Towards a cognitive-learning formulation of youth anxiety: A narrative review of theory and evidence and implications for treatment

Anhedonia is associated with overgeneralization of conditioned fear during late adolescence and early adulthood

BACKGROUND

Pavlovian fear paradigms involve learning to associate cues with threat or safety. Aberrances in Pavlovian fear learning correlate with psychopathology, especially anxiety disorders. This study evaluated symptom dimensions of anxiety and depression in relation to Pavlovian fear acquisition and generalization.

METHODS

256 participants (70.31 % female) completed a Pavlovian fear acquisition and generalization paradigm at ages 18-19 and 21-22 years. Analyses focused on indices of learning (self-reported US expectancy, skin conductance). Multilevel models tested associations with orthogonal symptom dimensions (Anhedonia-Apprehension, Fears, General Distress) at each timepoint.

RESULTS

All dimensions were associated with weaker acquisition of US expectancies at each timepoint. Fears was associated with overgeneralization only at age 21-22. General Distress was associated with overgeneralization only at age 18-19. Anhedonia-Apprehension was associated with overgeneralization at ages 18-19 and 21-22.

CONCLUSIONS

Anhedonia-Apprehension disrupts Pavlovian fear acquisition and increases overgeneralization of fear. These effects may emerge during adolescence and remain into young adulthood. General Distress and Fears also contribute to overgeneralization of fear, but these effects may vary as prefrontal mechanisms of fear inhibition continue to develop during late adolescence. Targeting specific symptom dimensions, particularly Anhedonia-Apprehension, may decrease fear generalization and augment interventions built on Pavlovian principles, such as exposure therapy.

Developmental pathways in youth anxiety disorders: potential mechanisms for (mal)adapting to crises and improving treatment - a commentary on Klein et al. (2023)

The ability to cope with threats is crucial in today's troubling times, especially for young people who are still developing coping mechanisms. Psychopathology and the development of anxiety disorders can be viewed as a failure to adapt to changing demands. We draw on a study by Klein et al. (Journal of Child Psychology and Psychiatry, 2023), which showed that anxious youths exhibited stronger conditioned fear responses and, during delayed extinction learning, greater electrocortical differences between threat and safety stimuli. Interestingly, these signatures of learning processes were also associated with treatment outcomes. We argue for developmentally sensitive research: Individual learning and associated cognitive-affective changes are strongly age-dependent and represent the key mechanism for both anxiety development and treatment. They also interact with social and environmental factors. Based on the call for age- and context-sensitive research, future research should focus on establishing reliable risk profiles that consider a variety of factors to enable evidence-based, individualized treatment decisions.

Anxiety disorders in children and adolescents: A summary and overview of the literature

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Approximating exposure therapy in the lab: Replacing the CS+ with a similar versus a different stimulus and including additional stimuli resembling the CS+ during extinction

Recent studies have shown that extinction training including the conditional stimulus (CS+) and stimuli that are similar to the CS + enhances extinction retention and generalisation to novel stimuli. However, in a clinical setting, the CS+ is rarely available for use during exposure therapy. The aim of the present study was to determine if replacing the CS+ with a similar versus different stimulus, and including other similar stimuli during extinction, could reduce fear at test on par with extinction using the original CS+ with and without other similar stimuli. In an experiment conducted in a single session, participants completed a habituation phase followed by an acquisition phase using two dog images presented with (CS+) and without (CS-) an acoustic unconditional stimulus (US). Participants were randomly allocated to four extinction conditions: similar CS + dog with novel dog images (Similar replacement extinction condition); different CS + dog with novel dog images (Different replacement extinction condition); original CS + dog with novel dog images (Multiple extinction control condition); and original CS + without novel dog images (Standard extinction control condition). All participants completed a test phase with the original CSs followed by a generalisation test with another two novel dog images. All groups acquired, and then extinguished differential skin conductance responses (SCRs) with no differences observed between groups. Whereas the Similar replacement extinction group and the Multiple and Standard extinction control groups did not exhibit significant differential SCRs when re-exposed to the original CS + relative to the CS- at test, differential responding to the CSs was significant at test in the Different replacement extinction group. There were no significant differences between groups in SCRs to the two novel dog images during the generalisation phase and in between-phase subjective ratings. Findings suggest that replacement stimuli used during extinction should be as similar as possible to the CS + to reduce physiological arousal to the original CS+.

Fear learning and extinction predicts anxiety in daily life: a study of Pavlovian conditioning and ecological momentary assessment

BACKGROUND

The association between anxious mood and aberrant fear learning mechanisms has not been fully elucidated. Studying how fear conditioning and extinction constructs relate to anxiety symptoms and reactivity to stressful and benign moments in everyday life provides a powerful addition to experimental paradigms.

METHOD

Fifty-one young adults completed laboratory-based differential conditioning and extinction tasks with (CS + ) and without (CS-) an aversive unconditional stimulus (US). Electrodermal skin conductance responses were measured during each phase, followed by ecological momentary assessment (EMA) tapping anxiety and stressors six times daily for seven days (2, 142 moments).

RESULTS

Conditioned electrodermal reactivity to the CS + and overgeneralisation to the CS- were associated with greater change in anxiety (measured via EMA), across non-stressful situations, remaining the same across stressful situations. Likewise, during extinction when the CS + is now safe, more electrodermal reactivity to the CS + was associated with more anxiety change across non-stressful situations and remained the same across stressful situations. Also, during extinction when threat is absent, more electrodermal reactivity at the late stage of the CS- was associated with less momentary anxiety change in response to stressful situations; more electrodermal activity at the late stage of the CS + was associated with more anxiety change across non-stressful situations and remained the same across stressful situations.

CONCLUSIONS

Sampling 'in vivo' emotion and stress experiences, study findings revealed links between conditioned electrodermal reactivity and overgeneralisation to safe stimuli and heightened anxious reactivity during non-stressful (i.e. safe) moments in daily life, coupled with less change in response to actual stressors.

Why worry with friends? Problem talk and anxiety in late adolescent friendships

INTRODUCTION

This study investigated a theoretically derived peer conversation style, problem anxiety talk, to examine the emotional regulation of anxiety in dyads as a possible mechanism of anxiety contagion that occurs between adolescent friends.

METHODS

In Study 1, 376 late adolescents residing in the United States, ages 17-24 with 68% female, responded to measures of anxiety, worry, friendship quality, depression, co-rumination, and a new measure of problem anxiety talk. In Study 2 problem anxiety talk, stress, anxiety and depression were evaluated in 481 late adolescents, ages 17-24 with 64% female.

RESULTS

Once controlling for worry and co-rumination, problem anxiety talk with a close friend predicted anxiety, stress and depression for both samples of late adolescents. Factor analysis in each sample supported problem anxiety talk as a single factor with high internal consistency.

CONCLUSIONS

Findings indicate that problem anxiety talk is a distinct construct representing interpersonal disclosures between friends involving threat perception, likelihood of negative events, and lack of coping skills; results also indicate that problem anxiety talk is associated with anxiety, stress, worry, and depression. Implications of problem anxiety talk in its potential role in the etiology and spread of anxiety are discussed.

Child maltreatment and victimization

It is estimated that up to 25% of all children growing up worldwide experience child maltreatment, making it a global emergency with substantial individual and public health consequences. This chapter addresses one of the most societally pervasive consequences of child maltreatment which is known as the "cycle of victimization." This concept depicts the increased risk of maltreated individuals to victimize others later in life, both within and outside the family environment. To understand the architecture of this victimization cycle, the chapter further sheds light on neurocognitive mechanisms aiding different forms of victimization and the buffering role of social support that could help break the cycle of victimization. Advancing our understanding of these complex and interrelated mechanisms will ultimately facilitate the design and implementation of more targeted early treatments and (preventive) interventions and support a move toward a safer society.

Efficacy of D-cycloserine augmented brief intensive cognitive-behavioural therapy for paediatric obsessive-compulsive disorder: A randomised clinical trial

OBJECTIVE

To examine the efficacy of weight-adjusted D-cycloserine (DCS) (35 or 70 mg) relative to placebo augmentation of intensive exposure therapy for youth with obsessive-compulsive disorder (OCD) in a double-blind, randomised controlled trial, and examine whether antidepressant medication or patient age moderated outcomes.

METHODS

Youth (n = 100, 7-17 years) with OCD were randomised in a 1:1 ratio to either DCS + exposure (n = 49) or placebo + exposure (n = 51). Assessments occurred posttreatment, 1 month later, and at 3 and 6 months. Pills were ingested immediately before sessions.

RESULTS

Significant improvements on all outcomes were observed at posttreatment, and to 6-month follow-up. Treatment arms did not differ across time, with no significant time-by-medication interactions on symptom severity (T1 to T2 estimate: 9.3, 95% confidence interval [CI]: -11.2 to -7.4, and estimate -10.7, 95% CI: -12.6 to -8.7), diagnostic severity (T1 to T2 estimate: -2.0, 95% CI: -2.4 to -1.5 and estimate -2.5, 95% CI: -3.0 to -2.0) or global functioning (T1 to T2 estimate: 13.8, 95% CI: 10.6 to 17.0, and estimate 16.6, 95% CI: 13.2 to 19.9). Neither antidepressants at baseline nor age moderated primary outcomes. There were significantly fewer responders/remitters at 1- and 6-month follow-up among youth in the DCS condition stabilised on SSRIs, relative to youth not taking SSRIs.

CONCLUSIONS

DCS augmented intensive exposure therapy did not result in overall additional benefits relative to placebo. Intensive exposure proved effective in reducing symptoms for the overall sample.

Early Adversity and Changes in Cortisol and Negative Affect in Response to Interpersonal Threats in the Laboratory

Adverse childhood experiences, such as abuse and neglect, are associated with poor health outcomes. This association may be partially explained by differences in stress physiology. Though most early adverse experiences occur within the context of interpersonal relationships, stress exposures manipulated in the laboratory rarely involve interpersonal interactions beyond the mere presence of others. This study examines whether adverse childhood experiences are associated with differences in affective and cortisol reactivity to two stressors which may more closely resemble the powerlessness and the lack of control characteristic of many adverse childhood experiences: a dominant (vs. submissive) interaction partner and lower (vs. higher) social status. We also manipulate social-evaluative threat as a test of whether these interpersonal stressors are more germane to stress reactivity associated with early adversity than the performance anxiety evoked by more traditional laboratory stressors, such as the Trier Social Stress Test. The results partially support the hypothesis that participants with greater early adversity may be more reactive to interpersonal stressors reminiscent of early adverse experience. Given the interpersonal nature of most adverse childhood experiences, conceptualizing and measuring associations with stress physiology in an interpersonal context may more closely capture the psychological and biological embedding of these early experiences.

Does irritability predict attention biases toward threat among clinically anxious youth?

Aberrant threat processing is a known cognitive characteristic of anxiety disorders and irritability. Youth with more severe symptomatology show greater allocation of attention towards threat relative to neutral stimuli. Although irritability contributes to poorer outcomes among anxious youths, irritability has not been considered as a contributing factor to threat processing in anxiety disorders. Thus, the current study examined the role of irritability in predicting attention biases for threat among clinically anxious youth. Our study included 84 clinically anxious youth (M = 9.31 years old, SD = 2.44) who completed a dot-probe task to determine attention biases. Anxiety disorders were assessed using semi-structured diagnostic interviews. Well validated measures were used to assess the severity of anxiety and irritability symptoms via child- and parent-report, respectively. Findings indicated that more severe irritability predicted greater attention biases toward threat among clinically anxious youth, covarying for age, anxiety severity, and the number of comorbid diagnoses. At a trend-level, anxiety severity also predicted attention bias for threat. Among clinically anxious youth, irritability severity was the strongest predictor of attention bias toward threat. Findings point to the salience of irritability, and to some extent anxiety severity, in relation to threat processing among youth with clinical anxiety disorders.

The transdiagnostic origins of anxiety and depression during the pediatric period: Linking NIMH research domain criteria (RDoC) constructs to ecological systems

In the last decade, an abundance of research has utilized the National Institute of Mental Health (NIMH) research domain criteria (RDoC) framework to examine mechanisms underlying anxiety and depression in youth. However, relatively little work has examined how these mechanistic intrapersonal processes intersect with context during childhood and adolescence. The current paper covers reviews and meta-analyses that have linked RDoC-relevant constructs to ecological systems in internalizing problems in youth. Specifically, cognitive, biological, and affective factors within the RDoC framework were examined. Based on these reviews and some of the original empirical research they cover, we highlight the integral role of ecological factors to the RDoC framework in predicting onset and maintenance of internalizing problems in youth. Specific recommendations are provided for researchers using the RDoC framework to inform future research integrating ecological systems and development. We advocate for future research and research funding to focus on better integration of the environment and development into the RDoC framework.

Fear learning, avoidance, and generalization are more context-dependent for adults than adolescents

This study examined developmental differences in contextual and perceptual generalization of fear and avoidance learning. Adults (N = 39) and adolescents (N = 44) completed differential fear acquisition wherein each conditional stimulus (CS) appeared in a background context. In the dangerous context, one stimulus (CS+) predicted an aversive sound, and the other stimulus (CS-) did not. In the safe context, the aversive sound was never administered with either CS. During fear generalization, participants were presented with three generalization stimuli (GSs), ranging on a perceptual continuum from threat to safety stimuli, in both contexts. Participants then completed avoidance conditioning and avoidance generalization phases, allowing them to actively avoid the upcoming aversive sound by pressing an avoidance button. Developmental differences emerged in threat perception, physiological arousal, avoidance behavior, and eye movements during contextual fear learning and generalization. Adolescents showed less discrimination between stimuli and contexts than adults, resulting primarily from their elevated fear responses to safety and generalized stimuli. Developmental differences in fear learning should be further explored in future research, as they could explain why adolescence is a sensitive developmental period for anxiety.

Irritability in Children and Adolescents With OCD

Irritability is a common, impairing transdiagnostic symptom in childhood psychopathology, though it has not been comprehensively studied in pediatric obsessive-compulsive disorder (OCD). Further, the central cognitive behavioral treatment component for OCD, exposure and response prevention therapy (ERP), has been recently proposed as a treatment for irritability. This study aimed to evaluate whether certain clinical characteristics are associated with irritability in pediatric OCD and whether irritability reduces following ERP. Participants were 161 youth (ages 7-17) with OCD and a caregiver participating in a randomized controlled trial of D-cycloserine or pill placebo augmented ERP. Participants completed validated assessments during treatment. Irritability was significantly and positively associated with depressive symptoms, defiance, functional impairment, and family accommodation, but was not associated with pretreatment OCD severity, symptom dimensions, obsessive beliefs. Irritability significantly declined following treatment, with over half of youth with any pretreatment irritability experiencing clinically significant change, though this change was not related to OCD improvement. Results suggest that irritability may be a marker of psychiatric comorbidity, parental accommodation, and impairment in youth with OCD. Implications for the exposure-based treatment of irritability are discussed.

The Limited Effect of Mindfulness-Based Interventions on Anxiety in Children and Adolescents: A Meta-Analysis

Anxiety disorders are common mental health problems amongst youth with harmful impacts often extending into adulthood. Mindfulness-based interventions (MBIs) have become increasingly popular for addressing mental health issues, particularly in schools; however, it remains unclear how effective they are for reducing youth anxiety. This meta-analysis aimed to evaluate the efficacy and effect moderators of MBIs on anxiety outcomes in children and adolescents. Eligible studies were published randomised controlled trials (RCTs) of MBIs conducted with participants aged 18 years or younger, investigating anxiety outcomes using a well-validated anxiety scale. A systematic search of RCTs published through to February 2019 identified 20 studies for inclusion (n = 1582). A random effects model was used to synthesise MBI effects. Stratified meta-analyses as well as individual, random effects meta-regressions were performed to examine how effects varied by age group, intervention setting, control type, research location, and intervention dosage. Although, across all studies, there was a small beneficial effect of MBIs on anxiety post treatment (d = 0.26), this was significantly moderated by research location, with RCTs conducted in Iran producing large effects (d = 1.25), and RCTs conducted in Western countries demonstrating no significant beneficial effect compared to controls (very small, d = 0.05). Effects were non-significant at follow-up assessment points. Post-treatment effects were significant for MBIs conducted with children (d = 0.41) and for MBIs when compared to passive controls (d = 0.33), but non-significant for adolescents (d = 0.21), for MBIs conducted in schools (d = 0.30) and in clinics (d = 0.13), and when MBIs were compared to active controls (d = 0.12). Results suggest that MBIs are likely to have a small to medium, yet temporary effect in reducing anxiety symptoms in children (not adolescents), but amongst Western youth populations the most likely outcome, from RCTs to date, is that MBIs produce no beneficial effect in anxiety reduction. Results revealed a lack of evidence to support investment in school-based MBIs to address youth anxiety.

The effects of presenting additional stimuli resembling the CS+ during extinction on extinction retention and generalisation to novel stimuli

Recent studies have shown that extinction training including the conditional stimulus (CS+) and stimuli similar to the CS + enhances extinction retention and generalisation to novel stimuli. The aim of the present study was to confirm that these effects are specific to presenting stimuli similar to the CS+ during extinction and not merely an effect of additional trials or additional stimuli unrelated to the CS+. In an experiment conducted in a single session on the same day, participants (134 adults; 70.7% female; 17-40 years of age, M = 20.04, SD = 4.36) completed a habituation phase followed by an acquisition phase using dog images presented with (CS+) and without (CS-) a dog growl paired with a scream unconditional stimulus (US). Participants were randomly allocated to four extinction conditions: Multiple exemplar extinction comprising the CSs and two novel dog images similar to the CS+; Standard extinction control matched for the number of CS+ and CS- presentations; Extended extinction control matched for the total number extinction trials, and Other stimuli extinction control comprising the CSs and two novel stimuli unrelated to the CS+. All participants completed an extinction test with the original CSs followed by a generalisation test with two novel dog images. Multiple, Standard and Other stimuli extinction groups exhibited larger skin conductance responses (SCRs) during extinction to the CSs compared to the Extended extinction group. SCRs to the additional dog images in the Multiple group were larger than SCRs to the additional CSs in the Extended group and the novel images in the Other stimuli group. There were no group differences in responses to the CSs during extinction test. Unlike the other groups, SCRs to the first presentation of the novel generalisation dogs did not differ from those to the last CS trials in extinction in the Multiple group. However, this group difference did not persist beyond the initial generalisation trial. Finally, the Multiple, Extended, and Other stimuli groups exhibited more negative CS evaluations after extinction, extinction test, and generalisation test than the Standard extinction group. The results suggest that extinction with the original CSs and additional stimuli resembling the CS + elevated physiological responses during extinction and reduced physiological responses to novel stimuli similar to the CSs. Further studies are needed including clinical samples and trial-by-trial evaluations of the stimuli presented.

Developmental Variation in the Associations of Attention Bias to Emotion with Internalizing and Externalizing Psychopathology

Attention biases to emotion are associated with symptoms of internalizing and externalizing psychopathology in children and adolescents. It is unknown whether attention biases to emotion and their associations with different symptoms of psychopathology vary across development from early childhood through young adulthood. We examine this age-related variation in the current study. Participants (N = 190; ages: 4-25) completed survey-based psychopathology symptom measures and a dot-probe task to assess attention bias to happy, sad, and angry relative to neutral faces. We tested whether linear or non-linear (e.g., spline-based models) associations best characterized age-related variation in attention to emotion. We additionally examined whether attention biases were associated with depression, anxiety, and externalizing symptoms and whether these associations varied by age. No age-related differences in attention biases were found for any of the emotional faces. Attention biases were associated with psychopathology symptoms, but only when examining moderation by age. Biased attention to angry faces was associated with greater symptoms of anxiety and depression in adolescents and young adults, but not children. Similarly, biased attention to happy faces was associated with externalizing symptoms in adolescents and young adults, but not in children. In contrast, biased attention to happy faces was associated with greater anxiety symptoms in children, but not in adolescents or young adults. Biased attention toward social threat and reward becomes more strongly coupled with internalizing and externalizing symptoms, respectively, during the transition to adolescence. These findings could inform when interventions such as attention bias modification training may be most effective.

Does the assessment of different combinations of within-phase subjective measures influence electrodermal responding and between-phase subjective ratings during fear conditioning and extinction experiments?

The type and number of dependent measures assessed have varied between fear conditioning and extinction experiments and it remains unclear whether methodological differences influence results. Measuring skin conductance responses (SCRs) and between-phase subjective ratings between four conditions; Con condition had no within-phase ratings; US Exp condition included within-phase US expectancy ratings only; CS Eval condition included within-phase CS evaluations only and All Meas condition included both. All Meas condition exhibited larger SCRs compared to other conditions during acquisition, extinction, and return of differential responding at test. Differential SCRs did not extinguish in CS Eval and Con conditions, and CS Eval condition exhibited smaller CS- SCRs than other conditions throughout phases. US Exp condition revealed differential conditioning, successful extinction, and no return of differential SCRs. Between-phase ratings were not affected by within-phase ratings. Researchers should consider assessing different combinations of within-phase subjective ratings depending on the aims of their research.

[Separation anxiety disorder]

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) separation anxiety disorder has been included in the chapter on anxiety disorders, thereby removing the age of onset restriction that previously required first onset during childhood or adolescence. Separation anxiety disorder has a lifetime prevalence of 4.8% and onset often occurs after the age of 18 years. Despite the high prevalence, separation anxiety disorder is often underdiagnosed and subsequently remains untreated. This narrative review summarizes the etiology, clinical features, diagnostic criteria as well as important differential diagnostic aspects, common comorbidity profiles and treatment implications of separation anxiety disorder. Furthermore, relevant implications for everyday practice and future perspectives for treatment and research are discussed.

Altered Neural Processing of Threat-Related Information in Children and Adolescents Exposed to Violence: A Transdiagnostic Mechanism Contributing to the Emergence of Psychopathology

OBJECTIVE

Exposure to violence in childhood is associated with increased risk for multiple forms of internalizing and externalizing psychopathology. We evaluated how exposure to violence in early life influences neural responses to neutral and threat-related stimuli in childhood and adolescence, developmental variation in these associations, and whether these neural response patterns convey transdiagnostic risk for psychopathology over time.

METHOD

Participants were 149 youths (75 female and 74 male), aged 8 to 17 years (mean = 12.8, SD = 2.63), who had experienced physical abuse, sexual abuse, or domestic violence (n = 76) or had never experienced violence (n = 73). Participants underwent functional magnetic resonance imaging scanning while passively viewing fearful, neutral, and scrambled faces presented rapidly in a block design without specific attentional demands. Internalizing and externalizing psychopathology were assessed concurrently with the scan and 2 years later and were used to compute a transdiagnostic general psychopathology factor (p factor).

RESULTS

Exposure to violence was associated with reduced activation in the dorsal anterior cingulate cortex (dACC) and frontal pole (1,985 voxels, peak x, y, z = 6, 4, 40) when viewing fearful (versus scrambled) faces, and reduced activation in dorsomedial prefrontal cortex and superior frontal gyrus (1,970 voxels, peak x, y, z = 16, 64, 10) when viewing neutral faces, but not amygdala activation or connectivity. Lower dACC response to fearful faces predicted increase in the p factor 2 years later (B = -0.186, p = .031) and mediated the association of violence exposure with longitudinal increases in the p factor.

CONCLUSION

Reduced recruitment of the dACC-a region involved in salience processing, conflict monitoring, and cognitive control-in response to threat-related cues may convey increased transdiagnostic psychopathology risk in youths exposed to violence.

Mapping the Specific Pathways to Early-Onset Mental Health Disorders: The "Watch Me Grow for REAL" Study Protocol

BACKGROUND

From birth, the human propensity to selectively attend and respond to critical super-stimuli forms the basis of future socio-emotional development and health. In particular, the first super-stimuli to preferentially engage and elicit responses in the healthy newborn are the physical touch, voice and face/eyes of caregivers. From this grows selective attention and responsiveness to emotional expression, scaffolding the development of empathy, social cognition, and other higher human capacities. In this paper, the protocol for a longitudinal, prospective birth-cohort study is presented. The major aim of this study is to map the emergence of individual differences and disturbances in the system of social-Responsiveness, Emotional Attention, and Learning (REAL) through the first 3 years of life to predict the specific emergence of the major childhood mental health problems, as well as social adjustment and impairment more generally. A further aim of this study is to examine how the REAL variables interact with the quality of environment/caregiver interactions.

METHODS/DESIGN

A prospective, longitudinal birth-cohort study will be conducted. Data will be collected from four assessments and mothers' electronic medical records.

DISCUSSION

This study will be the first to test a clear developmental map of both the unique and specific causes of childhood psychopathology and will identify more precise early intervention targets for children with complex comorbid conditions.

Practitioner Review: Anxiety disorders in children and young people - assessment and treatment

Despite significant advancements in our knowledge of anxiety disorders in children and adolescents, they continue to be underrecognised and undertreated. It is critical that these disorders are taken seriously in children and young people as they are highly prevalent, have a negative impact on educational, social and health functioning, create a risk of ongoing anxiety and other mental health disorders across the life span and are associated with substantial economic burden. Yet very few children with anxiety disorders access evidence-based treatments, and there is an urgent need for widespread implementation of effective interventions. This review aimed to provide an overview of recent research developments that will be relevant to clinicians and policymakers, particularly focusing on the development and maintenance of child anxiety disorders and considerations for assessment and treatment. Given the critical need to increase access to effective support, we hope this review will contribute to driving forward a step change in treatment delivery for children and young people with anxiety disorders and their families.

Anticipatory Threat Responding: Associations With Anxiety, Development, and Brain Structure

BACKGROUND

While translational theories link neurodevelopmental changes in threat learning to pathological anxiety, findings from studies in patients inconsistently support these theories. This inconsistency may reflect difficulties in studying large patient samples with wide age ranges using consistent methods. A dearth of imaging data in patients further limits translational advances. We address these gaps through a psychophysiology and structural brain imaging study in a large sample of patients across the lifespan.

METHODS

A total of 351 participants (8-50 years of age; 209 female subjects; 195 healthy participants and 156 medication-free, treatment-seeking patients with anxiety) completed a differential threat conditioning and extinction paradigm that has been validated in pediatric and adult populations. Skin conductance response indexed psychophysiological response to conditioned (CS+, CS-) and unconditioned threat stimuli. Structural magnetic resonance imaging data were available for 250 participants. Analyses tested anxiety and age associations with psychophysiological response in addition to associations between psychophysiology and brain structure.

RESULTS

Regardless of age, patients and healthy comparison subjects demonstrated comparable differential threat conditioning and extinction. The magnitude of skin conductance response to both conditioned stimulus types differentiated patients from comparison subjects and covaried with dorsal prefrontal cortical thickness; structure-response associations were moderated by anxiety and age in several regions. Unconditioned responding was unrelated to anxiety and brain structure.

CONCLUSIONS

Rather than impaired threat learning, pathological anxiety involves heightened skin conductance response to potential but not immediately present threats; this anxiety-related potentiation of anticipatory responding also relates to variation in brain structure. These findings inform theoretical considerations by highlighting anticipatory response to potential threat in anxiety.

The role of exposure in the treatment of anxiety in children and adolescents: protocol of a systematic review and meta-analysis

BACKGROUND

In children and adolescents, anxiety disorders (ADs) are among the most prevalent mental disorders. While there is a solid empirical foundation to support CBT as an evidence-based treatment for childhood ADs, the mechanisms underlying the efficacy of CBT are not well explored. Exposure is assumed to be vital to the efficacy of CBT in ADs, but empirical evidence (e.g., dismantling studies) showing that exposure is indeed a vital element of effective treatments is relatively scarce. The proposed meta-analysis aims to investigate the role of exposure in reducing symptoms of anxiety among children and adolescents.

METHODS

A systematic search of several electronic databases including PubMed/MEDLINE, PsycINFO, Psyndex plus, Web of Science, Scopus, and EMBASE will be conducted (from inception onwards). We will include randomized and non-randomized clinical trials examining exposure and anxiety among children and adolescents. If feasible, we will also include experimental, quasi-experimental, and observational studies. The primary outcome will be improvement in anxiety levels (recovery or change in anxiety rating scale) after exposure. Three reviewers will independently screen all citations, abstract data, and full-text articles. The methodological quality (or risk of bias) of individual studies will be appraised using an appropriate tool. If feasible, we will conduct mixed effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., dose of exposure, age group, methodological quality).

DISCUSSION

This systematic review and meta-analysis will examine the role of exposure in reducing symptoms of anxiety among youth. The review will provide information on the working mechanisms underlying the efficacy of CBT. Our findings will be of interest to mental health professionals, researchers, and policy makers who wish to support children and adolescents with anxiety disorders by guiding well-informed treatment decisions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42019128667).

Exposure to violence and neglect images differentially influences fear learning and extinction

The mechanisms by which exposure to adversity contributes to psychopathology development are poorly understood. Recent models link experiences of threat of harm and deprivation to psychopathology via disruptions in learning mechanisms underlying fear acquisition and extinction. We empirically tested dimensional elements of this model, by examining whether exposure to images of community violence or neglect differentially influenced fear learning and extinction relative to exposure to neutral images. Participants were randomly allocated to one of three exposure conditions: viewing images depicting neglect (n = 25), violence (n = 25) or control images (n = 24). All participants then completed a fear conditioning and extinction task in which the CS+ was paired with an aversive tone, and the CS- was presented alone during conditioning. Both CSs were presented alone during extinction and extinction retest. Skin conductance responses (SCR) and subjective ratings were assessed. Relative to control images, viewing scenes of neglect attenuated SCRs to the CSs during conditioning, extinction and extinction retest. Exposure to images of community violence accentuated SCRs during US anticipation on CS+ trials and impaired the retention of safety learning (larger SCRs to the CS+ compared to the CS- at retest and the CS+ at the end of extinction). No significant group differences emerged in subjective ratings. Findings lend preliminary support for suggestions that adverse experiences may be linked to impairments in fear and safety learning and provide key evidence suggesting that the expression of these impairments may differ as a function of the type of adversity.

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.

Internalizing symptoms and loneliness: Direct effects of mindfulness and protection against the negative effects of peer victimization and exclusion

Drawing from dispositional mindfulness research and stress and coping theories, we tested whether adolescents’ dispositional mindfulness was associated with perceptions of peer victimization and exclusion and internalizing symptoms. We further explored the role of dispositional mindfulness as a protective factor buffering the impact of peer victimization and exclusion (PVE) on internalizing symptoms. Participants were 361 (40% boys) adolescents aged between 11 and 18 years ( M = 14.9, SD = 1.4) who completed a questionnaire to assess dispositional mindfulness, perceptions of PVE, social anxiety and depressive symptoms, and loneliness. As expected, more frequent experience of PVE was associated with reporting more symptoms of social anxiety, depression, and loneliness. Further, adolescents who reported higher dispositional mindfulness also reported fewer symptoms of social anxiety, depression, and loneliness, even after controlling for gender and experiences of PVE. Dispositional mindfulness was not protective against (i.e., did not buffer) the effects of PVE on internalizing symptoms. Instead, we found that PVE had a stronger association with symptoms of social anxiety, depression, and loneliness when mindfulness was high relative to when it was medium or low. Yet, victimization was associated with greater social anxiety, depressive symptoms, and loneliness at all levels of mindfulness.

The roles of early-life adversity and rumination in neural response to emotional faces amongst anxious and depressed adults

BACKGROUND

Early-life adversity (ELA) is a risk factor for internalizing psychopathology (IP). ELA is also linked to alterations in neural phenotypes of emotion processing and maladaptive emotion regulatory strategies, such as ruminative brooding, in adulthood. We therefore expected that ELA would predict cortical brain activation to emotional faces in transdiagnostic IP and in turn, mediate the extent of rumination amongst patients with IPs and ELA (IP + ELA).

METHOD

One hundred and thirty-two individuals, including 102 treatment-seeking adults with heterogeneous IPs and 30 healthy controls (HCs) performed an Emotional Face-Matching Task during functional magnetic resonance imaging. Whole-brain analyses compared HC (n = 30), IP (n = 52), and IP + ELA (n = 50) neural responses to emotional (angry, fearful, happy, and sad) faces v. shapes, controlling for depression and anxiety symptoms. Parameter estimates of activation were extracted for significant between-group differences and tested as a mediator of ruminative brooding in IP + ELA.

RESULTS

IP + ELA demonstrated increased activation in the superior frontal gyrus and anterior cingulate cortex (fear), superior parietal lobule, precuneus, posterior cingulate, and inferior temporal gyrus (fear only), and cuneus (fear and angry). These regions were preferentially correlated with ruminative brooding in IP + ELA, many of which mediated the link between IP + ELA and ruminative brooding.

CONCLUSIONS

Results provide evidence that ELA history amongst IP patients augments engagement of brain regions involved in emotion processing, above and beyond what is accounted for by current symptoms. Though longitudinal designs are needed, alterations in the neural correlates of maladaptive processing of socio-emotional information may be a common pathway by which ELA poses risk for psychopathology.

Exposure therapy for pediatric irritability: Theory and potential mechanisms

Pediatric irritability is prevalent and impairing, yet little is known about its pathophysiology and treatment. In this article, we build on our and others' previous work to posit core mechanisms of irritability operating across the brain, behavior, and environment. Specifically, we propose proximal processes that surround the symptomatology of irritability and are potential targets for an exposure-based cognitive-behavioral therapy (CBT) for irritability that our group has developed. The heart of this model focuses on neurocognitive processes: youth's encoding of nonreward and threat stimuli, which involves prediction error signaling in the brain, and cognitive control in the context of frustration. Alterations in these processes are theorized to be central to chronic, severe irritability. Environmental responses to youth's symptom expression are also examined. Exposure-based CBT for irritability utilizes controlled, in vivo exposure to nonreward and threat stimuli with the aim to engage cognitive control and target top-down regulation of frustration. This intervention integrates selected parent management training techniques to target symptom reinforcement processes. Continued pathophysiological and treatment studies of irritability will not only refine our emerging understanding of the phenotype, but also inform broader questions on the brain and behavioral mechanisms of CBT efficacy.

Psychophysiological Markers of Fear and Anxiety

PURPOSE OF REVIEW

The purpose of this paper is to provide a current review of the recent literature (2015-2018) on psychophysiological markers of fear and anxiety.

RECENT FINDING

Relative to healthy controls, fear-based disorders are characterised by heightened physiological reactivity to circumscribe threat salient stimuli, whereas anxiety-related disorders are associated with a more blunted pattern of physiological reactivity. Fear and anxiety disorders are marked by abnormal patterns of physiological reactivity, characterised by hyper- and hypo-reactivity in response to stimuli varying in threat salience.

Toward a transdiagnostic model of common and unique processes leading to the major disorders of childhood: The REAL model of attention, responsiveness and learning

There is a growing recognition of the importance of identifying both trans-diagnostic risk factors across the major disorders that onset early in childhood, as well as precise vulnerabilities that differentiate among specific disorders. In this paper, we propose a model to explain individual differences in the development of the major forms of mental health problems that can be identified early in life through excesses and deficits in emotional attention, responsiveness and learning (i.e., the REAL model). The model leads to a number of specific hypotheses relating to trans-diagnostic (common to all disorders) and specific risk to the major mental disorders of childhood. Like earlier models of temperament, the REAL constructs are defined in terms of how the child responds to environmental conditions. Our proposal is that the development of psychopathology is in part based on how adverse environmental conditions trigger, inhibit, and interact with these specific biological vulnerabilities at sensitive periods in the developing human. To illustrate this interplay of biology and experience, we summarize key findings from the growing field of epigenetics and child mental health, arguing that epigenetic processes might mediate the relationship between environmental adversity and the major neurodevelopmental systems of REAL. Finally, we argued that the REAL model highlights important avenues for early intervention based on common and unique factors across childhood disorders.

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.

Mechanisms linking childhood adversity with psychopathology: Learning as an intervention target

Exposure to childhood adversity is common and a powerful risk factor for many forms of psychopathology. In this opinion piece, we argue for greater translation of knowledge about the developmental processes that are influenced by childhood adversity into targeted interventions to prevent the onset of psychopathology. Existing evidence has consistently identified several neurodevelopmental pathways that serve as mechanisms linking adversity with psychopathology. We highlight three domains in which these mechanisms are well-established and point to clear targets for intervention: 1) threat-related social information processing biases; 2) heightened emotional reactivity and difficulties with emotion regulation; and 3) disruptions in reward processing. In contrast to these established pathways, knowledge of how childhood adversity influences emotional learning mechanisms, including fear and reward learning, is remarkably limited. We see the investigation of these mechanisms as a critical next step for the field that will not only advance understanding of developmental pathways linking childhood adversity with psychopathology, but also provide clear targets for behavioral interventions. Knowledge of the mechanisms linking childhood adversity with psychopathology has advanced rapidly, and the time has come to translate that knowledge into clinical interventions to prevent the onset of mental health problems in children who have experienced adversity.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LIMITATIONS

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

The need for standards in the design of differential fear conditioning and extinction experiments in youth: A systematic review and recommendations for research on anxiety

Fear extinction studies in youth have yielded mixed results due to developmental processes and variations in design, methodology and dependent measures. This systematic review focused on studies with healthy youth between 2 and 17 years of age to identify experimental parameters of studies documenting extinction effects. Thirty-five studies met inclusion criteria and the following themes emerged (a) some studies employed parameters and task demands that are complex and require active participant involvement whereas others involved simple stimulus configurations and passive participant involvement, and (b) variation exists among dependent measures in units of measurement, timing and type of measurement. The review identified that studies using geometric shape conditioned stimuli (CS) paired with a tone unconditioned stimulus (US) (e.g., metal scraping on slate), as well as face CSs with a scream US produced the most reliable extinction effects, although the latter combination may be associated with higher drop-out than shape CSs and a tone US. The most commonly used and effective dependent measures for revealing extinction effects were skin conductance responses (SCR) and subjective ratings (SR) of CS valence, fearfulness and arousal. Fear potentiated startle (FPS) blink reflexes were also an effective but less commonly used measure. It is recommended that future studies use shape CSs and the metal scraping on slate US in studies involving children and either shape CSs and the metal scraping on slate US or face CSs paired with a scream US with adolescents. It is also recommended that US expectancy ratings and CS evaluations are assessed trial-by-trial and between-phase, and that startle-eliciting stimuli to measure startle blink reflexes are delivered on every second trial per CS so that SCR and FPS can be examined. However, further research is required to determine whether increased participant involvement due to providing trial-by-trial and between-phase ratings of the CSs and US differentially influences responding, particularly in children relative to adolescents and adults.

The role of avoidance behavior in the treatment of adolescents with irritable bowel syndrome: A mediation analysis

Irritable bowel syndrome (IBS) is common in adolescents with a pronounced negative impact on quality of life. A pattern of avoidance behavior is commonly seen in the IBS population, which is associated with more gastrointestinal (GI) symptoms. Exposure-based cognitive behavior therapy (CBT) targets the avoidance behavior to reduce symptoms, but it is unknown whether reduced avoidance is a mediator of symptom improvement in adolescent IBS. Stress has been suggested to play a key role in worsening GI symptoms and is also a potential mediator of the treatment effect in IBS. This study was based on data from a randomized controlled trial (N = 101) that evaluated exposure-based internet-delivered CBT (Internet-CBT) compared with a wait-list for adolescents with IBS. We investigated whether avoidance behavior and perceived stress mediated the improvement in global GI symptoms due to treatment. We found that a change in avoidance behavior, but not perceived stress, mediated the effect of exposure-based Internet-CBT on GI symptoms. The decrease in avoidance behavior explained a large portion (67%) of the total treatment effect. Moreover, a unidirectional relationship over time was observed between avoidance behavior and GI symptoms. Our conclusion is that exposure-based CBT in adolescent IBS reduces avoidance and, consequently, reduces GI symptoms.

Honoring the Past, Envisioning the Future: ABCT's 50th Anniversary Presidential Address

The theme of the Association for Behavioral and Cognitive Therapies (ABCT) 50^th Anniversary was to honor the past and envision the future. From the wisdom, foresight, and determination of the pioneers of our organization, and the continuous upholding of the scientific method over the last 50 years, cognitive behavioral therapy (CBT) has become the most empirically supported psychological treatment for a wide array of mental health problems. Yet, we still have a long way to go. This address outlines a vision for the future of CBT, which involves greater collaborative science, with all minds working together on the same problem, and greater attention to the risk factors and critical processes that underlie psychopathology and explain treatment change. Such knowledge generation can inform the development of new, more efficient and more effective therapies that are tailored with more precision to the needs of each person. Latest technologies provide tools for a precision focus while at the same time increasing the reach of our treatments to the many for whom traditional therapies are unavailable. Our impact will be greatly enhanced by large samples with common methods and measures that inform a precision approach. We have come a long way since ABCT was founded in 1966, and we are poised to make even larger strides in our mission to enhance health and well-being by harnessing science, our major guiding principle.

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.

Anxiety disorders

Anxiety disorders constitute the largest group of mental disorders in most western societies and are a leading cause of disability. The essential features of anxiety disorders are excessive and enduring fear, anxiety or avoidance of perceived threats, and can also include panic attacks. Although the neurobiology of individual anxiety disorders is largely unknown, some generalizations have been identified for most disorders, such as alterations in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis and genetic factors. In addition, general risk factors for anxiety disorders include female sex and a family history of anxiety, although disorder-specific risk factors have also been identified. The diagnostic criteria for anxiety disorders varies for the individual disorders, but are generally similar across the two most common classification systems: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, Tenth Edition (ICD-10). Despite their public health significance, the vast majority of anxiety disorders remain undetected and untreated by health care systems, even in economically advanced countries. If untreated, these disorders are usually chronic with waxing and waning symptoms. Impairments associated with anxiety disorders range from limitations in role functioning to severe disabilities, such as the patient being unable to leave their home.