Do worry and its associated cognitive variables alter following CBT treatment in a youth population with Social Anxiety Disorder? Results from a randomized controlled trial

Relationships between metacognitive beliefs and anxiety and depression in children and adolescents: A meta-analysis

BACKGROUND

As hypothesized in the Self-Regulatory Executive Function (S-REF) model, metacognitive beliefs are associated with anxiety and depression in adults. An important question is the extent to which such effects are present in children and adolescents, with the implication that the model may also apply to young people. The aim of this meta-analysis was to synthesize results on the nature and magnitude of associations between metacognitive beliefs and anxiety and depression in children and adolescents.

METHODS

Systematic searches were conducted to identify studies that investigated: (1) group differences in metacognitive beliefs in clinical compared to non-clinical samples or (2) correlations between metacognitive beliefs and symptoms of anxiety and depression.

RESULTS

Forty papers were identified comprising a total sample of 9,887 participants aged 7-18 years. Meta-analyses revealed that clinical samples endorsed significantly elevated metacognitive beliefs on four out of the five domains measured (i.e., negative beliefs about worry, cognitive confidence, need for control, and cognitive self-consciousness, with the only exception being positive beliefs about worry) compared to non-clinical samples with a small to large effect (Hedges' gs = 0.45-1.22). Moreover, all five domains of metacognitive beliefs were significantly and positively correlated with symptoms of anxiety and depression of a small to large effect (rs = .24-.53). Negative beliefs about worry showed the strongest relationship with clinical status and the magnitude of symptoms.

LIMITATIONS

The number of studies did not allow for an evaluation of metacognitive beliefs at a disorder-specific level.

CONCLUSIONS

In line with the S-REF model, our findings provide evidence of robust cross-sectional relationships between metacognitions and both anxiety and depression in childhood and adolescence.

Effectiveness of internet-delivered psychological treatments for children and adolescents with anxiety and/or depressive disorders: Systematic review and network meta-analysis

Background

Anxiety and depression symptomatology has increased in the child and adolescent population. Internet-delivered psychological treatments (IDPT) can help to reduce this symptomatology, attending to the largest possible population.

Aim

To conduct a systematic review and network meta-analysis of IDPT to reduce anxiety and depression symptoms in children and adolescents.

Methods

The search for studies was conducted in SCOPUS, PsycINFO, PSICODOC, PsycARTICLES and Medline, between 2000 and 2022, in December 2022. Studies were selected if they were conducted with a sample of children and/or adolescents with previous symptoms of anxiety and depression, had applied IDPT, and included at least two comparative groups with pretest-posttest measures. Network meta-analyses were separately performed for anxiety and depression outcomes. Publication bias was analyzed using Egger's test and funnel plots, and mixed-effects meta-regression models were applied to account for heterogeneity.

Results

37 studies were included in the meta-analysis, providing a total of 74 comparative groups. IDPT exhibited low-to-moderate, statistically significant average effect sizes when compared to both inactive and active controls. No statistical significance was found when IDPT was compared with other types of interventions.

Discussion

IDPT is recommended to reduce anxiety and depression symptomatology in children and adolescents, but more studies are needed which compare treatments with other types of interventions, such as face-to-face therapy.

Examining the Longitudinal Relationship Between Metacognitive Beliefs and Psychological Distress in an Adolescent Population: A Preliminary Analysis

Adolescence is a period marked by significant vulnerability to the onset of mental health concerns. Within adults, the metacognitive model of psychological disorders advocates for the involvement of metacognitive beliefs in the onset, and maintenance, of psychopathology. The current study aimed to assess the applicability of the metacognitive model in adolescence by exploring the relationship, as well as the trajectory, between metacognitive beliefs and psychological distress. The longitudinal prospective cohort study investigated data from a community-based sample of participants aged 12 to 13. Self-report assessment measures of metacognitive beliefs, psychological distress, and somatic distress are reported across four time-points. Baseline assessments are reported for 70 participants, which reduced to 53 participants at time-point four. Correlational analyses demonstrated a significant relationship between overall metacognition, as well as negative metacognitive beliefs, and psychological distress at each of the four time-points. Generalised Estimating Equations found a significant association between metacognitive predictors and psychological distress over the four time-points. These results indicate that negative metacognitive beliefs, positive metacognitive beliefs, metacognitive beliefs related to superstition, punishment, and responsibility, low perceived levels of cognitive confidence and cognitive self-consciousness predict psychological distress over 12 months in adolescents aged 12 to 13. The strongest longitudinal correlational structure was found for the model of negative metacognitive beliefs and psychological distress. These findings provide preliminary evidence for the positive linear relationship between metacognitive beliefs and psychological distress in adolescence. The study provides an important contribution to understanding the role of metacognitive beliefs in the aetiology and perpetuation of psychological distress in adolescence.

Feasibility of an Intensive, Disorder-Specific, Group-Based Cognitive Behavioural Therapy Intervention for Adolescents with Social Anxiety Disorder

This study examined the preliminary acceptability and efficacy of an intensive, group-based, disorder-specific cognitive behavioural therapy (CBT) intervention for adolescents with social anxiety disorder (SAD). Fourteen Australian adolescents with SAD (78.6% female, M age = 13.93 years) and their parents completed the program plus measures of treatment satisfaction, and provided feedback. Clinical interviews and surveys were administered pre-treatment, post-treatment, and at 6-month follow-up to determine diagnostic status and assess related variables. Post-treatment satisfaction scores were very high for adolescents and parents. Post-treatment, 32.3% of participants no longer met criteria for SAD diagnosis, increasing to 42.9% at follow-up. Participants showed sizeable reductions in comorbid diagnoses, significant improvements in global functioning, social anxiety symptoms, and internalising symptoms from pre- to post-treatment (maintained at follow-up), and significant improvements in social skills and social competence from pre-treatment to follow-up. This study supports the use of an intensive CBT program for adolescents with SAD.

Do Metacognitions of Children and Adolescents with Anxiety Disorders Change after Intensified Exposure Therapy?

Metacognitive beliefs have repeatedly proven to play a role in anxiety disorders in children and adolescents, but few studies have investigated whether they change after cognitive behavioral therapy. This longitudinal intervention study explores whether positive and negative metacognitive beliefs in particular change after exposure-focused treatment, and if metacognitive changes predict reductions in anxiety symptoms. A sample of 27 children between 8 and 16 years of age with a primary diagnosis of specific phobia, separation-anxiety disorder or social phobia completed assessments of anxiety symptoms, metacognitive beliefs, worry and repetitive negative thoughts before and after 11 sessions of intensified exposure treatment. Metacognitive beliefs did not change significantly after intensified exposure, but post-hoc power analysis revealed a lack of power here. Change in negative metacognitive beliefs correlated with a change in anxiety symptoms, but did not independently contribute as a predictor variable. Differences between subsamples showed that patients with separation-anxiety disorder scored higher on negative metacognitive beliefs than those with specific or social phobia. Consideration of metacognition, and negative metacognitive beliefs in particular could help us further improve the understanding and treatment of anxiety disorders in children and adolescents and should therefore receive more attention in psychotherapy research.

Coping during COVID-19: The Impact of Cognitive Appraisal on Problem Orientation, Coping Behaviors, Body Image, and Perceptions of Eating Behaviors and Physical Activity during the Pandemic

Large surveys indicate that many people perceive that their health behaviors (i.e., eating behaviors, physical activity, and self-care routines) and body image have changed during COVID-19; however, large individual variation exists. A person’s cognitive appraisal of COVID-19 disruptions may help account for individual differences. Those with a negative problem orientation perceive problems as “threats”, whereas those with a positive problem orientation reframe problems as “opportunities”. The present experimental study examined the impact of appraisals, specifically being prompted to reflect on the changes in health routines precipitated by COVID-19 restrictions as either “threats” or “opportunities”, on problem orientation, coping behaviours, body image, and perceptions of eating behaviors and physical activity in a sample of female undergraduate students (N = 363). The group that reflected on challenges/barriers reported having a more negative problem orientation, being more negatively impacted by COVID-19, engaging in more maladaptive coping behaviors, and having less positive body image compared to participants who reflected on opportunities presented during the pandemic. Findings suggest that appraisals and problem orientation are malleable, and that people who tend to fixate on the challenges associated with COVID-19 may benefit from strategically reflecting on their own resilience and new opportunities that have arisen for engaging in health behaviors.

Thinking about worry: A systematic review and meta-analysis on the assessment of metacognitions in children and adolescents

BACKGROUND

The metacognitive model of generalized anxiety disorder identifies three forms of metacognition: Positive metacognitive beliefs about worry (POS), negative metacognitive beliefs about worry (NEG), and meta-worry. Though this model was originally developed relying on adult samples, it has since been applied to children and youth in different studies, and results mostly support its validity for this group. As the roles of POS, meta-worry, and age-effects do not appear to be fully clarified for children and adolescents yet, an integration of studies on children and adolescents and the metacognitive model is both timely and worthwhile.

AIM

To summarize the current research on relationships, age-effects, and measurements for POS, NEG, and meta-worry in childhood and youth.

METHODS

We carried out a literature search in the electronic databases PsycINFO, PubMed, PSYNDEX, and ERIC in 2017 and updated in 2020. Empirical research in German or English language on metacognition was included with child and adolescent samples diagnosed with anxiety disorders or healthy controls if POS, NEG, or meta-worry were measured. Studies were included for meta-analysis if they reported correlations between these metacognitions and anxiety or worry. Consensus rating for eligibility was done for 20.89% of full-texts with 90.32% agreement. Risk of bias was assessed with the appraisal tool for cross-sectional studies and consensus rating of appraisal tool for cross-sectional studies for 20.83% of included studies attaining agreement of intraclass correlation = 0.898. Overall, correlations between metacognitions, anxiety and worry were calculated with RevMan 5.4.1, assuming random-effects models. Meta-regressions with mean age as the covariate were performed via the online tool MetaMar 2.7.0. PROSPERO-ID: CRD42018078852.

RESULTS

Overall, k = 763 records and k = 78 additional records were identified. Of those, k = 48 studies with 12839 participants were included and of those, k = 24 studies were included for meta-analysis. Most studies showed consistent NEG correlations with worry and anxiety, as well as higher values for clinical than for non-clinical samples. POS findings were less consistent. Meta-analysis revealed large effects for NEG correlating with worry and anxiety, small to medium effects for POS correlating with worry and anxiety, as well as small to medium effects for POS correlating with NEG. Meta-regressions did not reveal mean age as a significant covariate. Meta-worry was assessed in only one study. We identified eight questionnaires and one interview-format that assess metacognition about worry in children and adolescents.

CONCLUSION

POS and NEG are measurable from the age of seven upwards and correlate with anxiety and worry without influences by age. Meta-worry requires further investigation.

Potential mechanisms of change in cognitive behavioral therapy for childhood anxiety: A meta-analysis

Cognitive-behavioral therapy (CBT) is regarded as an effective treatment for anxiety disorders in childhood. Researchers have begun to investigate potential mechanisms of change that drive these positive outcomes, including shifts in cognitions, behavior, and affect. However, few studies have established the mediational effects of these factors as a proxy for establishing mechanistic change. This meta-analysis attempts to synthesize the literature on potential mechanisms of change in CBT for childhood anxiety and investigates the mediational effects of these factors on treatment outcomes. Seventeen studies met the inclusion criteria. Across studies, five potential mediators were identified: externalizing difficulties, negative self-talk, coping, fear, and depression. Results indicated that CBT was effective in improving outcomes on all potential mediators, except for fear. Mediational analyses showed that externalizing difficulties, negative self-talk, coping, and depression mediated anxiety following treatment. Fear did not mediate the relationship. Implications for future mechanisms of change research are proposed.

Effects of Group-Based CBT on Post-Event Processing in Children with Social Anxiety Disorder Following an Experimental Social Stressor

Theoretical models and previous research suggest that post-event processing (PEP) after social situations maintains social anxiety disorder (SAD). To date, little is known about PEP in childhood, a critical period for disorder development, or about possible positive effects of cognitive behavioral therapy (CBT) on PEP in children. Children with SAD (n = 71; aged 9-13 years) and healthy controls (n = 55) participated in a social stress task (Trier Social Stress Test for Children, TSST-C), which was repeated in children with SAD after either 12 sessions of CBT or a waiting period. PEP was assessed daily with regard to both valence and frequency, as well as in more detail regarding specific negative and positive ruminative thoughts 1 week after each TSST-C. Daily PEP after the TSST-C was more frequent and more negative in children with SAD compared to healthy controls, in particular during the first 2 days after the TSST-C. After CBT treatment, children with SAD reported more positive PEP but not less negative PEP compared to children in the waitlist control group. The current study suggests that negative PEP in children with SAD is most pronounced in the first days following social stress. Group-based CBT seems to be effective in building up positive cognitions after social stress in children, but developing specific interventions targeting negative PEP immediately after a social stressor may be necessary to further increase treatment efficacy.

Social anxiety disorder in children: investigating the relative contribution of automatic thoughts, repetitive negative thinking and metacognitions

BACKGROUND

Social anxiety disorder (SAD) is common in youths. However, our understanding of SAD in children is inferior to that of SAD in adolescents or adults, and it is unclear if known adult SAD maintenance mechanisms may also operate in children with SAD.

AIM

The paper sets out to investigate the specificity of positive automatic thoughts, social threat negative automatic thoughts, repetitive negative thinking, positive and negative metacognitions in predicting SAD symptoms and diagnoses in clinically anxious children.

METHOD

We enrolled 122 clinically anxious children aged 7-13 years; of these, 33 had an SAD diagnosis.

RESULTS

SAD symptoms correlated positively with social threat negative automatic thoughts, repetitive negative thinking, and negative metacognitions, and negatively with positive automatic thoughts. Linear regression indicated that, of these variables, only social threat negative automatic thoughts predicted social anxiety symptoms. Logistic regression indicated that social threat negative automatic thoughts, a higher number of diagnoses and negative metacognitive beliefs specifically predicted the presence of SAD diagnosis.

CONCLUSIONS

Our findings suggest that content-specific social threat negative automatic thoughts was the only variable that specifically distinguished both higher levels of social anxiety symptoms and diagnoses.

Social problem solving in social anxiety disorder

Successful social problem solving requires both an adaptive orientation toward the problem and the necessary skills to generate relevant and effective solutions. Surprisingly few studies have examined social problem solving in the context of social anxiety. We examined social problem solving in 38 participants with social anxiety disorder (SAD) in comparison to 30 healthy control (HC) participants with no history of anxiety problems. Participants rated their problem solving attitudes and abilities (i.e., problem orientation) and then generated solutions to hypothetical interpersonal problems from both their own perspective and that of an objective other. These solutions were coded for effectiveness and relevance, as well as the degree to which the solution was active versus passive. Participants with SAD exhibited a more negative problem orientation than HC participants. Furthermore, although SAD and HC participants demonstrated no overall differences in generating relevant and effective solutions to interpersonal problems, utilizing a personal perspective facilitated the generation of more active solutions for HC participants, but less active solutions for those with SAD. Findings illuminate new research directions regarding social problem solving in social anxiety, with potential implications for applied intervention.

Do Social Threat Cognitions Decrease With School-Based CBT and Predict Treatment Outcome in Adolescents With Social Anxiety Disorder?

Evidence suggests that Social Anxiety Disorder (SAD) is less responsive to cognitive behavioral treatment (CBT) compared to other anxiety disorders. Therefore, exploring what might facilitate clinical benefit is essential. Social threat cognitions, characterized by exaggerated perceptions of negative evaluation by others, may be one important avenue to examine. The current study investigated whether youths' social threat cognitions decreased with Skills for Academic and Social Success (SASS), a group, school-based CBT designed for SAD, and whether decreases predicted SAD severity and treatment response. Participants included 138 high school students with SAD randomly assigned to SASS, or a nonspecific school counseling intervention. SASS participants showed significantly decreased social threat cognitions at 5-month follow-up. Treatment responders had significantly greater reductions in social threat cognitions compared to nonresponders at post-intervention and follow-up. These findings suggest that social threat cognitions may be important to assess and monitor when treating youth with SAD.

The Metacognitions Questionnaire and Its Derivatives in Children and Adolescents: A Systematic Review of Psychometric Properties

Background: The Metacognitions Questionnaire (MCQ) and its derivatives have been instrumental in research examining the Self-Regulatory Executive Function Model in adults. Studies testing whether findings are applicable to children and adolescents have been increasing and several different measures adapting the MCQ for younger populations have been developed. The current study aimed to systematically review the psychometric properties of MCQ measures or derivatives used in young people (aged 18 or less), to help assess current findings in this population and to guide future research in this growing area of investigation. Method: Systematic searches were carried out on PubMed and PsycINFO of studies published up to June 2018. Additional studies were identified through Google Scholar and article references. Validity, reliability, range and responsiveness of measures were examined as well as analyses of age and gender differences on scores. Results: Forty-five articles were identified. The total sample consisted of 7,803 children and adolescents (6,922 non-clinical, 881 clinical) aged 7-18. Studies used one of seven versions of the questionnaire, five adapted from the MCQ for younger populations: (1) The Metacognitions Questionnaire-Adolescent version; (2) The Metacognitions Questionnaire-Child version; (3) The Metacognitions Questionnaire-Child Version-Revised; (4) The Metacognitions Questionnaire-Child-30; and (5) The Metacognitions Questionnaire-65 Positive Beliefs Scale Revised; and two adult versions used without adaptation: (1) The Metacognitions Questionnaire-30 and (2) The Cognitive Self Consciousness Scale-Expanded. The validity and reliability of the Metacognitions Questionnaire-Adolescent version had the most extensive support. Other questionnaires had either mixed psychometrics or promising initial findings but more limited data. Conclusions: It is recommended that studies using adolescents (age 12-18) consider using the Metacognitions Questionnaire-Adolescent version. Based on initial data, it is suggested studies using younger populations should consider the Metacognitions Questionnaire-Child-30 but further psychometric research into this and other measures is needed.