Attention Bias Modification Treatment for children with anxiety disorders who do not respond to cognitive behavioral therapy: a case series

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.

"Health Comes First": Action Tendencies to Health-Related Stimuli in People with Health-Anxiety as Revealed by an Emotional Go/No-Go Task

The processing of health-related stimuli can be biased by health anxiety and anxiety sensitivity but, at the moment, it is far from clear whether health-related stimuli can affect motor readiness or the ability to inhibit action. In this preliminary study, we assessed whether different levels of health anxiety and anxiety sensitivity affect disposition to action in response to positive and negative health-related stimuli in non-clinical individuals. An emotional go/no-go task was devised to test action disposition in response to positive (wellness-related), and negative (disease-related) stimuli in non-clinical participants who also underwent well-validated self-report measures of health anxiety and anxiety sensitivity. The main results showed that both health anxiety and anxiety sensitivity biased participants' responses. Importantly, safety-seeking and avoidance behaviors differently affected action disposition in response to positive and negative stimuli. These preliminary results support the idea that health anxiety and anxiety sensitivity could determine a hypervigilance for health-related information with a different perturbation of response control depending on the valence of the stimuli. Health anxiety and health anxiety disorder do form a continuum; thus, capturing different action tendencies to health-related stimuli could represent a valuable complementary tool to detect processing biases in persons who might develop a clinical condition.

A Randomized Controlled Trial of Attention Bias Modification Treatment in Youth With Treatment-Resistant Anxiety Disorders

OBJECTIVE

Randomized clinical trials of augmentation strategies for youth with treatment-resistant anxiety disorders do not exist. This report presents findings from an efficacy trial of attention bias modification treatment (ABMT) as an augment for this population compared with attention control training (ACT).

METHOD

Sixty-four youths (34 boys; mean age 11.7 years) who continued to meet for anxiety diagnoses after completing cognitive-behavioral therapy were randomized to ABMT or ACT. ABMT and ACT consisted of dot-probe attention training trials presenting angry and neutral faces; probes appeared in the location of neutral faces on 100% of trials in ABMT and 50% of trials in ACT. Independent evaluators, youths, and parents completed ratings of youth anxiety severity, and youths completed measures of attention bias to threat and attention control at pretreatment, post-treatment, and 2-month follow-up.

RESULTS

The 2 arms showed significant decreases in anxiety severity, with no differences between arms. Specifically, across informants, anxiety severity was significantly decreased at post-treatment and decreases were maintained at follow-up. Primary anxiety disorder diagnostic recovery combined across arms was 50% at post-treatment and 58% at follow-up. Attention control, but not attention bias to threat, was significantly improved at post-treatment in the 2 arms.

CONCLUSION

This is the first study to show anxiety can be decreased in youth who did not respond to cognitive-behaviorial therapy, and that the anxiety-decreasing effect is found using these 2 attention training contingency schedules. These findings and increases in attention control in the 2 arms raise intriguing questions about mechanisms of decreasing anxiety in treatment-resistant youth with attention training that require further research.

CLINICAL TRIAL REGISTRATION INFORMATION

Attention Bias Modification Training for Child Anxiety CBT Nonresponders; https://clinicaltrials.gov/; NCT01819311.

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.

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.

Multisession Cognitive Bias Modification Targeting Multiple Biases in Adolescents with Elevated Social Anxiety

Research studies applying cognitive bias modification of attention (CBM-A) and interpretations (CBM-I) training to reduce adolescent anxiety by targeting associated cognitive biases have found mixed results. This study presents a new multi-session, combined bias CBM package, which uses a mix of training techniques and stimuli to enhance user-engagement. We present preliminary data on its viability, acceptability and effectiveness on reducing symptoms and biases using an A–B case series design. 19 adolescents with elevated social anxiety reported on their social anxiety, real-life social behaviours, general anxiety, depression, and cognitive biases at pre/post time-points during a 2-week baseline phase and a 2-week intervention phase. Retention rate was high. Adolescents also reported finding the CBM training helpful, particularly CBM-I. Greater reductions in social anxiety, negative social behaviour, and general anxiety and depression, characterised the intervention but not baseline phase. There was a significant correlation between interpretation bias change and social anxiety symptom change. Our enhanced multi-session CBM programme delivered in a school-setting appeared viable and acceptable. Training-associated improvements in social anxiety will require further verification in a study with an active control condition/group.

Assessment of determinants and quality of life of university students with social phobias in a coastal city of south India

BACKGROUND

Social phobia is a common psychiatric disorder, and its onset happens usually around late adolescence period. Therefore, early diagnosis and its management is essential in any educational setting.

OBJECTIVES

To identify university students with social phobia, to find out its determinants and to observe its impact on their quality of life.

METHODS

The data was collected using a self-administered questionnaire. Social Phobia Inventory Questionnaire and Quality of Life Enjoyment and Satisfaction Questionnaire were used.

RESULTS

The mean age of the 450 student participants was 20.6 ± 1.6 years. Majority [312(69.3%)] were males and majority [305(67.8%)] were native of urban areas. Of the total, 169(37.6%) were found to have social phobia. Among them, 114(67.5%) had mild, 47(27.8%) had moderate and 8(4.7%) had severe social phobia. Family history of anxiety disorders (P = 0.006), embarrassment with own socio-economic status (P = 0.001) and past history of failure in academic examinations (P < 0.001) were significantly associated with the presence of social phobia among the participants. Preference of interaction using social media instead of face to face communication with people (P = 0.013), and by texting rather than calling the person (P = 0.002) were seen significantly more among those with social phobia. The mean quality of life scores was found to be deteriorating significantly with increasing intensity of social phobia among students (P < 0.001).

CONCLUSION

Social phobia was seen among more than one-third of the participants. Counselling centers are therefore required to address this problem at universities. This will also help to improve the quality of life and the socializing skills of those affected.

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.

Examining the Mechanisms of Therapeutic Change in a Cognitive-Behavioral Intervention for Anxious Children: The Role of Interpretation Bias, Perceived Control, and Coping Strategies

This study examined the role of theoretically meaningful mediators of therapeutic change-interpretation bias, perceived control, and coping strategies-in a cognitive-behavioral intervention for anxious youth. This is one of the few studies that examined the change in potential mediator and outcome variables by means of a longitudinal design that included four assessment points: pretreatment, in-treatment, post-treatment, and at 4-months follow-up. Forty-seven 8- to 12-year-old children with a principal DSM-IV diagnosis of anxiety disorder participated in the study. On each assessment point, questionnaires assessing the mediator variables and a standardized anxiety scale were administered to the children. The results showed that perceived control and interpretation bias (but not coping strategies) accounted for a significant proportion in the variability of various types of anxiety symptoms, providing a preliminary support for the notion that these cognitive dimensions' act as mechanisms of therapeutic change in cognitive-behavioral therapy for anxious children.

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.

Executive Attention and Empathy-Related Responses in Boys with Oppositional Defiant Disorder or Conduct Disorder, With and Without Comorbid Anxiety Disorder

This is a first study that investigated the relationships between executive attention-as an important aspect of emotion regulation-and state empathy and sympathy in ODD/CD boys with (N = 31) and without (N = 18) comorbid anxiety disorder (7-12 years). Empathic reactions were evoked using three sadness-inducing film clips. One clip was highly evocative involving a bear cub losing his mother, whilst two other clips were mildly evocative involving children in common childhood situations. Self-reports of empathy and sympathy were collected and executive attention was assessed with a performance task. Poor executive attention skills were associated with less empathy and sympathy, particularly in ODD/CD boys with anxiety and under conditions of a highly evocative stimulus. Our findings support the view that different mechanisms may be involved in empathy problems of ODD/CD children.

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

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

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

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

Threat-Related Attention Bias Variability and Posttraumatic Stress

OBJECTIVE

Threat monitoring facilitates survival by allowing one to efficiently and accurately detect potential threats. Traumatic events can disrupt healthy threat monitoring, inducing biased and unstable threat-related attention deployment. Recent research suggests that greater attention bias variability, that is, attention fluctuations alternating toward and away from threat, occurs in participants with PTSD relative to healthy comparison subjects who were either exposed or not exposed to traumatic events. The current study extends findings on attention bias variability in PTSD.

METHOD

Previous measurement of attention bias variability was refined by employing a moving average technique. Analyses were conducted across seven independent data sets; in each, data on attention bias variability were collected by using variants of the dot-probe task. Trauma-related and anxiety symptoms were evaluated across samples by using structured psychiatric interviews and widely used self-report questionnaires, as specified for each sample.

RESULTS

Analyses revealed consistent evidence of greater attention bias variability in patients with PTSD following various types of traumatic events than in healthy participants, participants with social anxiety disorder, and participants with acute stress disorder. Moreover, threat-related, and not positive, attention bias variability was correlated with PTSD severity.

CONCLUSIONS

These findings carry possibilities for using attention bias variability as a specific cognitive marker of PTSD and for tailoring protocols for attention bias modification for this disorder.

The scientific legacy of Little Hans and Little Albert: future directions for research on specific phobias in youth

We review issues associated with the phenomenology, etiology, assessment, and treatment of specific phobias in children and adolescents and provide suggestions for future research and clinical practice. In doing so, we highlight the early case studies of Little Hans and Little Albert and the advances that have been made following the publication of these seminal cases. In recent years, we have witnessed a deeper understanding of the etiology of specific phobias and developed a rich array of evidence-based assessments and treatments with which to address specific phobias in youth. Although much has been accomplished in this area of inquiry, we also note that much remains to be done before we can advance more fully our understanding, assessment, and treatment of specific phobias in youth. It will be important for future work to build more firmly on these developments and to better determine the moderators and mediators of change with our evidence-based treatments and to more vigorously pursue their dissemination in real-word settings.

A Critical Review of Attentional Threat Bias and Its Role in the Treatment of Pediatric Anxiety Disorders

Threat bias, or exaggerated selective attention to threat, is considered a key neurocognitive factor in the etiology and maintenance of pediatric anxiety disorders. However, upon closer examination of the literature, there is greater heterogeneity in threat-related attentional biases than typically acknowledged. This is likely impacting progress that can be made in terms of interventions focused on modifying this bias and reducing anxiety, namely attention bias modification training. We suggest that the field may need to "take a step back" from developing interventions and focus research efforts on improving the methodology of studying attention bias itself, particularly in a developmental context. We summarize a neurocognitive model that addresses the issue of heterogeneity by broadly incorporating biases toward and away from threat, linking this variation to key neurodevelopmental factors, and providing a basis for future research aimed at improving the utility of threat bias measures and interventions in clinical practice.

Mental Health on the Go: Effects of a Gamified Attention Bias Modification Mobile Application in Trait Anxious Adults

Interest in the use of mobile technology to deliver mental health services has grown in light of the economic and practical barriers to treatment. Yet, research on alternative delivery strategies that are more affordable, accessible, and engaging is in its infancy. Attention bias modification training (ABMT), has potential to reduce treatment barriers as a mobile intervention for stress and anxiety, but the degree to which ABMT can be embedded in a mobile gaming format and its potential for transfer of benefits is unknown. The present study examined effects of a gamified ABMT mobile application in highly trait anxious participants (N = 78). A single session of the active compared to placebo training reduced subjective anxiety and observed stress reactivity. Critically, the long (45 minutes) but not short (25 minutes) active training condition reduced the core cognitive process implicated in ABMT (threat bias) as measured by an untrained, gold-standard protocol.