studies.

CONCLUSIONS

OCD may be characterized by vigilance, but mainly in tasks entailing specific demands and/or goals. Conversely, attentional maintenance may be evident only when using tasks that pose no requirements or demands for participants.

Bochum Assessment of Avoidance-based Emotion Regulation for Children (BAER-C): Development and evaluation of a new instrument measuring anticipatory avoidance-based emotion regulation in anxiety eliciting situations

Avoidance-based emotion regulation plays a central role in the development and maintenance of anxiety disorders across the life span. However, measures for children that account for different avoidance strategies, are scarce. Derived from Gross' Process Model of Emotion Regulation, the Bochum Assessment of Avoidance-based Emotion Regulation for Children (BAER-C) was developed to assess avoidance strategies (cognitive avoidance, behavioural avoidance, verbal reassurance, and social reassurance) and reappraisal in anticipatory anxious situations. In the present study, the BAER-C was administered to 129 school children aged 8 to 14 and 199 children with anxiety disorders aged 8 to 16 and their parents, along with established measures on anxiety, psychopathology, and emotion regulation. Factor structure, internal consistency, convergent, divergent and construct validity were analysed. Results of the anxious sample showed a satisfactory internal consistency (McDonald's ω = .94) for all scales as well as positive correlations with anxiety symptoms (all rs > .17, all ps < .05). Factor analysis supported a five-factor model. This model was confirmed in the student sample. Children with an anxiety disorder scored higher on behavioural avoidance, verbal reassurance, and social reassurance than school children (F (5,304) = 12.63, p = .003, ηp2 = .17). Results for construct validity were ambiguous. Our analyses suggest that the BAER-C is a promising theory-based new instrument to reliably assess different avoidance strategies in children. More research is needed to further analyse construct validity with other emotion regulation questionnaires.

Relationships between attention to emotion and anxiety among a community sample of adolescents

BACKGROUND

Attentional bias to threat has been implicated as a cognitive mechanism in anxiety disorders for youth. Yet, prior studies documenting this bias have largely relied on a method with questionable reliability (i.e. dot-probe task) and small samples, few of which included adolescents. The current study sought to address such limitations by examining relations between anxiety - both clinically diagnosed and dimensionally rated - and attentional bias to threat.

METHODS

The study included a community sample of adolescents and employed eye-tracking methodology intended to capture possible biases across the full range of both automatic (i.e. vigilance bias) and controlled attentional processes (i.e. avoidance bias, maintenance bias). We examined both dimensional anxiety (across the full sample; n = 215) and categorical anxiety in a subset case-control analysis (n = 100) as predictors of biases.

RESULTS

Findings indicated that participants with an anxiety disorder oriented more slowly to angry faces than matched controls. Results did not suggest a greater likelihood of initial orienting to angry faces among our participants with anxiety disorders or those with higher dimensional ratings of anxiety. Greater anxiety severity was associated with greater dwell time to neutral faces.

CONCLUSIONS

This is the largest study to date examining eye-tracking metrics of attention to threat among healthy and anxious youth. Findings did not support the notion that anxiety is characterized by heightened vigilance or avoidance/maintenance of attention to threat. All effects detected were extremely small. Links between attention to threat and anxiety among adolescents may be subtle and highly dependent on experimental task dimensions.

Eye-tracking to assess anxiety-related attentional biases among a large sample of preadolescent children

A considerable body of research in adults has demonstrated that anxiety disorders are characterised by attentional biases to threat. Findings in children have been inconsistent. The present study examined anxiety-related attention biases using eye tracking methodology in 463 preadolescents between 10 and 12 years of age, of whom 92 met criteria for a DSM-5 anxiety disorder and 371 did not. Preadolescent's gaze was recorded while they viewed adolescent face pairs depicting angry-neutral and happy-neutral expressions with each face pair presented for 5000 ms. No group differences were observed across any eye tracking indices including probability of first fixation direction, latency to first fixation, first fixation duration and dwell time. The sample overall showed faster initial attention towards threat cues, followed by a later broadening of attention away from threat. There is a need to identify the types of threats and the developmental period during which visual attention patterns of anxious and non-anxious youth diverge to inform more developmentally sensitive treatments.

The role of ventromedial and dorsolateral prefrontal cortex in attention and interpretation biases in individuals with general anxiety disorder (GAD): A tDCS study

BACKGROUND

and purpose of the study: Individuals with general anxiety disorder (GAD) have deficits in emotional and cognitive processing, including cognitive bias, which plays a causal role in anxiety. Hyperactivity of the ventromedial prefrontal cortex (vmPFC) and dorsolateral prefrontal cortex (dlPFC) is assumed to be involved in cognitive bias. We aimed to explore the causal contribution of the dorsolateral and ventromedial prefrontal cortices (dlPFC, vmPFC) on cognitive bias via non-invasive brain stimulation, and expected a bias-reducing effect of cortical activity enhancement over these areas in GAD, with a larger contribution of the vmPFC to perceptual, and of the dlPFC to interpretation bias.

MATERIAL AND METHODS

The study was conducted in a randomized, single-blinded, and complete crossover design. Thirty-four adults with GAD, received transcranial direct current stimulation (tDCS) in 5 separate sessions (1.5 mA, 20 min) with the following electrode montages: anodal dlPFC/cathodal vmPFC, anodal vmPFC/cathodal dlPFC, anodal dlPFC/cathodal right shoulder, anodal vmPFC/cathodal left shoulder, and sham stimulation. During stimulation, in each session, participants performed the Dot-Probe and Reading Mind from Eyes tests to measure attention and interpretation biases.

RESULTS

A significant effect of stimulation condition on attention and interpretation biases was observed. Anodal vmPFC and dlPFC stimulation coupled with an extracranial cathodal electrode reduced attention bias to threat-related stimuli in the dot-probe test. Furthermore, anodal dlPFC/cathodal vmPFC stimulation reduced negative interpretation bias in reading from eyes test.

CONCLUSION

As suggested by the results of this study, both dlPFC and vmPFC are involved in cognitive bias in GAD, but with partially different roles. Anodal stimulation over the right vmPFC and the left dlPFC reduced attention bias, supporting the relevance of these areas for attention bias. For interpretation bias, the significant effect of anodal dlPFC/cathodal vmPFC stimulation, but only trendwise effect of anodal tDCS over the dlPFC combined with an extracephalic return electrode is in accordance with a predominant effect of the dlPFC on interpretation bias, but does not rule out an additional minor involvement of the vmPFC. Based on these results, a new model is suggested for the neural underpinnings of anxiety symptoms.

Neural sensitivity to trustworthiness cues from realistic face images is associated with temperament: An electrophysiological study with 6-month-old infants

Discriminating facial cues to trustworthiness is a fundamental social skill whose developmental origins are still debated. Prior investigations used computer-generated faces, which might fail to reflect infants' face processing expertise. Here, Event-Related Potentials (ERPs) were recorded in Caucasian adults (N = 20, 7 males, M age = 25.25 years) and 6-month-old infants (N = 21, 10 males) in response to variations in trustworthiness intensity expressed by morphed images of realistic female faces associated with explicit trustworthiness judgments (Study 1). Preferential looking behavior in response to the same faces was also investigated in infants (N = 27, 11 males) (Study 2). ERP results showed that both age groups distinguished subtle stimulus differences, and that interindividual variability in neural sensitivity to these differences were associated with infants' temperament. No signs of stimulus differentiation emerged from infants' looking behavior. These findings contribute to the understanding of the developmental origins of human sensitivity to social cues from faces by extending prior evidence to more ecological stimuli and by unraveling the mediating role of temperament.

Initial Maintenance of Attention to Threat in Children with Social Anxiety Disorder? Findings from an Eye-Tracking Experiment

Background

Attentional biases are assumed to be a core feature in the etiology and maintenance of clinical anxiety. The present study focuses on initial maintenance of attention to threat, one of three attentional components investigated the least, particularly in child anxiety.

Methods

Angry and neutral facial expressions were presented in a free-viewing task, while eye-movements were recorded. Participants were N = 96 school-aged children, with n = 50 children with a clinical social anxiety disorder (SAD) and n = 46 healthy control children (HC). Prior to the task, social stress was induced in half of participating children to investigate the impact of increased levels of distress on initial attention allocation.

Results

The length of first fixation to angry faces in children with SAD neither differed from the length of first fixation to neutral faces nor the length of first fixation to angry faces in HC children. Furthermore, this variable was not affected by a stress induction procedure. However, children with SAD initially fixated longer on faces than HC children.

Conclusion

Our findings provide evidence for difficulties disengaging attention from faces. This may indicate that attention allocation is determined by the social nature of the stimuli rather than by the specific emotional valence.

Attention Deployment to the Eye Region of Emotional Faces among Adolescents with and without Social Anxiety Disorder

BACKGROUND

Avoidance of the eye region, especially of faces showing anger, may maintain social anxiety symptoms by negatively reinforcing expectations and fears associated with social situations. Eye-tracking research, however, has yet to explicitly examine differences in attention allocation to the eye region of emotional faces among adolescents with social anxiety disorder (SAD).

METHODS

Gaze patterns were explored in a sample of youth with and without SAD matched on age and sex.

RESULTS

Adolescents with SAD were quicker to fixate, and maintained their initial gaze longer, to the eye region, regardless of emotion, relative to teens without SAD. Group-level differences also emerged for initial fixation duration directed to the eye region of angry faces (when compared with happy faces).

CONCLUSIONS

These findings suggest that vigilance to the eye region of faces, especially angry faces, (when compared with happy faces) is characteristic of adolescents with SAD. Adolescents with SAD seem drawn to the eye region, more so than teens without SAD.

Restricted Visual Scanpaths During Emotion Recognition in Childhood Social Anxiety Disorder

Background: Social anxiety disorder (SAD) has its typical onset in childhood and adolescence. Maladaptive processing of social information may contribute to the etiology and maintenance of SAD. During face perception, individuals execute a succession of visual fixations known as a scanpath which facilitates information processing. Atypically long scanpaths have been reported in adults with SAD, but no data exists from pediatric samples. SAD has also been linked to atypical arousal during face perception. Both metrics were examined in one of the largest eye-tracking studies of pediatric SAD to date. Methods: Participants were children and adolescents with SAD (n = 61) and healthy controls (n = 39) with a mean age of 14 years (range 10-17) who completed an emotion recognition task. The visual scanpath and pupil dilation (an indirect index of arousal) were examined using eye tracking. Results: Scanpaths of youth with SAD were shorter, less distributed, and consisted of a smaller number of fixations than those of healthy controls. These findings were supported by both frequentist and Bayesian statistics. Higher pupil dilation was also observed in the SAD group, but despite a statistically significant group difference, this result was not supported by the Bayesian analysis. Conclusions: The results were contrary to findings from adult studies, but similar to what has been reported in neurodevelopmental conditions associated with social interaction impairments. Restricted scanpaths may disrupt holistic representation of faces known to favor adaptive social understanding.

Anxiety-Related Attention Bias in Four- to Eight-Year-Olds: An Eye-Tracking Study

(1) Background: There is evidence of an attention bias–anxiety relationship in children, but lack of appropriate methods has limited the number of studies with children younger than eight years old. This study used eye tracking as a measure of overt attention in young children. The aim of this study was to assess anxiety-related attention bias in children aged four to eight years. Age was considered a moderator, and the influence of effortful control was investigated. (2) Method: A community sample of 104 children was shown pairs of happy–neutral and angry–neutral faces. Growth curve analyses were used to examine patterns of gaze over time. (3) Results: Analyses revealed moderation by age and anxiety, with distinct patterns of anxiety-related biases seen in different age groups in the angry–neutral face trials. Effortful control did not account for age-related effects. (4) Conclusions: The results support a moderation model of the development of anxiety in children.

Attentional processing of information related to illness: Biases and associations with emotional response in young adults with different levels of illness anxiety

This study investigated attentional processing of illness-related information and associations with emotional reactivity. 100 young adults with low to high illness anxiety levels underwent free and cued viewing tasks, while eye-tracking and emotional reactivity were recorded. During free viewing, participants showed early orienting bias and sustained vigilance bias toward illness vs neutral pictures. Increased illness anxiety predicted vigilance bias to illness vs fearful pictures. During cued viewing, participants showed avoidance bias for illness vs neutral pictures, predicted by greater cardiac acceleration. Task nature appears to influence attentional processing patterns of illness stimuli. Preliminary evidence supports that attention allocation may be an emotion regulation mechanism.

A neurobiological framework of separation anxiety and related phenotypes

In the DSM-5, separation anxiety disorder (SAD) is newly classified in the chapter on anxiety, renewing research efforts into its etiology. In this narrative review, we summarize the current literature on the genetic, endocrine, physiological, neural and neuropsychological underpinnings of SAD per se, SAD in the context of panic disorder, separation anxiety symptoms, and related intermediate phenotypes. SAD aggregates in families and has a heritability of ~43%. Variants in the oxytocin receptor, serotonin transporter, opioid receptor µ1, dopamine D4 receptor and translocator protein genes have all been associated with SAD. Dysregulation of the hypothalamus-pituitary-adrenal axis, dysfunctional cortico-limbic interaction and biased cognitive processing seem to constitute further neurobiological markers of separation anxiety. Hypersensitivity to carbon dioxide appears to be an endophenotype shared by SAD, panic disorder and anxiety sensitivity. The identification of biological risk markers and its multi-level integration hold great promise regarding the prediction of SAD risk, maintenance and course, and in the future may allow for the selection of indicated preventive and innovative, personalized therapeutic interventions.

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.

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.

Pupil dilation to emotional expressions in adolescent social anxiety disorder is related to treatment outcome

Atypical attention to potential social threats, such as emotional faces, may be one of the core mechanisms underlying social anxiety disorder (SAD). Pupil dilation is an index of locus coreuleus-noradrenergic activity, and closely linked to attention. In the present study, pupil dilation was studied in adolescents with SAD (N = 26; 22 Female) before the onset of a 12-week cognitive behavioral treatment, and in healthy controls (N = 23). Stimuli were faces with angry or happy emotional expressions. Contrary to our hypothesis, the SAD group did not show hyper-responsiveness to angry compared to happy faces. Instead, an atypical time course of the pupil dilation response was found, resulting in an attenuated response during late time stages. Larger pupil dilation amplitude to happy faces before treatment was related to worse treatment response. These results contribute significantly to our understanding of the mechanisms underlying adolescent SAD.

Heterogeneity of the Anxiety-Related Attention Bias: A Review and Working Model for Future Research

The anxiety-related attention bias (AB) has been studied for several decades as a clinically-relevant output of the dynamic and complex threat detection-response system. Despite research enthusiasm for the construct of AB, current theories and measurement approaches cannot adequately account for the growing body of mixed, contradictory, and null findings. Drawing on clinical, neuroscience, and animal models, we argue that the apparent complexity and contradictions in the empirical literature can be attributed to the field's failure to clearly conceptualize AB heterogeneity and the dearth of studies in AB that consider additional cognitive mechanisms in anxiety, particularly disruptions in threat-safety discrimination and cognitive control. We review existing research and propose a working model of AB heterogeneity positing that AB may be best conceptualized as multiple subtypes of dysregulated processing of and attention to threat anchored in individual differences in threat-safety discrimination and cognitive control. We review evidence for this working model and discuss how it can be used to advance knowledge of AB mechanisms and inform personalized prevention and intervention approaches.

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.

Can worry and physiological anxiety uniquely predict children and adolescents' academic achievement and intelligence?

When exploring the relationship anxiety has with IQ, academic achievement studies often rely on diagnostic groups or total scores for an anxiety measure. The differential effects caused by anxiety dimensions, as well as their interactions, were examined with an exploratory method. This study examined the main effect of worry and physiological anxiety as predictors of youths' academic and cognitive functioning. Two samples of youth that presented to an out-patient clinic (n = 121, M = 10.59, SD = 2.78, range = 6-16; n = 92, M = 10.07, SD = 2.76, range = 6-16) were administered well-established performance measures of academic and intellectual functioning, along with a measurement of anxiety. In an exploratory analysis, the interaction between worry and physiological anxiety was the only significant effect, robust across all academic composites and intelligence indices. Physiological anxiety had a differential relationship with academic achievement domains (and processing speed) dependent on levels of worry; low-levels of worry were predictive of improved scores at high, but not low-, levels of physiological anxiety. In contrast, high-, but not low-, levels of physiological anxiety were associated with lower scores when accompanied by elevated levels of worry when predicting intelligence indices.

Attention biases and social-emotional development in preschool-aged children who have been exposed to domestic violence

BACKGROUND

School-aged children and adolescents exposed to domestic violence (DV) disproportionality attend to threatening and sad cues in their environment. This bias in attention has been found to predict elevations in symptoms of psychopathology. Studies have yet to explore attention biases using eyetracking technology in preschool-aged children with DV exposure.

OBJECTIVE

This study investigated whether preschool-aged children exposed to DV show vigilance to angry and sad faces versus happy faces and a target non-face stimulus relative to non-exposed children, and whether such vigilance relates to child social-emotional development.

PARTICIPANTS AND SETTING

Preschool-aged children were recruited from a large, diverse, urban community. DV-exposed children were recruited from a dyadic, mother-child treatment group specifically designed for, and restricted to, mothers who have experienced domestic violence (DV-exposed group, n = 23). Children with no prior exposure to DV and their mothers were recruited within the same community (non-exposed group, n = 32).

METHODS

Children completed an eye-tracking task to assess their attention to face stimuli and mothers rated their children's social-emotional development. Total duration of fixations were analyzed.

RESULTS

Results showed that DV-exposed children have a significantly stronger attention bias away from sad faces (p = 0.03; d = 0.62) and neutral faces (p = 0.02; d = 0.70) relative to non-exposed children, and this attention bias away from sad and neutral faces is associated with child social-emotional problems. Contrary to our hypothesis, no bias towards anger was found for DV-exposed versus non-exposed children.

CONCLUSIONS

This study contributes to growing evidence that young children's negative attention biases influence functioning and have important implications for children's well-being and development.

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.

Attentional Avoidance for Guilty Knowledge Among Deceptive Individuals

The purpose of the present study is to differentiate between innocent suspects who have knowledge of crime information and guilty suspects. The study investigated eye-movement differences among three groups: a guilty group who took part in a mock crime, an innocent-aware group who did not commit a mock crime but were exposed to the crime stimuli, and an innocent-unaware group who neither committed a mock crime nor had crime-relevant information. Each group's eye movements were tracked while all participants viewed stimuli (crime-relevant, crime-irrelevant, and neutral). The results revealed that the guilty group not only viewed all stimuli later than the other groups, they also viewed crime-relevant and crime-irrelevant stimuli for a shorter time period than the innocent-aware group; the innocent-aware group focused their attention on crime-relevant and crime-irrelevant stimuli longer than neutral stimuli, and the innocent-unaware group showed no differences in their attention focus among all types of stimuli. This present study suggests that guilty individuals show attentional avoidance from all stimuli in a lie detection situation, whereas innocent-aware and innocent-unaware individuals did not show avoidance responses.

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.

The Influence of Social Communication Impairments on Gaze in Adolescents with Social Anxiety Disorder

Adolescents with social anxiety disorder (SAD) often present distorted beliefs related to expected social rejection, coupled with avoidance of social stimuli including interpersonal interactions and others' gaze. Social communication (SC) deficits, often seen in SAD, may play a role in avoidance of social stimuli. The present study evaluated whether SC impairment uniquely contributes to diminished or heightened attention to social stimuli. Gaze patterns to social stimuli were examined in a sample of 41 adolescents with SAD (12-16 years of age; 68% female). Unexpectedly, no significant relationship was observed between SC impairment and fixation duration to angry or neutral faces. However, SC impairment did predict greater fixation duration to happy faces, after controlling for social anxiety severity [adjusted R ²  = 0.201, F(2, 38) = 4.536, p = 0.018]. Clinical implications are discussed, focusing on the potential utility of targeting SC impairments directly in light of the role of SC difficulties in youth with SAD.

Variability of attention bias in socially anxious adolescents: differences in fixation duration toward adult and adolescent face stimuli

Prior research on attention bias in anxious youth, often utilising a visual dot probe task, has yielded inconsistent findings, which may be due to how bias is assessed and/or variability in the phenomenon. The present study utilises eye gaze tracking to assess attention bias in socially anxious adolescents, and explores several methodological and within-subject factors that may contribute to variability in attention bias. Attention bias to threat was measured in forty-two treatment-seeking adolescents (age 12-16 years) diagnosed with Social Anxiety Disorder. Bias scores toward emotional stimuli (vigilant attention) and bias scores away from emotional stimuli (avoidant attention) were explored. Bias scores changed between vigilance and avoidance within individuals and over the course of stimulus presentation. These differences were not associated with participant characteristics nor with self-reported social anxiety symptoms. However, clinician rated severity of social anxiety, explained a significant proportion of variance in the bias scores for adult, but not the adolescent, stimuli. Variability in attention bias among socially anxious adolescents is common and varies as a function of stimulus duration and type. Results may inform stimulus selection for future research.

Do Interoceptive Sensations Provoke Fearful Responses in Adolescents With Chronic Headache or Chronic Abdominal Pain? A Preliminary Experimental Study

Objective

To determine whether fear can be triggered when experiencing interoceptive sensations locally proximal to the primary pain region.  Two groups of adolescents (11-18 years) with chronic headache ( n  = 20) or chronic abdominal pain (CAP; n  = 20) completed three muscle tensing tasks to induce proximal versus distal sensations: (1) "frown" task (proximal for chronic headache; distal for CAP), (2) "tighten stomach" task (proximal for CAP; distal for chronic headache), and (3) safe comparison task (clench fist). Fear and avoidance were assessed via self-report. Adolescents with CAP reported greater fear and avoidance after the proximal compared with the distal task, while adolescents with chronic headache did not. Both groups reported similar levels of fear and avoidance in the frown and safe comparison task.  Results suggest that the perception of proximal interoceptive sensations appears to activate the fear system in adolescents with CAP. Future research is warranted.

Visual processing of one's own body over the course of time: Evidence for the vigilance-avoidance theory in adolescents with anorexia nervosa?

OBJECTIVE

The vigilance-avoidance theory postulates a specific threat-related pattern of attention deployment, characterized by initial orientation towards fear-evoking stimuli and subsequent directing of attention away from them. The current eye-tracking study was the first to examine the applicability of the theory for patients with eating disorders, who perceive their own body as a highly aversive, threat-evoking stimulus.

METHOD

N = 56 female adolescents with anorexia nervosa (AN) and n = 43 healthy controls (HC) aged 13-18 viewed own-body pictures while their eye movements were recorded. Relative fixation times on self-defined unattractive body areas were compared between the groups by sequencing the overall presentation time of 6,000 ms into six intervals à 1,000 ms.

RESULTS

Participants with AN showed a significantly stronger attentional bias for unattractive body areas than HC within the time intervals 1, 2, and 3. However, for intervals 4, 5, and 6, no significant group differences occurred. Within the AN group, the bias for unattractive body areas was significantly stronger in interval 1 compared to intervals 4, 5, and 6; whereas within the HC group, a stable pattern of attention deployment emerged. In AN, early attention deployment was positively correlated with the negative affect reported after photo presentation.

DISCUSSION

The early vigilance in AN and the subsequent decrease in attention to unattractive body parts is in line with our assumptions. However, no indication of attentional avoidance was found. The current findings partially support the vigilance-avoidance theory for the exposure to one's own body in adolescents with AN.

Serotonin 5-HTTLPR Genotype Modulates Reactive Visual Scanning of Social and Non-social Affective Stimuli in Young Children

Previous studies have documented the 5-HTTLPR polymorphisms as genetic variants that are involved in serotonin availability and also associated with emotion regulation and facial emotion processing. In particular, neuroimaging and behavioral studies of healthy populations have produced evidence to suggest that carriers of the Short allele exhibit heightened neurophysiological and behavioral reactivity when processing aversive stimuli, particularly in brain regions involved in fear. However, an additional distinction has emerged in the field, which highlights particular types of fearful information, i.e., aversive information which involves a social component versus non-social aversive stimuli. Although processing of each of these stimulus types (social and non-social) is believed to involve a subcortical neural system which includes the amygdala, evidence also suggests that the amygdala itself may be particularly responsive to socially significant environmental information, potentially due to the critical relevance of social information for humans. Examining individual differences in neurotransmitter systems which operate within this subcortical network, and in particular the serotonin system, may be critically informative for furthering our understanding of the neurobiological mechanisms underlying responses to emotional and affective stimuli. In the present study we examine visual scanning patterns in response to both aversive and positive images of a social or non-social nature in relation to 5-HTTLPR genotypes, in 49 children aged 4–7 years. Results indicate that children with at least one Short 5-HTTLPR allele spent less time fixating the threat-related non-social stimuli, compared with participants with two copies of the Long allele. Interestingly, a separate set of analyses suggests that carriers of two copies of the short 5-HTTLPR allele also spent less time fixating both the negative and positive non-social stimuli. Together, these findings support the hypothesis that genetically mediated differences in serotonin availability mediate behavioral responses to different types of emotional stimuli in young children.

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.

Try to look on the bright side: Children and adults can (sometimes) override their tendency to prioritize negative faces

We used eye tracking to examine 4- to 10-year-olds' and adults' (N = 173) visual attention to negative (anger, fear, sadness, disgust) and neutral faces when paired with happy faces in 2 experimental conditions: free-viewing ("look at the faces") and directed ("look only at the happy faces"). Regardless of instruction, all age groups more often looked first to negative versus positive faces (no age differences), suggesting that initial orienting is driven by bottom-up processes. In contrast, biases in more sustained attention-last looks and looking duration-varied by age and could be modified by top-down instruction. On the free-viewing task, all age groups exhibited a negativity bias which attenuated with age and remained stable across trials. When told to look only at happy faces (directed task), all age groups shifted to a positivity bias, with linear age-related improvements. This ability to implement the "look only at the happy faces" instruction, however, fatigued over time, with the decrement stronger for children. Controlling for age, individual differences in executive function (working memory and inhibitory control) had no relation to the free-viewing task; however, these variables explained substantial variance on the directed task, with children and adults higher in executive function showing better skill at looking last and looking longer at happy faces. Greater anxiety predicted more first looks to angry faces on the directed task. These findings advance theory and research on normative development and individual differences in the bias to prioritize negative information, including contributions of bottom-up salience and top-down control. (PsycINFO Database Record

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.

Stimulus-Driven Attention, Threat Bias, and Sad Bias in Youth with a History of an Anxiety Disorder or Depression

Attention biases towards threatening and sad stimuli are associated with pediatric anxiety and depression, respectively. The basic cognitive mechanisms associated with attention biases in youth, however, remain unclear. Here, we tested the hypothesis that threat bias (selective attention for threatening versus neutral stimuli) but not sad bias relies on stimulus-driven attention. We collected measures of stimulus-driven attention, threat bias, sad bias, and current clinical symptoms in youth with a history of an anxiety disorder and/or depression (ANX/DEP; n = 40) as well as healthy controls (HC; n = 33). Stimulus-driven attention was measured with a non-emotional spatial orienting task, while threat bias and sad bias were measured at a short time interval (150 ms) with a spatial orienting task using emotional faces and at a longer time interval (500 ms) using a dot-probe task. In ANX/DEP but not HC, early attention bias towards threat was negatively correlated with later attention bias to threat, suggesting that early threat vigilance was associated with later threat avoidance. Across all subjects, stimulus-driven orienting was not correlated with early threat bias but was negatively correlated with later threat bias, indicating that rapid stimulus-driven orienting is linked to later threat avoidance. No parallel relationships were detected for sad bias. Current symptoms of depression but not anxiety were related to decreased stimulus-driven attention. Together, these results are consistent with the hypothesis that threat bias but not sad bias relies on stimulus-driven attention. These results inform the design of attention bias modification programs that aim to reverse threat biases and reduce symptoms associated with pediatric anxiety and depression.

Attentional avoidance of fearful facial expressions following early life stress is associated with impaired social functioning

BACKGROUND

Early life stress is associated with poorer social functioning. Attentional biases in response to threat-related cues, linked to both early experience and psychopathology, may explain this association. To date, however, no study has examined attentional biases to fearful facial expressions as a function of early life stress or examined these biases as a potential mediator of the relation between early life stress and social problems.

METHODS

In a sample of 154 children (ages 9-13 years) we examined the associations among interpersonal early life stressors (i.e., birth through age 6 years), attentional biases to emotional facial expressions using a dot-probe task, and social functioning on the Child Behavior Checklist.

RESULTS

High levels of early life stress were associated with both greater levels of social problems and an attentional bias away from fearful facial expressions, even after accounting for stressors occurring in later childhood. No biases were found for happy or sad facial expressions as a function of early life stress. Finally, attentional biases to fearful faces mediated the association between early life stress and social problems.

CONCLUSIONS

Attentional avoidance of fearful facial expressions, evidenced by a bias away from these stimuli, may be a developmental response to early adversity and link the experience of early life stress to poorer social functioning.

Anxiety and Attentional Bias in Preschool-Aged Children: An Eyetracking Study

Extensive research has examined attentional bias for threat in anxious adults and school-aged children but it is unclear when this anxiety-related bias is first established. This study uses eyetracking technology to assess attentional bias in a sample of 83 children aged 3 or 4 years. Of these, 37 (19 female) met criteria for an anxiety disorder and 46 (30 female) did not. Gaze was recorded during a free-viewing task with angry-neutral face pairs presented for 1250 ms. There was no indication of between-group differences in threat bias, with both anxious and non-anxious groups showing vigilance for angry faces as well as longer dwell times to angry over neutral faces. Importantly, however, the anxious participants spent significantly less time looking at the faces overall, when compared to the non-anxious group. The results suggest that both anxious and non-anxious preschool-aged children preferentially attend to threat but that anxious children may be more avoidant of faces than non-anxious children.

Vigilance in the laboratory predicts avoidance in the real world: A dimensional analysis of neural, behavioral, and ecological momentary data in anxious youth

Vigilance and avoidance of threat are observed in anxious adults during laboratory tasks, and are posited to have real-world clinical relevance, but data are mixed in anxious youth. We propose that vigilance-avoidance patterns will become evident in anxious youth through a focus on individual differences and real-world strategic avoidance. Decreased functional connectivity between the amygdala and prefrontal cortex (PFC) could play a mechanistic role in this link. 78 clinically anxious youth completed a dot-probe task to assess vigilance to threat while undergoing fMRI. Real-world avoidance was assessed using Ecological Momentary Assessment (EMA) of self-reported suppression and distraction during negative life events. Vigilance toward threat was positively associated with EMA distraction and suppression. Functional connectivity between a right amygdala seed region and dorsomedial and right dorsolateral PFC regions was inversely related to EMA distraction. Dorsolateral PFC-amygdalar connectivity statistically mediated the relationship between attentional vigilance and real-world distraction. Findings suggest anxious youth showing attentional vigilance toward threat are more likely to use suppression and distraction to regulate negative emotions. Reduced PFC control over limbic reactivity is a possible neural substrate of this pattern. These findings lend ecological validity to laboratory vigilance assessments and suggest PFC-amygdalar connectivity is a neural mechanism bridging laboratory and naturalistic contexts.

Attentional biases to emotional stimuli: Key components of the RDoC constructs of sustained threat and loss

Biased attention to emotional stimuli plays a key role in the RDoC constructs of Sustained Threat and Loss. In this article, we review approaches to assessing these biases, their links with psychopathology, and the underlying neural influences. We then review evidence from twin and candidate gene studies regarding genetic influences on attentional biases. We also discuss the impact of developmental and environmental influences and end with a number of suggestions for future research in this area.

Time Course of Visual Attention to High-Calorie Virtual Food in Individuals with Bulimic Tendencies

The aim of the present study was to use an eye-tracking device to investigate attention bias and its mechanism toward high-calorie virtual food in individuals with bulimic tendencies (BT). A total of 76 participants were divided into two groups: a BT group (n = 38) and a control group (n = 38). The eye movements of all participants were continuously measured while the participants were confronted with pairs of high-calorie, low-calorie, and nonfood virtual stimuli (pictures). It was found that the BT group detected high-calorie food more quickly than they did the low-calorie food and nonfood stimuli, but they also avoided the high-calorie food. These results indicate that individuals with BT automatically allocate their attention toward high-calorie food and, subsequently, try to avoid it. Based on these results, we suggest that this approach-avoidance pattern for high-calorie virtual food could be a factor in the development and maintenance of bulimia symptoms by encouraging individuals with BT to be in conflict with the urge to overeat.

Threats, rewards, and attention deployment in anxious youth and adults: An eye tracking study

The current study examines anxiety and age associations with attention allocation and physiological response to threats and rewards. Twenty-two healthy-adults, 20 anxious-adults, 26 healthy-youth, and 19 anxious-youth completed two eye-tracking tasks. In the Visual Scene Task (VST), participants' fixations were recorded while they viewed a central neutral image flanked by two threatening or two rewarding stimuli. In the Negative Words Task (NWT), physiological response was measured by means of pupil diameter change while negative and neutral words were presented. For both tasks, no interaction was found between anxiety and age-group. In the VST, anxious participants avoided the threatening images when groups were collapsed across age. Similarly, adults but not adolescents avoided the threatening images when collapsed across anxiety. No differences were found for rewarding images. In NWT, all subjects demonstrated increase in pupil dilation after word presentation. Only main effect of age emerged with stronger pupil dilation in adults than children. Finally, maximum pupil change was correlated with threat avoidance bias in the scene task. Gaze patterns and pupil dilation show that anxiety and age are associated with attention allocation to threats. The relations between attention and autonomic arousal point to a complex interaction between bottom-up and top-down processes as they relate to attention allocation.

Selective looking at natural scenes: Hedonic content and gender

Choice viewing behavior when looking at affective scenes was assessed to examine differences due to hedonic content and gender by monitoring eye movements in a selective looking paradigm. On each trial, participants viewed a pair of pictures that included a neutral picture together with an affective scene depicting either contamination, mutilation, threat, food, nude males, or nude females. The duration of time that gaze was directed to each picture in the pair was determined from eye fixations. Results indicated that viewing choices varied with both hedonic content and gender. Initially, gaze duration for both men and women was heightened when viewing all affective contents, but was subsequently followed by significant avoidance of scenes depicting contamination or nude males. Gender differences were most pronounced when viewing pictures of nude females, with men continuing to devote longer gaze time to pictures of nude females throughout viewing, whereas women avoided scenes of nude people, whether male or female, later in the viewing interval. For women, reported disgust of sexual activity was also inversely related to gaze duration for nude scenes. Taken together, selective looking as indexed by eye movements reveals differential perceptual intake as a function of specific content, gender, and individual differences.

The effect of automatic attentional bias modification on alcohol ambivalence

Conscious strategies such as psychoeducation are commonly used to resolve alcohol ambivalence. However, conscious strategies have had little effect on automatic approach inclination, which is one of the components of alcohol ambivalence. The purpose of this study was to investigate the effect of automatic attentional bias modification that can affect the approach inclination in alcohol ambivalence. The study included 43 problem drinkers with alcohol ambivalence who were recruited from the university and provided informed consent. They were randomly assigned to either a group that underwent attentional bias modification or a group that underwent psychoeducation. The level of alcohol ambivalence and readiness to change was assessed using self-report questionnaires, and the pattern of alcohol ambivalence was assessed using eye movements. The results showed that psychoeducation increased problem drinkers' readiness to change. In addition, attentional bias modification changed their attentional pattern of alcohol ambivalence by decreasing the approach inclination and increasing the avoidance inclination. Based on these results, attentional bias modification was shown to be a useful method for changing the automatic approach inclination as well as the controlled avoidance inclination, and psychoeducation was shown to be a beneficial strategy for increasing problem drinkers' extrinsic readiness to change.