Attention bias modification treatment augmenting effects on cognitive behavioral therapy in children with anxiety: randomized controlled trial

Attention Training for Child Anxiety and Its Disorders: Moving from Research to Clinical Implementation

Attention training is an evidence-based, computerized treatment for anxiety and its disorders rooted in cognitive neuroscience. Though experimental research and clinical trials data on attention training in children span two decades, the literature has focused on attention training's anxiety reduction effects, with little guidance on its implementation in clinical practice. Guidance on implementation is needed given recent efforts to increase accessibility of attention training in clinical practice settings. In this article, we move from research to clinical implementation, providing guidelines with pragmatic clinical steps. We include guidance on psychoeducation, setting and delivery of sessions, potential challenges, and frequently asked questions regarding implementation.

Reliability (or lack thereof) of smartphone ecological momentary assessment of visual dot probe attention bias toward threat indices

BACKGROUND AND OBJECTIVES

Cognitive bias theories posit that generalized anxiety disorder (GAD) and social anxiety disorder (SAD) are entwined with attention bias toward threats, commonly indexed by faster response time (RT) on threat-congruent (vs. threat-incongruent) trials on the visual dot probe. Moreover, although smartphone ecological momentary assessment (EMA) of the visual dot probe has been developed, their psychometric properties are understudied. This study thus aimed to assess the reliability of 8 smartphone-delivered visual dot probe attention bias and related indices in persons with and without GAD and SAD.

METHODS

Community-dwelling adults (n = 819; GAD: 64%; SAD: 49%; Mixed GAD and SAD: 37%; Non-GAD/SAD Controls: 24%) completed a five-trial smartphone-delivered visual dot probe for a median of 60 trials (12 sessions x 5 trials/session) and an average of 100 trials (20 sessions x 5 trials/session).

RESULTS

As hypothesized, Global Attention Bias Index, Disengagement Effect, and Facilitation Bias had low-reliability estimates. However, retest-reliability and internal reliability were good for Trial-Level Bias Scores (TLBS) (Bias Toward Treat: intra-class correlation coefficients (ICCs) = 0.626-0.644; split-half r = 0.640-0.670; Attention Bias Variability: ICCs = 0.507-0.567; split-half r = 0.520-0.580) and (In)congruent RTs. Poor retest-reliability and internal reliability estimates were consistently observed for all traditional attention bias and related indices but not TLBS.

LIMITATIONS

Our visual dot probe EMA should have administered ≥320 trials to match best-practice guidelines based on similar laboratory studies.

CONCLUSIONS

Future research should strive to examine attention bias paradigms beyond the dot-probe task that evidenced meaningful test-retest reliability properties in laboratory and real-world naturalistic settings.

Current and Future Approaches to Pediatric Anxiety Disorder Treatment

This overview critically appraises the literature on the treatment of pediatric anxiety disorders. The two established treatments for these conditions comprise cognitive-behavioral therapy (CBT) and antidepressant medications. Many youths receiving these treatments fail to achieve remission, which creates a need for new treatments. After summarizing the literature on CBT and currently available medications, the authors describe research that lays a foundation for improvements in the treatment of pediatric anxiety disorders. This foundation leverages neuroscientific investigations, also described in the overview, which provide insights on mechanisms of successful treatment.

Novel mechanism-based treatments for pediatric anxiety and depressive disorders

Pediatric anxiety and depressive disorders are common, can be highly impairing, and can persist despite the best available treatments. Here, we review research into novel treatments for childhood anxiety and depressive disorders designed to target underlying cognitive, emotional, and neural circuit mechanisms. We highlight three novel treatments lying along a continuum relating to clinical impact of the disorder and the intensity of clinical management required. We review cognitive training, which involves the lowest risk and may be applicable for problems with mild to moderate impact; psychotherapy, which includes a higher level of clinical involvement and may be sufficient for problems with moderate impact; and brain stimulation, which has the highest potential risks and is therefore most appropriate for problems with high impact. For each treatment, we review the specific underlying cognitive, emotional, and brain circuit mechanisms that are being targeted, whether treatments modify those underlying mechanisms, and efficacy in reducing symptoms. We conclude by highlighting future directions, including the importance of work that leverages developmental windows of high brain plasticity to time interventions to the specific epochs in childhood that have the largest and most enduring life-long impact.

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.

Effectiveness of Psychotherapy for Internalising Symptoms in Children and Adolescents When Delivered in Routine Settings: A Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to examine the effectiveness of psychological interventions for internalising disorders in youth when delivered in routine settings. Secondary aims were to examine the effectiveness of cognitive behavioural therapy and determine moderators of treatment response. The study was pre-registered (PROSPERO 2020 CRD42020202776). Databases were systematically searched (PsycINFO, Medline, Embase, PubMed, ERIC) in December 2022 and screened according to the PRISMA 2020 statement. Inclusion: School aged participants (4-18 years) with a primary internalising disorder; psychotherapy delivered in a routine setting (e.g. outpatient clinic, school) by setting staff; compared psychotherapy to any control in a randomised controlled trial; reported pre-to-post or pre-to-follow-up comparisons on the primary disorder according to child, parent or independent evaluator report; and was published in English. Risk of bias was assessed using the ROB 2.0 Cochrane tool. Results were synthesised using random effects to pool estimates. Risk ratios were used to analyse dichotomous data and standardised mean differences (SMD) for continuous data. Forty-five studies were included (N = 4901 participants; M = 13 years; range 8-16; SD = 2.5). Nine used waitlist control, 17 treatment as usual, 4 placebo; 15 compared psychotherapy to active control. Psychotherapy was associated with small significant effects pre- to post-treatment compared to non-active controls for anxiety (SMD =  - 0.24 to 0.50) and depression (SMD =  - 0.19 to 0.34) with effects differing by informant. Psychotherapy led to small significant pre-to-post-benefits in youth internalising disorders in routine settings. Results are limited by reporter type and follow-up.

Internet-based cognitive behavioural therapy combined with attentional bias modification training in generalized anxiety disorder: a randomized, controlled multi-session experiment

BACKGROUND

Although attentional bias modification training (ABM) and cognitive behavioural therapy (CBT) are two effective methods to decrease the symptoms of generalized anxiety disorders (GAD), to date, no randomized controlled trials have yet evaluated the effectiveness of an intervention combining internet-based cognitive behavioural therapy (ICBT) and ABM for adults with GAD.

AIMS

This study aimed to investigate the effectiveness of an intervention combining ICBT and ABM for adults with GAD.

METHOD

Sixty-three participants diagnosed with GAD were randomly assigned to the treatment group (ICBT with ABM; 31 participants) or the control group (ICBT with ABM placebo; 32 participants), and received 8 weeks of treatment and three evaluations. The CBT, ABM and ABM-placebo training were conducted via the internet. The evaluations were conducted at baseline, 8 weeks later, and 1 month later, respectively.

RESULTS

Both the treatment and control groups reported significantly reduced anxiety symptoms and attentional bias, with no clear superiority of either intervention. However, the treatment group showed a greater reduction in negative automatic thoughts than the control group after treatment and at 1-month follow-up (η² = 0.123).

CONCLUSION

The results suggest that although not differing in therapeutic efficacy, the intervention combining ICBT and ABM is superior to the intervention combining ICBT and ABM-placebo in the reduction of negative automatic thoughts. ABM may be a useful augmentation of ICBT on reducing anxiety symptoms.

Attention Training as a Low-Intensity Treatment for Concerning Anxiety in Clinic-Referred Youth

Although youth anxiety treatment research has focused largely on severe and impairing anxiety levels, even milder anxiety levels, including levels that do not meet full criteria for a diagnosis, can be impairing and cause for concern. There is a need to develop and test viable treatments for these concerning anxiety levels to improve functioning and reduce distress. We present findings from a randomized controlled efficacy trial of attention bias modification treatment (ABMT) and attention control training (ACT) for youths with concerning anxiety levels. Fifty-three clinic-referred youths (29 boys, M age = 9.3 years, SD age = 2.6) were randomized to either ABMT or ACT. ABMT and ACT consisted of attention-training trials in a dot-probe task presenting angry and neutral faces; probes appeared in the location of neutral faces in 100% of ABMT trials and 50% of ACT trials. Independent evaluators provided youth anxiety severity ratings; youths and parents provided youth anxiety severity and global impairment ratings; and youths completed measures of attention bias to threat and attention control at pretreatment, posttreatment, and 2-month follow-up. In both arms, anxiety severity and global impairment were significantly reduced at posttreatment and follow-up. At follow-up, anxiety severity and global impairment were significantly lower in ACT compared with ABMT. Attention control, but not attention bias to threat, was significantly improved at follow-up in both arms. Changes in attention control and attention focusing were significantly associated with changes in anxiety severity. Findings support the viability of attention training as a low-intensity treatment for youths with concerning anxiety levels, including levels that do not meet full criteria for a diagnosis. Superior anxiety reduction effects in ACT highlight the critical need for mechanistic research on attention training in this population.

Attentional biases in human anxiety

Across clinical and subclinical samples, anxiety has been associated with increased attentional capture by cues signaling danger. Various cognitive models attribute the onset and maintenance of anxiety symptoms to maladaptive selective information processing. In this brief review, we 1) describe the evidence for the relations between anxiety and attention bias toward threat, 2) discuss the neurobiology of anxiety-related differences in threat bias, 3) summarize work investigating the developmental origins of attention bias toward threat, and 4) examine efforts to translate threat bias research into clinical intervention. Future directions in each area are discussed, including the use of novel analytic approaches improving characterization of threat-processing-related brain networks, clarifying the role of cognitive control in the development of attention bias toward threat, and the need for larger, well-controlled randomized clinical trials examining moderators and mediators of treatment response. Ultimately, this work has important implications for understanding the etiology of and for intervening on anxiety difficulties among children and adults.

The Circle of Security Parenting Program (COS-P): A Randomized Controlled Trial of a Low Intensity, Individualized Attachment-Based Program With at-Risk Caregivers

The Circle of Security-Parenting Intervention (COS-P; Cooper et al., 2009) is a psychoeducational program for caregivers of young children that has been widely disseminated. The program is founded in attachment theory and relies on computer-delivered content and parent reflection and discussion to teach concepts of safety and security to promote better caregiver-child relationships and child wellbeing. The present study is a randomized controlled trial of COS-P, individually delivered to 85 Australian caregivers (51 COS-P, 34 waitlist control) who reported parenting distress and child disruptive behaviors. Caregivers completed a baseline assessment and repeated the assessment after completion of COS-P or 8 weeks on the waitlist. Caregivers completed surveys to report child symptoms, and parenting stress, anxious and avoidant attachment, reflective functioning, parenting practices, and depressive symptoms. No differences in COS-P vs. waitlist participants were found at baseline. Analyses of complete data (35 COS-P, 25-26 waitlist) revealed a greater decline in caregivers' attachment anxiety and negative parenting relative to waitlist, but only attachment anxiety in intent-to-treat analyses. Other improvements were found, but these extended to both the COS-P and waitlist conditions and did not differ between conditions. Overall, effects of COS-P were small and rarely significant, suggesting the need to consider alternative programs that have evidence of effectiveness when providing services to at-risk families.

An Eye-Tracking Study of Attention Biases in Children at High Familial Risk for Depression and Their Parents with Depression

Attention biases (AB) are a core component of cognitive models of depression yet it is unclear what role they play in the transgenerational transmission of depression. 44 children (9-14 years) with a high familial risk of depression (HR) were compared on multiple measures of AB with 36 children with a low familial risk of depression (LR). Their parents: 44 adults with a history of depression (HD) and 36 adults with no history of psychiatric disorder (ND) were also compared. There was no evidence of group differences in AB; neither between the HR and LR children, nor between HD and ND parents. There was no evidence of a correlation between parent and child AB. The internal consistency of the tasks varied greatly. The Dot-Probe Task showed unacceptable reliability whereas the behavioral index of the Visual-Search Task and an eye-tracking index of the Passive-Viewing Task showed better reliability. There was little correlation between the AB tasks and the tasks showed minimal convergence with symptoms of depression or anxiety. The null-findings of the current study contradict our expectations and much of the previous literature. They may be due to the poor psychometric properties associated with some of the AB indices, the unreliability of AB in general, or the relatively modest sample size. The poor reliability of the tasks in our sample suggest caution should be taken when interpreting the positive findings of previous studies which have used similar methods and populations.

The ERN as a neural index of changes in performance monitoring following attention training in pediatric obsessive-compulsive disorder

Evidence of associations between obsessive compulsive disorder (OCD) and alterations in neural indices of performance monitoring, i.e., elevated neural activity following errors, have accelerated interest in the error-related negativity (ERN) as a biomarker for pediatric OCD. The study investigates the degree to which attention bias training is linked to changes in neural measures of performance monitoring (ERN, correct response negativity or CRN) and whether pre-to-post training changes in these neural indices are associated with symptom changes in youth with OCD. The sample included 36 youth (8-17 years) diagnosed with OCD who completed a 12-session attention training program and pre- and post-training EEG assessment of performance monitoring using cognitive and emotional flanker tasks. The emotional flanker task was individualized to each participant's negative ratings of stimuli at pre-treatment to enhance salience of threat-related stimuli across youth. Results indicated that unlike participants who received attentional control protocol (CON), those who received attentional bias modification protocol (ABM) showed significant attenuations in neural activity following erroneous and correct responses in the emotional flanker task. The ERN amplitude during the cognitive flanker task was unchanged in both ABM and CON groups. Attenuations in the ERN were also linked to decreases in social anxiety and depressive symptoms. Findings highlight the relevance of including emotionally-salient tasks when investigating potential neural mechanisms of treatments and suggest that alterations in neural processes underlying performance monitoring can be targeted via attention training programs in pediatric OCD.

Whole-Brain Resting-State Functional Connectivity Patterns Associated With Pediatric Anxiety and Involuntary Attention Capture

BACKGROUND

Pediatric anxiety disorders are linked to dysfunction in multiple functional brain networks, as well as to alterations in the allocation of spatial attention. We used network-level analyses to characterize resting-state functional connectivity (rs-fc) alterations associated with 1) symptoms of anxiety and 2) alterations in stimulus-driven attention associated with pediatric anxiety disorders. We hypothesized that anxiety was related to altered connectivity of the frontoparietal, default mode, cingulo-opercular, and ventral attention networks and that anxiety-related connectivity alterations that include the ventral attention network would simultaneously be related to deviations in stimulus-driven attention.

METHODS

A sample of children (n = 61; mean = 10.6 years of age), approximately half of whom met criteria for a current anxiety disorder, completed a clinical assay, an attention task, and rs-fc magnetic resonance imaging scans. Network-level analyses examined whole-brain rs-fc patterns associated with clinician-rated anxiety and with involuntary capture of attention. Post hoc analyses controlled for comorbid symptoms.

RESULTS

Elevated clinician-rated anxiety was associated with altered connectivity within the cingulo-opercular network, as well as between the cingulo-opercular network and the ventral attention, default mode, and visual networks. Connectivity between the ventral attention and cingulo-opercular networks was associated with variation in both anxiety and stimulus-driven attention.

CONCLUSIONS

Pediatric anxiety is related to aberrant connectivity patterns among several networks, most of which include the cingulo-opercular network. These results help clarify the within- and between-network interactions associated with pediatric anxiety and its association with altered attention, suggesting that specific network connections could be targeted to improve specific altered processes associated with anxiety.

Differences in Parent and Child Report on the Screen for Child Anxiety-Related Emotional Disorders (SCARED): Implications for Investigations of Social Anxiety in Adolescents

Social anxiety typically emerges by adolescence and is one of the most common anxiety disorders. Many clinicians and researchers utilize the Screen for Child Anxiety Related Disorders (SCARED) to quantify anxiety symptoms, including social anxiety, throughout childhood and adolescence. The SCARED can be administered to both children and their parents, though reports from each informant tend to only moderately correlate. Here, we investigated parent-child concordance on the SCARED in a sample of adolescents (N = 360, M_age = 13.2) using a multi-trait multi-method (MTMM) model. Next, in a selected sample of the adolescents, we explored relations among child report, parent report, and latent social anxiety scores with two laboratory tasks known to elicit signs of social anxiety in the presence of unfamiliar peers: a speech task and a "Get to Know You" task. Findings reveal differences in variance of the SCARED accounted for by parent and child report. Parent report of social anxiety is a better predictor of anxiety signs elicited by a structured speech task, whereas child report of social anxiety is a better predictor of anxiety signs during the naturalistic conversation with unfamiliar peers. Moreover, while latent social anxiety scores predict both observed anxiety measures, parent report more closely resembles latent scores in relation to the speech task, whereas child report functions more similarly to latent scores in relation to the peer conversation. Thus, while latent scores relate to either observed anxiety measure, parent and child report on the SCARED each provide valuable information that differentially relate to naturalistic social anxiety-related behaviors.

Leveraging big data to map neurodevelopmental trajectories in pediatric anxiety

Anxiety disorders are the most prevalent psychiatric condition among youth, with symptoms commonly emerging prior to or during adolescence. Delineating neurodevelopmental trajectories associated with anxiety disorders is important for understanding the pathophysiology of pediatric anxiety and for early risk identification. While a growing literature has yielded valuable insights into the nature of brain structure and function in pediatric anxiety, progress has been limited by inconsistent findings and challenges common to neuroimaging research. In this review, we first discuss these challenges and the promise of ‘big data’ to map neurodevelopmental trajectories in pediatric anxiety. Next, we review evidence of age-related differences in neural structure and function among anxious youth, with a focus on anxiety-relevant processes such as threat and safety learning. We then highlight large-scale cross-sectional and longitudinal studies that assess anxiety and are well positioned to inform our understanding of neurodevelopment in pediatric anxiety. Finally, we detail relevant challenges of ‘big data’ and propose future directions through which large publicly available datasets can advance knowledge of deviations from normative brain development in anxiety. Leveraging ‘big data’ will be essential for continued progress in understanding the neurobiology of pediatric anxiety, with implications for identifying markers of risk and novel treatment targets.

Attention bias modification for anxiety disorders in children and adolescents: A systematic review and meta-analysis

Despite accumulating evidence suggesting the effectiveness of Attention Bias Modification (ABM) in adults, little is known about its efficacy in children and adolescents. As anxiety has been the chief target in most studies and research in this area has grown rapidly in recent years, we conducted the first meta-analysis to establish the effects of ABM alone for anxiety disorders in children and adolescents. Studies were identified through a systematic search in three main databases: PubMed, EMBASE and PsycInfo, resulting in 17 randomized studies. The quality of these studies, possible publication bias and moderators were then examined. ABM had small but significant effects on clinician-rated anxiety symptoms and attention bias towards threat, while the effect on self or parent-reported anxiety measures was non-significant. Evidence quality ranged from moderate to very low. ABM was more effective when conducted as a stand-alone treatment than as an adjunct to other treatments. In addition, younger age and larger number of training sessions were associated with a greater reduction in clinician-rated anxiety symptoms. Results indicate that ABM may have significant effects on anxiety and attention bias in children and adolescents. Overall, the effects of ABM are mainly evident when clinical outcome is assessed by a clinician.

Can attention bias modification augment the effect of CBT for anxiety disorders? A systematic review and meta-analysis

Attention Bias Modification (ABM) is a novel computerized therapy for anxiety disorders and is thought to augment the effect of Cognitive Behavior Therapy (CBT) as it may target different mechanisms. Recently, a growing number of studies have examined the combined effects of ABM and CBT on clinically anxious patients, with mixed results. This review examined the combined efficacy of ABM and CBT. A literature search was conducted in four main databases: PsycINFO, Embase, Pubmed and the Cochrane library, resulting in 11 randomized studies. The combination of ABM and CBT had small but significant effects on clinician-rated anxiety symptoms and attention bias towards threat compared to the control group, while ESs for anxiety (all measures), self-reported or parent-reported anxiety measures and depression symptoms were non-significant. Studies in which ABM was conducted as an integral part of each CBT session yielded greater reduction in anxiety symptoms than those conducting ABM and CBT at separate time points. Older participants and patients with social anxiety disorder tended to benefit less from the combination of ABM and CBT based on bias scores. This study may provide preliminary evidence that ABM and CBT have the potential to complement each other, especially when they are conducted integrally.

Attention Alterations in Pediatric Anxiety: Evidence From Behavior and Neuroimaging

BACKGROUND

Pediatric anxiety disorders involve greater capture of attention by threatening stimuli. However, it is not known if disturbances extend to nonthreatening stimuli, as part of a pervasive disturbance in attention-related brain systems. We hypothesized that pediatric anxiety involves greater capture of attention by salient, nonemotional stimuli, coupled with greater activity in the portion of the inferior frontal gyrus (IFG) specific to the ventral attention network (VAN).

METHODS

A sample of children (n = 129, 75 girls, mean 10.6 years of age), approximately half of whom met criteria for a current anxiety disorder, completed a task measuring involuntary capture of attention by nonemotional (square boxes) and emotional (angry and neutral faces) stimuli. A subset (n = 61) completed a task variant during functional magnetic resonance imaging. A priori analyses examined activity in functional brain areas within the right IFG, supplemented by a whole-brain, exploratory analysis.

RESULTS

Higher clinician-rated anxiety was associated with greater capture of attention by nonemotional, salient stimuli (F1,125 = 4.94, p = .028) and greater activity in the portion of the IFG specific to the VAN (F1,57 = 10.311, p = .002). Whole-brain analyses confirmed that the effect of anxiety during capture of attention was most pronounced in the VAN portion of the IFG, along with additional areas of the VAN and the default mode network.

CONCLUSIONS

The pathophysiology of pediatric anxiety appears to involve greater capture of attention to salient stimuli, as well as greater activity in attention-related brain networks. These results provide novel behavioral and brain-based targets for treatment of pediatric anxiety disorders.

Emerging Domain-Based Treatments for Pediatric Anxiety Disorders

Domain-specific cognitive training treatments for pediatric anxiety disorders rely on accurate and reliable identification of specific underlying deficits and biases in neurocognitive functions. Once identified, such biases can serve as specific targets for therapeutic intervention. Clinical translations typically reflect mechanized training protocols designed to rectify the identified biases. Here, we review and synthesize research on key neurocognitive processes that emerge as potential targets for specialized cognitive training interventions in pediatric anxiety disorders in the domains of attention, interpretation, error monitoring, working memory, and fear learning. For each domain, we describe the current status of target establishment (i.e., an association between pediatric anxiety and a specific neurocognitive process), and then review extant translational efforts regarding these targets and the evidence supporting their clinical utility in youths. We then localize each of the domains within the path leading to efficacious, evidence-supported treatments for pediatric anxiety, providing a roadmap for future research. The review indicates that specific cognitive targets in pediatric anxiety have been established in all the reviewed domains except for fear learning, where a clear target is yet to be elucidated. In contrast, evidence for clinical efficacy emerged only in the threat-related attention domain, with some preliminary findings in the domains of interpretation and working memory. The path to clinical translation in the domain of error monitoring is yet unclear. Implications and potential avenues for future research and translation are discussed.

How technology can enhance treatment: A scoping review of clinical interventions for anxiety and obsessive-compulsive spectrum disorders

OBJECTIVES

Researchers are increasingly investigating how technology could be used to improve the efficacy of treatment for anxiety and obsessive-compulsive (OC) spectrum disorders. A broad range of technologies, disorders and therapeutic processes have been examined in the literature. This review summarizes the evidence for using technology in clinical interventions for anxiety and OC-spectrum disorders and highlights research gaps that should be addressed to improve the evidence base.

METHODS

A scoping review was conducted based on systematic searches of three databases. Broadly, the criteria included interventions that had integrated technology into clinical contexts to enhance treatment for anxiety and OC-spectrum disorders. All records were double-screened by two reviewers, and data were extracted on the characteristics of interventions, symptom outcomes, and implementation factors.

RESULTS

Searches returned 2,475 studies, of which 117 were eligible for inclusion in this review. Although almost all studies reported pre-post-symptom reductions, only one quarter of the controlled studies demonstrated additive effect of technology-based interventions in between-group analyses. We noted a trend in underreporting implementation factors.

CONCLUSIONS

Technology-based interventions can improve the efficacy of treatment for anxiety and OC-spectrum disorders, but there are challenges to achieving this goal. Based on a review of the included studies, we provide four specific recommendations to improve the quality and likelihood of success of future research projects.

PRACTITIONER POINTS

Technology-based adjuvants are unlikely to improve the efficacy of treatment for anxiety or OC-spectrum disorders based on their novelty or convenience alone. A subset of studies gives hope that specific innovations can improve treatment when targeting a therapeutic process that has been problematic. Clinicians seeking to improve the efficacy of their treatment should first define client-specific therapeutic factors (e.g., homework compliance) that could be leveraged, then apply a specific innovation to address this factor.

Tackling Mental Health in Youth Sporting Programs: A Pilot Study of a Holistic Program

Linking mental health services to organised sport offers an avenue to identify and improve mental health among adolescents. In this study, we investigated the efficacy, acceptability and feasibility of an integrated mental health system embedded within a junior sports development program. A three-step integrated mental health program for 12- to 15-year-old rugby league players (N = 74) was delivered in urban (n = 44) and rural (n = 33) areas. Specifically, this system (a) assessed participant mental health on primary outcome measures of anxiety, depression, and anger/conduct problems (and secondary outcome measures of personal attributes and relationships), (b) provided feedback to participants, parents and program coordinators, and (c) connected participants and parents to a multi-component intervention including online resources, a group-based workshop program (4 × 30-min sessions), and tailored individual-level follow-up and referral to further care for participants at high risk of mental health problems. From pre- to post-program, boys' anxiety symptoms declined significantly (with only a trend-level reduction in depression), and there were significant improvements in grit (for urban boys only), efficacy to manage negative emotions, and prosocial behaviour. In addition, when boys reported symptoms associated with high risk for mental health problems, providing parents with feedback enhanced boys' access to care and was associated with significant declines in anxiety symptoms. The program was generally acceptable and feasible, with very high retention in the youth sports development program. Overall, early findings support further deployment and evaluation of integrated mental health systems embedded within sporting contexts to address mental health problems among adolescent boys.

Psychometric properties of threat-related attentional bias in young children using eye-tracking

Anxiety is one of the most common forms of child psychopathology associated with persistent impairment across the lifespan. Therefore, investigating mechanisms that underlie anxiety in early childhood may improve prevention and intervention efforts. Researchers have linked selective attention toward threat (i.e., attentional bias to threat) with the development of anxiety. However, previous work on attentional bias has used less reliable, reaction time (RT)-based measures of attention. Additionally, few studies have used eye-tracking to measure attentional bias in young children. In the present study, we investigated the psychometric properties of an eye-tracking measure of attentional bias in a sample of young children between 6- and 9-years-old and explored if trait and clinical anxiety were related to attentional biases to threat. Results showed good psychometric properties for threat and neutral attentional biases, comparable to those found in adult eye-tracking studies. Temperamental and clinical anxiety did not significantly relate to threat/neutral dwell time and attentional biases. The significance of these null findings was discussed in relation to existing developmental theories of attentional biases. Future studies should explore if temperamental or clinical anxiety prospectively predict threat attentional bias and the onset of anxiety in older children using a longitudinal design.

A pilot study augmenting cognitive behavioral therapy for panic disorder with attention bias modification: Clinical and psychophysiological outcomes

BACKGROUND AND OBJECTIVES

Studies show that attentional bias towards threat is a key maintenance factor for panic disorder (PD). Attentional bias may be an important mechanism of symptom reduction, and thus, a useful target for optimizing outcomes. The current study examined whether an attention bias modification (ABM) task enhanced CBT outcomes. Multiple methods for assessing PD were used, including physiological measurement and clinician-rated assessment.

METHODS

Adults with panic disorder (N = 24) received seven sessions of CBT with either ABM or sham attention tasks. Psychophysiological reaction to a loud tones startle paradigm was assessed before and after treatment.

RESULTS

Across both groups, panic symptom severity decreased with CBT. The ABM group showed greater reductions in PD symptoms compared to the placebo group. Notably, however, changes in attentional bias were not associated with symptom reductions across groups. No significant group differences on psychophysiological assessment were observed.

LIMITATIONS

This study is limited by the small sample size, which rendered our power to investigate mediators and moderators insufficient. More research is needed to validate the effect of attention bias modification on attentional bias to threat.

CONCLUSIONS

This pilot study suggests that future research should investigate attentional bias in conjunction with CBT. A larger sample would provide opportunity to further investigate the mechanisms through which ABM works, along with potential moderating factors and the use of psychophysiological measurements in panic disorder.

Gaze-Contingent Music Reward Therapy for Clinically Anxious 7- to 10-Year-Olds: An Open Multiple Baseline Feasibility Study

This multiple-baseline open pilot trial examined feasibility, compliance, acceptability, and preliminary indices of efficacy of Gaze-Contingent Music Reward Therapy (GC-MRT) for anxious 7- to 10-year-old children. GC-MRT is a novel therapy for anxiety disorders that relies on eye-tracking technology and operant conditioning principles to divert attention toward neutral over threat stimuli, with music serving as a reward. Using a multiple-baseline design, 12 children (M age = 8.3 years, SD = .72, range = 7-10; 4 girls) with social anxiety disorder, generalized anxiety disorder, or separation anxiety disorder received 8 therapy sessions. Clinical status was determined via semistructured interviews and questionnaires. Patients were randomized to wait 1, 3, or 5 weeks between initial assessment and beginning of therapy. Self-reported anxiety was recorded weekly, and comprehensive clinical assessments were obtained pre- and posttreatment. All 12 patients completed the full course of GC-MRT within the allocated therapy period. Therapy credibility rates were moderate to high as reported by both children and parents. Clinician-rated anxiety levels remained consistent during baseline measurement and decreased significantly following treatment. Parent-reports also yielded significant reductions in child anxiety symptoms from pre- to posttreatment. However, child-reported anxiety did not change significantly. The results provide preliminary evidence for feasibility, acceptability, and efficacy of GC-MRT for young children with anxiety disorders. Efficacy should now be tested in randomized controlled trials.

Age Moderates Link Between Training Effects and Treatment Response to Attention Bias Modification Treatment for Social Anxiety Disorder

Attention bias modification treatment (ABMT) aims to reduce anxiety symptoms via practice on computerized attention training tasks. Despite evidence of efficacy, clinical effects appear heterogeneous. More research on ABMT mechanisms and moderators of treatment response is needed. Age is one potentially important moderator, as developmental differences in training effects may impact response. We examined developmental links between ABMT training effects and response in social anxiety disorder (SAD). We pooled data from two randomized controlled trials in treatment-seeking youths and adults with SAD (N = 99) that used identical ABMT methods. We first characterized learning effects associated with the eight-session ABMT training protocol. We then tested whether learning magnitude predicted the clinical (change in SAD symptoms) and cognitive (change in attention bias) responses to treatment. Finally, we tested whether age moderated the association between ABMT learning and treatment response. Results indicate that ABMT was associated with an incremental learning curve during the protocol, and that learning improved with age. Age further moderated the association between learning gains during the ABMT protocol and subsequent reduction in self-reported SAD symptoms, such that this association was stronger with age. These effects were not evident in bias scores or clinician ratings. Finally, pre-treatment SAD symptoms and bias scores predicted ABMT learning gains. This study highlights the links among age, learning processes, and clinical response to ABMT. These insights may inform attempts to increase the clinical efficacy of ABMT for anxiety.

Effectiveness of cognitive behavioral therapy (CBT) for child and adolescent anxiety disorders across different CBT modalities and comparisons: a systematic review and meta-analysis

Aim: Pediatric Anxiety Disorders (AD) are common. Cognitive behavioral therapy (CBT) is one of two first-line treatments of youth AD and it has previously been shown to be superior to wait-list but not placebo therapy. This study consists of a systematic review and meta-analysis of the literature to assess the efficacy of CBT modalities in comparison to control contingencies for pediatric anxiety disorders.Methods: Studies were included if they were randomized controlled trials, and if CBT was manualized or modular, alone or in combination with medication. CBT was required to include behavioral treatment, exposure treatment, or cognitive elements. Eligible studies included participants aged 18 years or younger.Results: Eighty-one studies were included, with 3386 CBT participants and 2527 control participants. The overall results indicated that CBT is an effective treatment for childhood AD. The results showed that individual-based CBT is superior to wait-list and attention control. Group-based CBT is superior to wait-list control and treatment as usual. Remote-based CBT was superior to attention control and wait-list control. Family-based CBT was superior to treatment as usual, wait-list control, and attention control. Selective serotonin reuptake inhibitors were no more effective than individual-based CBT. Combination treatment was, however, more effective than individual-based CBT.Conclusion: To the best of our knowledge, no meta-analysis has thus far disentangled the effects of CBT modalities across various comparisons. This meta-analysis hence provides an important update to the literature on the efficacy of CBT for treating anxiety disorders in young people.

Effortful control, interpretation biases, and child anxiety symptom severity in a sample of children with anxiety disorders

INTRODUCTION

Effortful control-the ability to inhibit impulsive reactions in favor of more adaptive responses-is negatively related to child anxiety severity. One potential explanation is that greater effortful control may "slow down" automatic, threat-laden interpretations, thereby lowering children's anxiety. The present investigation tested this hypothesis by examining associations between effortful control (and its subcomponents) and anxiety symptom severity, mediated by interpretation biases, in a diverse sample of clinically anxious youth.

METHOD

Participants (N = 105; M_age = 10.09 years, SD = 1.22; 56.7% female; 49% ethnic minority) completed a diagnostic interview; self-report measures of temperament, anxiety, and interpretation biases; a performance-based measure of interpretation biases; and a parent-child interaction task for which an index of behavioral anxiety was computed.

RESULTS

Significant indirect effects were found for effortful control, attentional control, and inhibitory control on child self-reported anxiety severity by way of self-reported (but not behaviorally-indexed) interpretation biases. Models predicting behaviorally-indexed child anxiety severity were not significant.

DISCUSSION

Greater effortful control may result in enhanced attentional capacities that allow children to assess automatic cognitions more objectively, potentially lowering their anxiety. Future work should evaluate whether targeting malleable temperamental constructs, such as effortful control, leads to clinically meaningful reductions in interpretation biases and child anxiety symptoms.

Efficacy and mechanisms underlying a gamified attention bias modification training in anxious youth: protocol for a randomized controlled trial

BACKGROUND

Attention bias modification training (ABMT) and cognitive behavioral therapy (CBT) likely target different aspects of aberrant threat responses in anxiety disorders and may be combined to maximize therapeutic benefit. However, studies investigating the effect of ABMT in the context of CBT have yielded mixed results. Here, we propose an enhanced ABMT to target the attentional bias towards threat, in addition to classic CBT for anxiety disorders in youth. This enhanced ABMT integrates the modified dot-probe task used in previous studies, where a target is always presented at the previous location of the neutral and not the simultaneously presented threatening stimulus, with a visual search, where the targets are always presented distally of threatening distractors. These two training elements (modified dot-probe and visual search) are embedded in an engaging game to foster motivation and adherence. Our goal is to determine the efficacy of the enhanced ABMT in the context of CBT. Further, we aim to replicate two previous findings: (a) aberrant amygdala connectivity being the neurobiological correlate of the attentional bias towards threat at baseline; and (b) amygdala connectivity being a mediator of the ABMT effect. We will also explore moderators of treatment response (age, sex, depressive symptoms and irritability) on a behavioral and neuronal level.

METHODS

One hundred and twenty youth (8-17 years old) with a primary anxiety disorder diagnosis all receive CBT and are randomized to nine weeks of either active or control ABMT and symptom improvement will be compared between the two study arms. We will also recruit 60 healthy comparison youth, who along with eligible anxious youth, will be assessed with the dot-probe task during fMRI (anxious youth: before and after training; healthy volunteers: second measurement twelve weeks after initial assessment).

DISCUSSION

The present study will contribute to the literature by (1) potentially replicating that aberrant amygdala connectivity mediates the attentional bias towards threat in anxious youth; (2) determining the efficacy of enhanced ABMT; and (3) advancing our understanding of the mechanisms underlying ABMT.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT03283930 Trial registration date: September 14th 2017. The trial registration took place retrospectively. Data acquisition started February 1st 2017.

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.

Fear extinction learning as a predictor of response to cognitive behavioral therapy for pediatric obsessive compulsive disorder

BACKGROUND

While cognitive behavior therapy (CBT) is an effective treatment for many children and adolescents with Obsessive Compulsive Disorder (OCD), therapeutic response is variable. Fear conditioning and extinction are central constructs underlying exposure-based CBT. Fear extinction learning assessed prior to CBT may be a useful predictor of CBT response for guiding treatment decisions.

METHODS

Sixty-four youth who participated in a randomized placebo-controlled trial of CBT with and without d-cycloserine (DCS) completed a fear conditioning task. Skin conductance response (SCR) scores were used to measure fear acquisition and extinction to determine whether extinction learning could predict CBT response.

RESULTS

CBT responders and non-responders appeared to acquire conditioned fear SCRs in a similar manner. However, differences between treatment responders and non-responders emerged during the extinction phase. A responder (responder, non-responder) by conditioned stimulus type (CS+, CS-) interaction showed that CBT responders differentiated the stimulus paired with (CS+) and without (CS-) the unconditioned stimulus correctly during early and late extinction, whereas the CBT non-responders did not (p = .004).

CONCLUSIONS

While the small sample size makes conclusions tentative, this study supports an emerging literature that differential fear extinction may be an important factor underlying clinical correlates of pediatric OCD, including CBT response.

Efficacy of Attention Bias Training for Child Anxiety Disorders: A Randomized Controlled Trial

A growing evidence base supports attention bias modification (ABM) as a novel intervention for anxiety. However, research has been largely conducted with adults and analogue samples, leaving the impact of ABM for child anxiety be fully elucidated. Thus, we conducted a double-blind, randomized controlled trial testing ABM efficacy versus an attention control condition (CC) in 31 children diagnosed with anxiety disorder. Youth were assigned to 4 weeks of ABM where attention was trained away from threat, or a sham CC in which no bias training occurred. Findings indicate that significantly more youth in the ABM versus CC group were considered treatment responders post training. The ABM versus CC group also demonstrated a greater decrease in anxiety severity, with this difference being marginally significant. Findings lend support for the potential of ABM in reducing youth anxiety. Further work regarding mechanisms of action is warranted to advance ABM research.

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.

Improving the Efficacy of Cognitive Training for Digital Mental Health Interventions Through Avatar Customization: Crowdsourced Quasi-Experimental Study

Background

The success of internet-based mental health interventions in practice—that is, in the wild—depends on the uptake and retention of the application and the user’s focused attention in the moment of use. Incorporating game-based motivational design into digital interventions delivered in the wild has been shown to increase uptake and retention in internet-based training; however, there are outstanding questions about the potential of game-based motivational strategies to increase engagement with a task in the moment of use and the effect on intervention efficacy.

Objective

Designers of internet-based interventions need to know whether game-based motivational design strategies can increase in-the-moment engagement and thus improve digital interventions. The aim of this study was to investigate the effects of 1 motivational design strategy (avatar customization) in an example mental health intervention (computerized cognitive training for attention bias modification).

Methods

We assigned 317 participants to either a customized avatar or an assigned avatar condition. After measuring state anxiety (State-Trait Anxiety Inventory), we randomly assigned half of the participants in each condition to either an attentional retraining condition (Attention Bias Modification Training) or a control condition. After training, participants were exposed to a negative mood induction using images with strong negative valance (International Affective Picture System), after which we measured state anxiety again.

Results

Avatar customization decreased posttraining state anxiety when controlling for baseline state anxiety for those in the attentional retraining condition; however, those who did not train experienced decreased resilience to the negative mood induction (F_1,252=6.86, P=.009, η_p²=.027). This interaction effect suggests that customization increased task engagement with the intervention in the moment of use. Avatar customization also increased avatar identification (F_5,252=12.46, P<.001, R²=.23), regardless of condition (F_1,252=.79, P=.38). Avatar identification reduced anxiety after the negative mood induction for participants who underwent training but increased poststimulus anxiety for participants who did not undergo training, further suggesting that customization increases engagement in the task (F_1,252=6.19, P=.01). The beneficial effect of avatar customization on training was driven by participants who were low in their basic satisfaction of relatedness (F_10,248=18.5, P<.001, R²=.43), which is important because these are the participants who are most likely in need of digital interventions for mental health.

Conclusions

Our results suggest that applying motivational design—specifically avatar customization—is a viable strategy to increase engagement and subsequently training efficacy in a computerized cognitive task.

Group Cognitive Behavioral Therapy and Attention Bias Modification for Childhood Anxiety Disorders: A Factorial Randomized Trial of Efficacy

BACKGROUND

The objective of this study is to assess group differences in symptom reduction between individuals receiving group cognitive behavioral therapy (G-CBT) and attention bias modification (ABM) compared to their respective control interventions, control therapy (CT), and attention control training (ACT), in a 2 × 2 factorial design.

METHODS

A total of 310 treatment-naive children (7-11 years of age) were assessed for eligibility and 79 children with generalized, separation or social anxiety disorder were randomized and received G-CBT (n = 42) or CT (n = 37). Within each psychotherapy group, participants were again randomized to ABM (n = 38) or ACT (n = 41) in a 2 × 2 factorial design resulting in four groups: G-CBT + ABM (n = 21), G-CBT + ACT (n = 21), CT + ABM (n = 17), and CT + ACT (n = 20). Primary outcomes were responder designation as defined by Clinical Global Impression-Improvement (CGI-I) scale (≤2) and change on the Pediatric Anxiety Rating Scale (PARS).

RESULTS

There were significant improvements of symptoms in all groups. No differences in response rates or mean differences in PARS scores were found among groups: G-CBT + ABM group (23.8% response; 3.9 points, 95% confidence interval [CI] -0.3 to 8.1), G-CBT + ACT (42.9% response; 5.6 points, 95% CI 2.2-9.0), CT + ABM (47.1% response; 4.8 points 95% CI 1.08-8.57), and CT + ACT (30% response; 0.8 points, 95% CI -3.0 to 4.7). No evidence or synergic or antagonistic effects were found, but the combination of G-CBT and ABM was found to increase dropout rate.

CONCLUSIONS

We found no effect of G-CBT or ABM beyond the effects of comparison groups. Results reveal no benefit from combining G-CBT and ABM for anxiety disorders in children and suggest potential deleterious effects of the combination on treatment acceptability.

Attention bias modification augments cognitive-behavioral group therapy for social anxiety disorder: a randomized controlled trial

BACKGROUND

Cognitive-behavioral group therapy (CBGT) is a first-line treatment for social anxiety disorder (SAD). However, since many patients remain symptomatic post-treatment, there is a need for augmenting procedures. This randomized controlled trial (RCT) examined the potential augmentation effect of attention bias modification (ABM) for CBGT.

METHODS

Fifty patients with SAD from three therapy groups were randomized to receive an 18-week standard CBGT with either ABM designed to shift attention away from threat (CBGT + ABM), or a placebo protocol not designed to modify threat-related attention (CBGT + placebo). Therapy groups took place in a large mental health center. Clinician and self-report measures of social anxiety and depression were acquired pre-treatment, post-treatment, and at 3-month follow-up. Attention bias was assessed at pre- and post-treatment.

RESULTS

Patients randomized to the CBGT + ABM group, relative to those randomized to the CBGT + placebo group, showed greater reductions in clinician-rated SAD symptoms post-treatment, with effects maintained at 3-month follow-up. Group differences were not evident for self-report or attention-bias measures, with similar reductions in both groups. Finally, reduction in attention bias did not mediate the association between group and reduction in Liebowitz Social Anxiety Scale Structured Interview (LSAS) scores.

CONCLUSIONS

This is the first RCT to examine the possible augmenting effect of ABM added to group-based cognitive-behavioral therapy for adult SAD. Training patients' attention away from threat might augment the treatment response to standard CBGT in SAD, a possibility that could be further evaluated in large-scale RCTs.

Electrophysiological evidence of an attentional bias towards appetitive and aversive words in adults with attention-deficit/hyperactivity disorder

OBJECTIVE

Emotional dysregulation has emerged as a core symptom domain in adults with Attention-Deficit/Hyperactivity Disorder (ADHD). However, the pathophysiological underpinnings remain poorly understood. This study investigated attentional biases to positive and negative emotional words as possible contributing mechanisms.

METHODS

Event-related potentials (ERPSs) and behavioral attention bias indices were recorded from 39 adult patients with ADHD and 41 healthy controls during a verbal dot-probe task with positive-neutral, negative-neutral, and neutral-neutral word pairs.

RESULTS

Cue-locked N2pc amplitudes indicated a significant attentional bias towards emotional words in patients with ADHD and healthy controls. In healthy controls, the bias was only significant in positive trials. In patients, the bias was associated with ADHD severity and self-reported poor emotion regulation skills. ADHD patients also exhibited reduced target-locked P1 amplitudes and inferior behavioral performance compared with healthy controls.

CONCLUSIONS

Our findings provide evidence of an attention bias to positive and negative emotional stimuli in adult patients with ADHD and adverse effects of emotional stimuli on task performance.

SIGNIFICANCE

An attentional bias to emotional stimuli might contribute to emotional reactivity and dysregulation in adult patients with ADHD.

Attention and interpretation bias modification treatment for social anxiety disorder: A randomized clinical trial of efficacy and synergy

BACKGROUND AND OBJECTIVES

Attention bias modification treatment (ABMT) and cognitive bias modification of interpretation (CBM-I) both have demonstrated efficacy in alleviating social anxiety, but how they compare with each other, their combination, and with a combined control condition has not been studied. We examined their relative and combined efficacy compared to control conditions in a randomized controlled trial (RCT).

METHODS

Ninety-five adults diagnosed with social anxiety disorder (SAD), were randomly allocated to 4 groups: ABMT + CBM-I control (hereafter ABMT; n = 23), CBM-I + ABMT control (hereafter CBM-I; n = 24), combined ABMT + CBM-I (n = 23), and combined control (n = 25). Treatment included eight sessions over four weeks. Clinician-rated and self-reported measures of social anxiety symptoms, functional impairment, and threat-related attention and interpretive biases were evaluated at baseline, post-treatment, and 3-month follow-up.

RESULTS

ABMT yielded greater symptom reduction as measured by both clinician-ratings (Cohen's ds = 0.57-0.70) and self-reports (ds = 0.70-0.85) compared with the CBM-I, the combined ABMT + CBM-I, and the combined control conditions. Neither of the other conditions demonstrated superior symptom change compared to the control condition. No group differences were found for functioning or cognitive biases measures.

LIMITATIONS

Limitations mainly include the mix of active and control treatments applied across the different groups. Therefore, the net effect of each of the treatments by itself could not be clearly tested.

CONCLUSIONS

Results suggest superiority of ABMT compared to CBM-I and their combination in terms of symptom reduction. Possible interpretations and methodological issues underlying the observed findings are discussed.

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

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

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent-child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study's limitations, and future directions for research are further discussed.

Biobehavioral Markers of Attention Bias Modification in Temperamental Risk for Anxiety: A Randomized Control Trial

OBJECTIVE

Children with behavioral inhibition, a temperament characterized by biologically based hypervigilance to novelty and social withdrawal, are at high risk for developing anxiety. This study examined the effect of a novel attention training protocol, attention bias modification (ABM), on symptomatic, behavioral, and neural risk markers in children with behavioral inhibition.

METHOD

Nine- to 12-year-old typically developing children identified as having behavioral inhibition (N = 84) were assigned to a 4-session active ABM training (n = 43) or placebo protocol (n = 41) using a double-blinded, randomized, controlled trial approach. Anxiety symptoms (Diagnostic Interview Schedule for Children-Fourth Edition), attention bias (AB; measured by a dot-probe task; AB = incongruent reaction time - congruent reaction time), and AB-related neural activation (measured by functional magnetic resonance imaging activation for the incongruent > congruent contrast in the dot-probe task) were assessed before and after the training sessions.

RESULTS

Results showed that active ABM (n = 40) significantly alleviated participants' symptoms of separation anxiety, but not social anxiety, compared with the placebo task (n = 40); ABM did not modify behavioral AB scores in the dot-probe task; and at the neural level, active ABM (n = 15) significantly decreased amygdala and insula activation and increased activation in the ventrolateral prefrontal cortex compared with placebo (n = 19).

CONCLUSION

These findings provide important evidence for ABM as a potentially effective protective tool for temperamentally at-risk children in a developmental window before the emergence of clinical disorder and open to prevention and intervention. Clinical trial registration information-Attention and Social Behavior in Children (BRAINS); http://clinicaltrials.gov/; NCT02401282.

Improving Treatment Response for Paediatric Anxiety Disorders: An Information-Processing Perspective

Cognitive behavioural therapy (CBT) is considered the treatment of choice for paediatric anxiety disorders, yet there remains substantial room for improvement in treatment outcomes. This paper examines whether theory and research into the role of information-processing in the underlying psychopathology of paediatric anxiety disorders indicate possibilities for improving treatment response. Using a critical review of recent theoretical, empirical and academic literature, the paper examines the role of information-processing biases in paediatric anxiety disorders, the extent to which CBT targets information-processing biases, and possibilities for improving treatment response. The literature reviewed indicates a role for attentional and interpretational biases in anxious psychopathology. While there is theoretical grounding and limited empirical evidence to indicate that CBT ameliorates interpretational biases, evidence regarding the effects of CBT on attentional biases is mixed. Novel treatment methods including attention bias modification training, attention feedback awareness and control training, and mindfulness-based therapy may hold potential in targeting attentional biases, and thereby in improving treatment response. The integration of novel interventions into an existing evidence-based protocol is a complex issue and faces important challenges with regard to determining the optimal treatment package. Novel interventions targeting information-processing biases may hold potential in improving response to CBT for paediatric anxiety disorders. Many important questions remain to be answered.

Developmental Relations Among Behavioral Inhibition, Anxiety, and Attention Biases to Threat and Positive Information

This study examined relations between behavioral inhibition (BI) assessed in toddlerhood (n = 268) and attention biases (AB) to threat and positive faces and maternal-reported anxiety assessed when children were 5- and 7-year-old. Results revealed that BI predicted anxiety at age 7 in children with AB toward threat, away from positive, or with no bias, at age 7; BI did not predict anxiety for children displaying AB away from threat or toward positive. Five-year AB did not moderate the link between BI and 7-year anxiety. No direct association between AB and BI or anxiety was detected; moreover, children did not show stable AB across development. These findings extend our understanding of the developmental links among BI, AB, and anxiety.

Complementary Features of Attention Bias Modification Therapy and Cognitive-Behavioral Therapy in Pediatric Anxiety Disorders

OBJECTIVE

In the treatment of anxiety disorders, attention bias modification therapy (ABMT) and cognitive-behavioral therapy (CBT) may have complementary effects by targeting different aspects of perturbed threat responses and behaviors. ABMT may target rapid, implicit threat reactions, whereas CBT may target slowly deployed threat responses. The authors used amygdala-based connectivity during a threat-attention task and a randomized controlled trial design to evaluate potential complementary features of these treatments in pediatric anxiety disorders.

METHOD

Prior to treatment, youths (8-17 years old) with anxiety disorders (N=54), as well as healthy comparison youths (N=51), performed a threat-attention task during functional MRI acquisition. Task-related amygdala-based functional connectivity was assessed. Patients with and without imaging data (N=85) were then randomly assigned to receive CBT paired with either active or placebo ABMT. Clinical response was evaluated, and pretreatment amygdala-based connectivity profiles were compared among patients with varying levels of clinical response.

RESULTS

Compared with the CBT plus placebo ABMT group, the CBT plus active ABMT group exhibited less severe anxiety after treatment. The patient and healthy comparison groups differed in amygdala-insula connectivity during the threat-attention task. Patients whose connectivity profiles were most different from those of the healthy comparison group exhibited the poorest response to treatment, particularly those who received CBT plus placebo ABMT.

CONCLUSIONS

The study provides evidence of enhanced clinical effects for patients receiving active ABMT. Moreover, ABMT appears to be most effective for patients with abnormal amygdala-insula connectivity. ABMT may target specific threat processes associated with dysfunctional amygdala-insula connectivity that are not targeted by CBT alone. This may explain the observation of enhanced clinical response to CBT plus active ABMT.