Reducing children's social anxiety symptoms: Exploring a novel parent-administered cognitive bias modification training intervention

Is interpretation bias for threat content specific to youth anxiety symptoms/diagnoses? A systematic review and meta-analysis

Anxiety is the most common mental health problem in youth. Numerous studies have identified that youth anxiety is associated with interpretation bias or the attribution of threatening meaning to ambiguity. Interpretation bias has been proposed as a mechanism underlying the development and maintenance of pediatric anxiety. Theoretically, interpretation bias should be content-specific to individual youth anxiety symptom domains. However, extant studies have reported conflicting findings of whether interpretation bias is indeed content specific to youth anxiety symptoms or diagnoses. The present meta-analysis aimed to synthesize the literature and answer the question: is the relationship between interpretation bias and anxiety content specific? Search of PubMed and PsycINFO databases from January 1, 1960 through May 28, 2019 yielded 9967 citations, of which 19 studies with 20 comparisons and 2976 participants met eligibility criteria. Meta-analysis with random effects models was conducted to examine an overall effect (Pearson r) between anxiety domain and content-specific interpretation bias in single sample studies, and an overall effect size difference (Cohen's d) in studies comparing anxious to non-anxious youth. Results support a content specific correlation between interpretation bias and anxiety symptom domain in single sample studies (r = 0.18, p = 0.03). However, it is currently undetermined whether this relationship holds in studies that compare the relationship between content-specific interpretation bias and anxiety in anxious versus non-anxious youth. A variety of methodologic considerations across studies are discussed, with implications for further investigation of interpretation bias and youth anxiety.

Targeting hostile attributions in inclusive schools through online cognitive bias modification: A randomised experiment

The tendency to make hostile attributions in ambiguous social situations has been associated with aggression and may be targeted through cognitive bias modification for interpretations (CBM-I). Despite their high prevalence of aggression and internalising problems, children and young people with neurodevelopmental disorders (NDD) or special educational needs (SEN) are markedly absent from CBM-I studies. This pilot study investigates whether online CBM-I can reduce hostile attributions and reactive aggression in inclusive school pupils. In Study 1, 71 pupils (mean age = 12.2, SD = 1.5; 25.4% presented with NDD or SEN) were randomly allocated to complete three sessions of either CBM-I (n = 37) or active control training (n = 34). CBM-I involved interpreting ambiguous scenarios or faces in a non-hostile manner, whereas the control training involved attention and memory exercises without resolving ambiguity. Between-group comparison showed CBM-I to reduce both hostile attributions and reactive aggression. In Study 2, follow-up focus groups with 23 pupils demonstrated the acceptability of training content and delivery. Together, these findings show online CBM-I to be acceptable and effective at reducing both hostile attributions and reactive aggression in an inclusive setting. The possibility of intervention effects on behavioural outcomes and potential confounding variables require further investigation.

Inclusiveness of cognitive bias modification research toward children and young people with neurodevelopmental disorders: A systematic review

Cognitive bias modification (CBM) is increasingly used to target cognitive biases related to internalising or externalising problems, which are common in neurodevelopmental disorders (NDD). This systematic review assesses the available evidence for using CBM in children and young people with NDD, in particular regarding ambiguous interpersonal information, and the extent of their exclusion from this type of intervention research. PsycINFO, PsycARTICLES, MEDLINE, Cochrane Central Register of Controlled Trials and Science Citation Index were consulted using MeSH terms and synonyms of "neurodevelopmental disorders", "mental health problems", "cognitive bias", "modification" and "review". Data extraction focused on the efficacy of CBM for NDD, how CBM was delivered, whether studies adopted exclusion criteria relating to NDD and the rationale for such criteria. The search identified 2270 records, of which twenty-nine studies assessed CBM for interpretations and were included in the qualitative synthesis. Three studies targeted bias in NDD, whereas a third of studies explicitly excluded participants based on NDD-related criteria: most frequently intellectual impairment, reading or learning difficulties and autism spectrum disorder (ASD). Only one study provided a rationale for excluding NDD which related to the reading demands of their intervention. There is tentative evidence for the feasibility of using CBM to reduce interpretation bias in children and young people with mild intellectual disability, ASD or attention-deficit/hyperactivity disorder (ADHD). We recommend that CBM research should consider including participants with NDD, use CBM tasks and adaptations that enable this group's inclusion, or provide a sufficient rationale for their exclusion.

Anxiety and Interpretation of Ambiguity in Autistic Children, Typical Children and Their Mothers

Anxiety is highly prevalent in autistic children. Yet interpretation biases implicated in anxiety in non-autistic individuals have received little research attention in this group. Twenty-two autistic children and 25 typical children completed an ambiguous scenarios interview and questionnaire-based measures of anxiety. A subsample of mothers completed parent-report and adult relevant versions of the interview and anxiety questionnaires. Autistic children self-reported similar interpretations of ambiguous scenarios, and similar levels of anxiety, to their typical peers. In contrast, mothers of autistic children reported greater levels of anxiety, and more negative interpretations of ambiguous scenarios in both their children and themselves, relative to mothers of typical children. These data highlight the importance of including autistic children’s self-reports when measuring and treating anxiety.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Ethnicity's Role in the Relationship Between Anxiety and Negative Interpretation Bias Among Clinically Anxious Youth: A Pilot Study

Negative interpretation bias, a correlate of anxiety, is defined as an individual's tendency to interpret ambiguous events as negative or threatening. The current study examined associations between interpretation bias and anxiety symptoms in clinically anxious youth and potential moderators of these relationships. Thirty anxious youth and their parents participated in a clinical interview and reported on child anxiety symptoms. Youth completed implicit, explicit-personally irrelevant, and explicit-personally relevant interpretation bias measures. Child-reported anxiety was only associated with negative interpretation bias on the explicit-personally relevant measure and parent-reported social anxiety was negatively associated with positive bias on this measure. Hispanic individuals displayed marginally higher anxiety symptoms and significantly more intense negative interpretation on the implicit measure. While this pilot study revealed preliminary findings that Hispanic ethnicity may play a role in relationships between interpretation bias and anxiety, future work may further elucidate associations between interpretation bias, anxiety, and ethnicity in anxious youth.

Threat interpretation and parental influences for children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the cognitive and parent factors that may underpin this relationship. The present study investigated interpretation biases in children with asthma and anxiety and their parents, and whether parent-child discussions influenced children's interpretations. Eighty-nine parent-child dyads were included across four groups: children with asthma and anxiety, children with anxiety only, children with asthma only and healthy children (aged between 8 and 13 years old). Interpretation bias was assessed using ambiguous scenarios. Children with anxiety showed an interpretation bias in the general threat scenarios, whereas children with asthma showed an interpretation bias in the asthma threat scenarios. Parental predictions of their child's responses showed similar results. Parent-child discussions increased avoidance for children with anxiety and no asthma across all scenarios, but only for children with asthma and anxiety in the asthma threat scenarios. The results provide partial support for a cognitive theory of asthma and anxiety in children and suggest that parents play a role in influencing children's thinking styles. Treatment programs could thus aim to target and modify interpretation biases in children with anxiety, and include parents as part of treatment.

Do you think I should be scared? The effect of peer discussion on children's fears

This study investigated whether close friends affect each other's fear responses (fear beliefs and avoidance) when they discuss fear-related issues together. Children (N = 242) aged 7-10 years were first presented with ambiguous and threatening information about two novel animals respectively, after which their fear responses towards each animal were assessed (T1). Next, dyads of close friends had a discussion about their feelings regarding the animals, and their fear responses were measured again (T2). Results showed that children influenced each other's cognitions following the discussion; from T1 to T2 their fear responses became more similar and close friends' fear responses at T1 significantly predicted children's fear responses at T2. Gender pair type predicted change in children's fear responses over time. Children in boy-boy pairs showed a significant increase in fear responses following the discussion; their fear level became more in line with that of other gender pairs at T2, while those in girl-girl pairs showed a significant decrease in their fear beliefs, at least when threatening information was given. Differences in anxiety level between close friends did not affect change in fear responses over time. Altogether, the results indicate that children may affect each other's fears.

Interpretation bias modification for youth and their parents: a novel treatment for early adolescent social anxiety

Social anxiety is the most prevalent anxiety disorder of late adolescence, yet current treatments reach only a minority of youth with the disorder. Effective and easy-to-disseminate treatments are needed. This study pilot tested the efficacy of a novel, online cognitive bias modification for interpretation (CBM-I) intervention for socially anxious youth and their parents. The CBM-I intervention targeted cognitive biases associated with early adolescents' maladaptive beliefs regarding social situations, and with parents' intrusive behavior, both of which have been theoretically linked with the maintenance of social anxiety in youth. To investigate the efficacy of intervening with parents and/or children, clinically diagnosed early adolescents (ages 10-15; N=18) and their mothers were randomly assigned to one of three conditions: the first targeted early adolescents' cognitive biases related to social anxiety (Child-only condition); the second targeted parents' biases associated with intrusive behavior (Parent-only condition); and the third targeted both youth and parents' biases in tandem (Combo condition). The use of a multiple baseline design allowed for the efficient assessment of causal links between the intervention and reduction in social anxiety symptoms in youth. Results provided converging evidence indicating modest support for the efficacy of CBM-I, with no reliable differences across conditions. Taken together, results suggest that online CBM-I with anxious youth and/or their parents holds promise as an effective and easily administered component of treatment for child social anxiety that deserves further evaluation in a larger trial.