Cognitive bias modification of interpretation in children with social anxiety disorder

A Brief Measure of Positive and Negative Interpretation Biases: Development and Validation of the Ambiguous Social Scenarios Questionnaire

Positive and negative interpretation biases have been conceptualized as distinct constructs related to anxiety and social anxiety, but the field lacks psychometrically sound self-report measures to assess positive and negative interpretations of social ambiguity. This study examined the psychometric properties of the Ambiguous Social Scenarios Questionnaire (ASSQ) in two samples of 2,188 and 454 undergraduates with varying levels of anxiety. Results supported a bifactor model with a general interpretation bias factor and specific factors assessing positive and negative interpretation biases. The ASSQ demonstrated measurement invariance across genders and levels of social anxiety, as well as convergent and incremental validity with two existing measures of interpretation bias. It also demonstrated concurrent validity with attentional control, intolerance of uncertainty, total anxiety, and social anxiety and discriminant validity with emotional awareness. Findings support the ASSQ as a brief, valid, and reliable measure of positive and negative interpretation biases toward ambiguous social situations.

Implication of Social Rejection in Cognitive Bias Modification Interpretation Training in Adolescents With Eating Disorders

Objectives

Difficulties in interpersonal relationships intensify negative emotions and act as risk and maintenance factors for eating pathology in eating disorders. Rejection sensitivity refers to the tendency to react sensitively to a rejection. Patients with eating disorders experience difficulties in interpersonal relationships because of their high sensitivity to rejection. Cognitive bias modification interpretation (CBM-I) is a treatment developed to correct interpretation bias for social and emotional stimuli. In this review, we searched for research characteristics and trends through a systematic literature analysis of CBM-I for eating disorders.

Methods

Five papers that met the selection and exclusion criteria were included in the final literature review and analyzed according to detailed topics (participant characteristics, design, and results).

Results

The literature supports the efficacy of the CBM-I in reducing negative interpretation bias and eating disorder psychopathology in patients with eating disorders. CBM-I targets emotional dysregulation in adolescent patients with eating disorders and serves as an additional strengthening psychotherapy to alleviate eating disorder symptoms.

Conclusion

The current findings highlight the potential of CBM-I as an individualized adjunctive treatment for adolescents with eating disorders and social functioning problems.

Cognitive bias modification of interpretations for anxiety and depression in children and adolescents: A meta-analysis

Background

Evidence suggests that cognitive bias modification of interpretations (CBM-I) is effective in modifying interpretation biases and has a small effect on reducing anxiety in children and adolescents. However, most evidence to date is based on studies which report anxiety or general distress using ad-hoc Likert-type or Visual Analogue Scales, which are useful but do not reliably index symptoms of clinical importance. This meta-analysis aimed to establish the effects of CBM-I for children and adolescents on both anxiety and depression using psychometrically validated symptom measures, as well as state negative affect and negative and positive interpretation bias.

Methods

We identified studies through a systematic search. To be eligible for inclusion, studies needed to target interpretation biases, not combine CBM-I with another intervention, randomly allocate participants to CBM-I or a control condition, assess a mental health outcome (i.e., anxiety or depression symptoms using validated measures or state measures of negative affect) and/or interpretation bias and have a mean age less than 18 years.

Results

We identified 36 studies for inclusion in the meta-analysis. CBM-I had a small and non-significant unadjusted effect on anxiety symptoms (g = 0.16), no effect on depression symptoms (g = -0.03), and small and non-significant unadjusted effects on state negative affect both at post-training (g = 0.16) and following a stressor task (g = 0.23). In line with previous findings, CBM-I had moderate to large unadjusted effects on negative and positive interpretations (g = 0.78 and g = 0.52). No significant moderators were identified.

Conclusions

CBM-I is effective at modifying interpretation bias, however there were no effects on mental health outcomes. The substantial variability across studies and paucity of studies using validated symptom measures highlight the need to establish randomized controlled trial protocols that evaluate CBM-I in clinical youth samples to determine its future as a clinical intervention.

Insecure Attachment Orientation in Adults and Children and Negative Attribution Bias: A Meta-Analysis

This is the first meta-analysis to synthesize the literature on insecure attachment and negative attribution bias (NAB) from both developmental and social/personality attachment traditions. This meta-analysis is important because extant studies report inconsistent associations, making it difficult to draw conclusions about the nature of these associations. Based on 41 samples (N = 8,727) from 32 articles, we specify and compare the effect sizes of these associations across studies. Results confirmed positive associations between NAB and anxious and avoidant attachment dimensions and an insecure composite, with a medium effect size. Correlations were moderated by age group, type of attachment measurement, and cultural background. Our findings advance knowledge and build on attachment and attribution theories, reconcile mixed findings, and inform the development of NAB interventions. Important gaps in the literature are revealed that will inspire future research.

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.

An Emotional Bias Modification for Children With Attention-Deficit/Hyperactivity Disorder: Co-design Study

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the common neurodevelopment disorders. Children with ADHD typically have difficulties with emotional regulation. Previous studies have investigated the assessment for underlying emotional biases using the visual probe task. However, one of the significant limitations of the visual probe task is that it is demanding and repetitive over time. Previous studies have examined the use of gamification methods in addressing the limitations of the emotional bias visual probe task. There has also been increased recognition of the potential of participatory action research methods and how it could help to make the conceptualized interventions more relevant.

OBJECTIVE

The primary aim of this study was to collate health care professionals' perspectives on the limitations of the existing visual probe task and to determine if gamification elements were viable to be incorporated into an emotional bias modification task.

METHODS

A co-design workshop was conducted. Health care professionals from the Department of Development Psychiatry, Institute of Mental Health, Singapore, were invited to participate. Considering the COVID-19 pandemic and the restrictions, a web-based workshop was conducted. There were 3 main phases in the workshops. First, participants were asked to identify limitations and suggest potential methods to overcome some of the identified limitations. Second, participants were shown examples of existing gaming interventions in published literature and commercial stores. They were also asked to comment on the advantages and limitations of these interventions. Finally, participants were asked if gamification techniques would be appropriate.

RESULTS

Overall, 4 health care professionals consented and participated. Several limitations were identified regarding the conventional emotional bias intervention. These included the nature of the task parameters, included stimulus set, and factors that could have an impact on the accuracy of responding to the task. After examining the existing ADHD games, participants raised concerns about the evidence base of some of the apps. They articulated that any developed ADHD game ought to identify the specific skill set that was targeted clearly. Regarding gamification strategies, participants preferred economic and performance-based gamification approaches.

CONCLUSIONS

This study has managed to elucidate health care professionals' perspectives toward refining a conventional emotional bias intervention for children with ADHD. In view of the repetitiveness of the conventional task, the suggested gamification techniques might help in influencing task adherence and reduce the attrition rates.

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

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

Attention and interpretation cognitive bias change: A systematic review and meta-analysis of bias modification paradigms

This systematic review and meta-analysis examines the effect of Cognitive Bias Modification for attention (CBM-A) and interpretation (CBM-I) on reducing the targeted biases and investigates moderators of each approach. PsycINFO, PsychArticles, and PubMED databases were searched for randomized-controlled studies published before March 2020 with pre- and post-CBM cognitive bias outcome measures, resulting in 91 CBM-A (n = 5914 individuals) and 70 CBM-I samples (n = 4802 individuals). Random-effects models and Hedge's g calculation showed significant medium overall effects of bias reduction with moderate to high heterogeneity (CBM-A g = 0.49 [0.36, 0.64], I² = 85.19%; CBM-I g = 0.58 [0.48, 0.68], I² = 70.92%). Effect sizes did not differ between approaches and remained significant after trim-and-fill adjustment for possible publication bias. Moderator variables were investigated with meta-regression and subgroup analyses. Participant age, symptom type, control condition and number of trials moderated CBM-A; student and clinical status moderated CBM-I effect size. Results support attention and interpretation modification in controlled laboratory and variable (online) training settings for non-clinical and clinical samples across various symptom types (anxiety, depression, substance use, eating disorders). Further empirical evidence is necessary to determine optimal sample and methodological combinations most strongly associated with adaptive behavioral outcomes.

Examining the Effects of Stuttering and Social Anxiety on Interpretations of Ambiguous Social Scenarios Among Adolescents

PURPOSE

The proclivity to construe ambiguous information in a negative way is known as interpretation bias, which has been implicated in the onset and/or maintenance of social anxiety. The purpose of this study was to examine group and individual differences in interpretation bias among young people who stutter and their typically fluent peers during the adolescent years when social fears and worries tend to escalate.

METHODS

A total of 99 adolescents (13 to 19 years old) participated, including 48 adolescents who stutter (67% male) and 51 typically fluent controls (68% male). They completed a computerized vignette-based interpretation bias task in which they first read 14 short ambiguous social scenarios (half including a verbal interaction, half including a non-verbal interaction). They were then presented with four possible interpretations of each scenario including two negative interpretations (one target, one foil) and two positive interpretations (one target, one foil). Participants used a 4-point Likert scale to rate how similar in meaning each interpretation was to the original scenario. Participants also completed self-report measures of social and general anxiety, and provided a speech sample for stuttering analysis.

RESULTS

There was no effect of stuttering on interpretations; the adolescents who stutter rated interpretations across both verbal and non-verbal scenarios comparably to the controls, and stuttering severity did not affect interpretation ratings. However, across groups, there was a significant effect of social anxiety such that higher social anxiety was associated with more negative interpretations, and lower social anxiety was associated with more positive interpretations.

DISCUSSION

This study provides preliminary evidence that social anxiety may affect how adolescents interpret ambiguous social cues in verbal and non-verbal scenarios more than stuttering, although more research into how people who stutter process social information is warranted.

Neural correlates of cognitive bias modification for interpretation

The effectiveness of cognitive bias modification for interpretation (CBM-I), a treatment method employed to reduce social anxiety (SA), has been examined. However, the neural correlates of CBM-I remain unclear, and we aimed to elucidate brain activities during intervention and activity changes associated with CBM-I effectiveness in a pre–post intervention comparison. Healthy participants divided into two groups (CBM, control) were scanned before, during and after intervention using functional magnetic resonance imaging. Ambiguous social situations followed by positive outcomes were repeatedly imagined by the CBM group during intervention, while half of the outcomes in the control group were negative. Whole-brain analysis revealed that activation of the somatomotor and somatosensory areas, occipital lobe, fusiform gyrus and thalamus during intervention was significantly greater in the CBM than in the control group. Furthermore, altered activities in the somatomotor and somatosensory areas, occipital lobe and posterior cingulate gyrus during interpreting ambiguous social situations showed a significant group × change in SA interaction. Our result suggests that when facing ambiguous social situations, positive imagery instilled by CBM-I is recalled, and interpretations are modified to contain social reward. These findings may help to suggest an alternative manner of enhancing CBM-I effectiveness from a cognitive-neuroscience perspective.

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

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

[Cognition in children with social anxiety disorder experiencing stress]

Cognition in children with social anxiety disorder experiencing stress Abstract. Empirical data on cognitions of children with social anxiety disorder (SAD) are inconclusive. Objective: The present study examines the significance of cognition in children with SAD. Method: Thirty children suffering from SAD and 30 control children free of diagnosis (HC) aged between 9 and 15 years took part in an experiment. Their cognition was assessed before, during, and after a stress-inducing social situation. The assessment method was a self-report measurement. Coping perception was also assessed. Results: Children with SAD did not report a higher level of negative or coping cognition than those in the HC group. An interaction was apparent on the positive cognition scale: Older children (11-12 or 13-15 years) with SAD reported less positive cognition than those in the HC group, and younger children with SAD (9-10 years) reported more than those in the HC group. No group differences were found for perceived coping. Conclusions: The findings are important to the cognitive model and for the psychological treatment of SAD in children.

My Child's thoughts frighten me: Maladaptive effects associated with parents' interpretation and management of children's intrusive thoughts

BACKGROUND AND OBJECTIVES

Environmental factors explain substantial variance in youth's obsessive-compulsive symptoms (OCS) and much of this research has focused upon overt parenting behaviors (e.g., accommodation). No work, however, has examined how parents' internal processes (e.g., perception of children's intrusions) influence youth's OCS. Based upon the cognitive theory of obsessions, we propose that parents' misappraisal of children's intrusions as threatening will be positively associated with (a) the number of maladaptive intrusion management strategies recommended by the parent, as well as (b) children's obsessive beliefs, (c) interpretation biases, and (d) OCS severity.

METHODS

Twenty-seven children (M = 12.81; SD = 3.43) and the parent most involved in childcare completed diagnostic interviews and self-report questionnaires. In the laboratory, we induced obsessional anxiety in youth through a standardized in vivo paradigm (e.g., think about a personalized harm-related negative event occurring). Parents rated how they interpreted their children's unwanted thought and the intrusion management strategies they would recommend.

RESULTS

Parents who interpreted their children's intrusions as threatening recommended more maladaptive intrusion management strategies and their misappraisal positively and significantly correlated with the severity of children's obsessive beliefs, interpretation biases, and OCS, even after controlling for co-occurring internalizing symptoms.

LIMITATIONS

Small sample and cross-sectional design precludes causal conclusions.

CONCLUSIONS

Parents' misinterpretation of children's intrusions may operate as a mechanism by which OCS are generationally transmitted. Results can inform OC prevention programs that target parents' cognitive biases in their own psychotherapy.

A new cognitive bias modification technique to influence risk factors for eating disorders

OBJECTIVE

Eating disorder psychopathology is associated with a propensity to interpret ambiguous stimuli to be negatively related to one's appearance and self-worth. The relative impact of modifying interpretation bias for these respective stimuli is unknown. Hence the main aim of the current study was to compare two cognitive bias modification protocols targeting interpretation bias (CBM-I), one focused on appearance and the other on self-worth, in terms of impacting interpretation bias, body dissatisfaction and negative affect. The appearance-based CBM-I protocol was developed for the current study.

METHOD

Female university students (N = 123) were randomized into one of three CBM-I conditions: appearance, self-worth or control. Immediately following a negative induction that significantly increased body dissatisfaction and negative affect, participants underwent their respective CBM-I training.

RESULTS

The CBM-I for appearance produced significant changes in the targeted bias, as well as significant improvements (moderate effect sizes) in appearance satisfaction, relative to the CBM-I for self-worth and control conditions.

DISCUSSION

The results support the usefulness of the CBM-I for appearance protocol, and suggests that this technique warrants further investigation with respect to modifying interpretation bias and risk factors associated with eating disorder psychopathology. Null effects of CBM-I for self-worth should be interpreted in light of study limitations, including the potential unsuitability of training material for young women. CBM-I for both types of interpretation bias should be evaluated in future research.

Research Review: Cognitive bias modification of interpretations in youth and its effect on anxiety: a meta-analysis

BACKGROUND

Emerging evidence suggests that cognitive bias modification of interpretations (CBM-I) is effective in altering interpretation biases and reducing anxiety in adults. Less is known about the impact of CBM-I in young people, but some recent findings, including a meta-analysis of combined cognitive bias modification of interpretation and attention techniques, have cast doubt on its clinical utility. Given the current debate, this meta-analysis sought to establish the independent effects of CBM-I on interpretations biases and anxiety in youth.

METHODS

Studies were identified through a systematic literature search of PsycINFO, Ovid MEDLINE, PsycARTICLES, Web of Science and EMBASE between January 1992 and March 2017. Eligible studies aimed to target interpretation biases; did not combine CBM-I with another intervention; included a control condition; randomly allocated participants to conditions; assessed interpretation bias and/or anxiety as an outcome; included individuals up to age 18; and did not present previously reported data. Reference lists of included articles were checked for further eligible studies, and authors were contacted for unpublished data.

RESULTS

We identified 26 studies meeting eligibility criteria that included in the meta-analysis. CBM-I had moderate effects on negative and positive interpretations (g = -0.70 and g = -0.52, respectively) and a small but significant effect on anxiety assessed after training (g = -0.17) and after a stressor (g = -0.34). No significant moderators were identified.

CONCLUSIONS

In contrast to previous meta-analytic findings, our results indicate that CBM-I has potential but weak anxiolytic effects in youth. Our findings suggest that it may be premature to disregard the potential value of CBM-I research and further research in this field is warranted.