Reduced Reward Responsiveness Predicts Change in Depressive Symptoms in Anxious Children and Adolescents Following Treatment

Amplification of positivity for depression and anxiety: Neural prediction of treatment response

Psychosocial treatments targeting the positive valence system (PVS) in depression and anxiety demonstrate efficacy in enhancing positive affect (PA), but response to treatment varies. We examined whether individual differences in neural activation to positive and negative valence incentive cues underlies differences in benefitting from a PVS-targeted treatment. Individuals with clinically elevated depression and/or anxiety (N = 88, ages 18 to 55) participated in one of two randomized, waitlist-controlled trials of Amplification of Positivity (AMP; NCT02330627, NCT03196544), a cognitive and behavioral intervention targeting the PVS. Participants completed a monetary incentive delay (MID) task during fMRI acquisition at baseline measuring neural activation to the possibility of gaining or losing money. Change in PA from before to after treatment was assessed using the Positive and Negative Affect Schedule. No significant associations were observed between baseline neural activation during gain anticipation and AMP-related changes in PA in regions of interest (striatum and insula) or whole-brain analyses. However, higher baseline striatal and insula activation during loss anticipation was associated with greater increases in PA post-AMP. This study provides preliminary evidence suggesting neural reactivity to negative valence cues may inform who stands to benefit most from treatments targeting the PVS.

Reduced reward responsiveness and depression vulnerability: Consideration of social contexts and implications for intervention

Depression is a prevalent, heterogeneous, and debilitating disorder that often emerges in adolescence, and there is a need to better understand vulnerability processes to inform more targeted intervention efforts. Psychophysiological methods, like event-related potentials (ERPs), can offer unique insights into the cognitive and emotional processes underlying depression vulnerability. I review my and others' research examining ERP measures of reward responsiveness in youth depression and present a conceptual model of the development of low reward responsiveness, its role in depression vulnerability, and potential windows for targeted intervention. There is evidence that a blunted reward positivity (RewP) is observable in children at risk for depression, appears to be shaped in part by early social experiences, and predicts later depressive symptoms in combination with other risk factors like stress exposure. Further, a component consistent with RewP is reliably elicited in response to social acceptance feedback in computerized peer interaction tasks and demonstrates unique associations with social contextual factors and depressive symptoms, supporting the utility of developing psychophysiological tasks that may better capture youths' real-world experiences and social risk processes. In addition, I address the translational implications of clinical psychophysiological research and describe a series of studies showing that a reduced RewP predicts greater reductions in depressive symptoms with treatment but is not modifiable by current treatments like cognitive behavioral therapy. Finally, I describe our preliminary efforts to develop a positive emotion-focused intervention for the offspring of depressed mothers, informed by the RewP literature, and describe future directions for translating psychophysiological research to intervention and prevention.

Major depressive disorder: hypothesis, mechanism, prevention and treatment

Worldwide, the incidence of major depressive disorder (MDD) is increasing annually, resulting in greater economic and social burdens. Moreover, the pathological mechanisms of MDD and the mechanisms underlying the effects of pharmacological treatments for MDD are complex and unclear, and additional diagnostic and therapeutic strategies for MDD still are needed. The currently widely accepted theories of MDD pathogenesis include the neurotransmitter and receptor hypothesis, hypothalamic-pituitary-adrenal (HPA) axis hypothesis, cytokine hypothesis, neuroplasticity hypothesis and systemic influence hypothesis, but these hypothesis cannot completely explain the pathological mechanism of MDD. Even it is still hard to adopt only one hypothesis to completely reveal the pathogenesis of MDD, thus in recent years, great progress has been made in elucidating the roles of multiple organ interactions in the pathogenesis MDD and identifying novel therapeutic approaches and multitarget modulatory strategies, further revealing the disease features of MDD. Furthermore, some newly discovered potential pharmacological targets and newly studied antidepressants have attracted widespread attention, some reagents have even been approved for clinical treatment and some novel therapeutic methods such as phototherapy and acupuncture have been discovered to have effective improvement for the depressive symptoms. In this work, we comprehensively summarize the latest research on the pathogenesis and diagnosis of MDD, preventive approaches and therapeutic medicines, as well as the related clinical trials.

Characterizing positive and negative valence systems function in adolescent depression: An RDoC-informed approach integrating multiple neural measures

Depression is a prevalent, debilitating, and costly disorder that often manifests in adolescence. There is an urgent need to understand core pathophysiological processes for depression to inform more targeted intervention efforts. The Research Domain Criteria (RDoC) Positive Valence Systems (PVS) and Negative Valence Systems (NVS) have both been implicated in depression symptomatology and vulnerability; however, the nature of NVS alterations is unclear across studies, and associations between single neural measures and symptoms are often small in magnitude and inconsistent. The present study advances characterization of depression in adolescence via an innovative data-driven approach to identifying subgroups of PVS and NVS function by integrating multiple neural measures (assessed by electroencephalogram [EEG]) relevant to depression in adolescents oversampled for clinical depression and depression risk based on maternal history (N = 129; 14-17 years old). Results of the k-means cluster analysis supported a two-cluster solution wherein one cluster was characterized by relatively attenuated reward and emotion responsiveness across valences and the other by relatively intact responsiveness. Youth in the attenuated responsiveness cluster reported significantly greater depressive symptoms and were more likely to have major depressive disorder diagnoses than youth in the intact responsiveness cluster. In contrast, associations of individual neural measures with depressive symptoms were non-significant. The present study highlights the importance of innovative neuroscience approaches to characterize emotional processing in depression across domains, which is imperative to advancing the clinical utility of RDoC-informed research.

Neural Predictors of Improvement With Cognitive Behavioral Therapy for Adolescents With Depression: An Examination of Reward Responsiveness and Emotion Regulation

Earlier depression onsets are associated with more debilitating courses and poorer life quality, highlighting the importance of effective early intervention. Many youths fail to improve with evidence-based treatments for depression, likely due in part to heterogeneity within the disorder. Multi-method assessment of individual differences in positive and negative emotion processing could improve predictions of treatment outcomes. The current study examined self-report and neurophysiological measures of reward responsiveness and emotion regulation as predictors of response to cognitive-behavioral therapy (CBT). Adolescents (14-18 years) with depression (N = 70) completed monetary reward and emotion regulation tasks while electroencephalogram (EEG) was recorded, and self-report measures of reward responsiveness, emotion regulation, and depressive symptoms at intake. Adolescents then completed a 16-session group CBT program, with depressive symptoms and clinician-rated improvement assessed across treatment. Lower reward positivity amplitudes, reflecting reduced neural reward responsiveness, predicted lower depressive symptoms with treatment. Larger late positive potential residuals during reappraisal, potentially reflecting difficulty with emotion regulation, predicted greater clinician-rated improvement. Self-report measures were not significant predictors. Results support the clinical utility of EEG measures, with impairments in positive and negative emotion processing predicting greater change with interventions that target these processes.

All the Pringle ladies: Neural and behavioral responses to high-calorie food rewards in young adult women

Reward processing is vital for learning and survival, and can be indexed using the Reward Positivity (RewP), an event-related potential (ERP) component that is larger for rewards than losses. Prior work suggests that heightened motivation to obtain reward, as well as greater reward value, is associated with an enhanced RewP. However, the extent to which internal and external factors modulate neural responses to rewards, and whether such neural responses motivate reward-seeking behavior, remains unclear. The present study investigated whether the degree to which a reward is salient to an individual's current motivational state modulates the RewP, and whether the RewP predicts motivated behaviors, in a sample of 133 women. To elicit the RewP, participants completed a forced-choice food reward guessing task. Data were also collected on food-related behaviors (i.e., type of food chosen, consumption of the food reward) and motivational salience factors (i.e., self-reported hunger, time since last meal, and subjective "liking" of food reward). Results showed that hungrier participants displayed an enhanced RewP compared to less hungry individuals. Further, self-reported snack liking interacted with RewP magnitude to predict behavior, such that when participants reported low levels of snack liking, those with a smaller RewP were more likely to consume their snacks than those with a larger RewP. Our data suggest that food-related motivational state may increase neural sensitivity to food reward in young women, and that neural markers of reward sensitivity might interact with subjective reward liking to predict real-world eating behavior.

Manipulating Reward Sensitivity Using Reward Circuit-Targeted Transcranial Magnetic Stimulation

BACKGROUND

The reward circuit is important for motivation and learning, and dysregulations of the reward circuit are prominent in anhedonic depression. Noninvasive interventions that can selectively target the reward circuit may hold promise for the treatment of anhedonia.

METHODS

We tested a novel transcranial magnetic stimulation intervention for modulating the reward circuit. A total of 35 healthy individuals participated in a crossover controlled study targeting the reward circuit or a control site with intermittent theta burst stimulation (iTBS), an excitatory form of transcranial magnetic stimulation. Individual reward circuit targets were defined based upon functional magnetic resonance imaging functional connectivity with the ventral striatum, yielding targets in the rostromedial prefrontal cortex (rmPFC). Reward circuit function was assessed at baseline using functional magnetic resonance imaging, and reward circuit modulation was assessed using an event-related potential referred to as the reward positivity, which has been shown to reliably track reward sensitivity, as well as individual differences in depression and risk for depression.

RESULTS

Relative to control iTBS, rmPFC iTBS enhanced the reward positivity. This effect was moderated by reward function, suggesting greater enhancements in individuals with lower reward function. This effect was also moderated by rmPFC-ventral striatum connectivity insofar as iTBS reached the rmPFC, suggesting that efficacy relies jointly on the strength of the rmPFC-ventral striatum pathway and ability of transcranial magnetic stimulation to target the rmPFC.

CONCLUSIONS

These data suggest that the reward circuit can be modulated by rmPFC iTBS, and amenability to such modulations is related to measures of reward circuit function. This provides the first step toward a novel noninvasive treatment of disorders of the reward circuit.

A randomized trial of aerobic exercise for major depression: examining neural indicators of reward and cognitive control as predictors and treatment targets

BACKGROUND

Aerobic exercise has demonstrated antidepressant efficacy among adults with major depression. There is a poor understanding of the neural mechanisms associated with these effects. Deficits in reward processing and cognitive control may be two candidate targets and predictors of treatment outcome to exercise in depression.

METHODS

Sixty-six young adults aged 20.23 years (s.d. = 2.39) with major depression were randomized to 8 weeks of moderate-intensity aerobic exercise (n = 35) or light stretching (n = 31). Depressive symptoms were assessed across the intervention to track symptom reduction. Reward processing [reward positivity (RewP)] and cognitive control [error-related negativity (ERN)] were assessed before and after the intervention using event-related brain potentials.

RESULTS

Compared to stretching, aerobic exercise resulted in greater symptom reduction (gs = 0.66). Aerobic exercise had no impact on the RewP (gav = 0.08) or ERN (gav = 0.21). In the aerobic exercise group, individuals with a larger pre-treatment RewP [odds ratio (OR) = 1.45] and increased baseline depressive symptom severity (OR = 1.18) were more likely to respond to an aerobic exercise program. Pre-treatment ERN did not predict response (OR = 0.74).

CONCLUSIONS

Aerobic exercise is effective in alleviating depressive symptoms in adults with major depression, particularly for those with increased depressive symptom severity and a larger RewP at baseline. Although aerobic exercise did not modify the RewP or ERN, there is preliminary support for the utility of the RewP in predicting who is most likely to respond to exercise as a treatment for depression.

Outcome valence and stimulus frequency affect neural responses to rewards and punishments

The Reward-Positivity (RewP) is a frontocentral event-related potential elicited following reward and punishment feedback. Reinforcement learning theories propose the RewP reflects a reward prediction error that increases following more favorable (vs. unfavorable) outcomes. An alternative perspective, however, proposes this component indexes a salience-prediction error that increases following more salient outcomes. Evidence from prior studies that included both reward and punishment conditions is mixed, supporting both accounts. However, these studies often varied how feedback stimuli were repeated across reward and punishment conditions. Differences in the frequency of feedback stimuli may drive inconsistencies by introducing salience effects for infrequent stimuli regardless of whether they are associated with rewards or punishments. To test this hypothesis, the current study examined the effect of outcome valence and stimulus frequency on the RewP and neighboring P2 and P3 components in reward, punishment, and neutral contexts across two separate experiments that varied how often feedback stimuli were repeated between conditions. Experiment 1 revealed infrequent feedback stimuli generated overlapping positivity across all three components. However, controlling for stimulus frequency, experiment 2 revealed favorable outcomes that increased RewP and P3 positivity. Together, these results suggest the RewP reflects some combination of reward- and salience-prediction error encoding. Results also indicate infrequent feedback stimuli elicited strong salience effects across all three components that may inflate, eliminate, or reverse outcome valence effects for the RewP and P3. These results resolve several inconsistencies in the literature and have important implications for electrocortical investigations of reward and punishment feedback processing.

The time course of reactivity to social acceptance and rejection feedback: An examination of event-related potentials and behavioral measures in a peer interaction task

Measurement of social processes is of interest across areas of research. Event-related potentials (ERPs) measured using electroencephalography (EEG) offer high temporal resolution, but little work has leveraged this strength to characterize the time course of social feedback processing. The present study aimed to replicate and extend previous research by systematically identifying the temporal dynamics of responses to both social acceptance and rejection feedback relative to neutral feedback, examining internal consistency of ERPs, and exploring correspondence with behavioral measures elicited during a peer interaction task. Emerging adults (N = 118) completed a computerized peer interaction task in which they made decisions to accept or reject peers and received rejection, acceptance, and neutral feedback while EEG data were recorded. Principal component analysis was used to derive temporally and spatially distinct ERP components sensitive to positive and negative social feedback. Participant voting patterns and post-task liking ratings for computer-controlled peers were also examined. Replicating prior work, components consistent with N1, P2, reward positivity (RewP), and P3 emerged, but distinct patterns of modulation by acceptance and rejection relative to neutral feedback were observed. Most components showed acceptable internal consistency. Sensitivity to peer feedback assessed through participant voting patterns and liking ratings for peers was correlated with RewP and P3 components. Results highlight the complexity of social feedback processing observable in a computerized peer interaction task and offer promising neural and behavioral measures that can be used to examine individual differences in sensitivity to both social acceptance and rejection feedback.

Cognitive Behavioral Therapy for Anxiety Disorders in Youth: Efficacy, Moderators, and New Advances in Predicting Outcomes

PURPOSE OF REVIEW

This review integrates recent systematic reviews and meta-analyses on the efficacy of cognitive behavioral therapy (CBT) for the treatment of anxiety disorders in children and adolescents. To inform personalized approaches to intervention, we also review recent research on moderators and predictors of outcomes.

RECENT FINDINGS

Meta-analyses provide strong support for the efficacy of CBT for youth anxiety disorders, including with preschool-aged children using appropriate modifications. Furthermore, there is evidence that CBT is an effective adjunct treatment to psychopharmacological interventions, and the combination of treatments may be most effective for some youth. There is limited evidence of consistent demographic and clinical moderators of outcomes. Recent work in neuroscience has highlighted novel predictors of treatment outcomes that, with replication, may aid in more personalized approaches to youth anxiety treatment. CBT is efficacious for treating anxiety disorders in youth and lowering recurrence rates. CBT can also be an efficacious adjunct treatment for psychopharmacological interventions. Neuroimaging and psychophysiological measures of threat and motivational processing have shown initial promise in predicting symptom change with CBT, with potential implications for precision medicine.

Examining the relationship between anhedonia symptoms and trait positive appraisal style in adolescents: A longitudinal survey study

INTRODUCTION

Anhedonia, defined as a loss of interest and pleasure in previously enjoyable activities, is a core symptom of depression that predicts a poor treatment response in adolescents. We know little about the cognitive vulnerability factors that contribute to the development of anhedonia in youth. This cross-sectional and longitudinal survey study investigated the link between anhedonia symptoms and cognitive appraisal of positive affect.

METHODS

Baseline data were collected from 392 secondary school students in the UK (aged 13-16, 54 % Female), 170 of whom went on to complete the three-month follow-up assessment (a 43 % response rate). Participants rated their anhedonia symptoms and appraisal styles which were measured in terms of use of amplifying appraisals, dampening appraisals, and fear of positive emotion.

RESULTS

At baseline, greater anhedonia was significantly associated with increased levels of dampening and reduced levels of amplifying but was not significantly related to fear of positive emotion. Prospectively, greater baseline levels of amplifying uniquely predicted lower anhedonia severity at three-month follow-up, and vice-versa. There was no evidence for reciprocal prospective associations between anhedonia and, appraisal styles of dampening and fear of positive emotion.

CONCLUSION

These results indicate that cognitive appraisal of positive affect is associated with concurrent and to some extent can predict future symptoms of anhedonia in youth.

Increased self-reported reward responsiveness predicts better response to cognitive behavioral therapy for youth with anxiety

Few consistent predictors of differential cognitive behavioral therapy (CBT) outcome for anxious youth have been identified, although emerging literature points to youth reward responsiveness as a potential predictor. In a sample of youth ages 7-17 with a primary anxiety disorder (N = 136; Mage = 12.18 years, SDage = 3.12; 70 females; Caucasian n = 108, Black n = 12, Asian n = 4, Hispanic n = 5, other n = 7), the current study examined whether youth reward responsiveness assessed via the Behavioral Inhibition and Behavioral Activation System Scales for children, reward responsiveness subscale, predicted post-treatment (a) anxiety symptom severity, (b) depressive symptom severity, (c) functioning, (d) responder status and (e) number of homework/exposure tasks completed following 16-weeks of CBT, controlling for pre-treatment age, sex, anxiety/depressive symptom severity, and functioning. Moderation analyses examined whether relationships differed by age. Increased reward responsiveness was associated with lower anxiety and depressive symptom severity, higher functioning, and increased likelihood of being a responder, but not homework or exposure completion. Moderation analyses showed that younger, but not older, youth who were more reward responsive completed more exposures. Findings indicate that increased reward responsiveness is a predictor of better CBT outcomes for anxious youth, particularly functional outcomes, and that reward responsiveness may play a different role in exposure completion across development.

Association of Neural Reward Circuitry Function With Response to Psychotherapy in Youths With Anxiety Disorders

OBJECTIVE

Identifying neural correlates of response to psychological treatment may inform targets for interventions designed to treat psychiatric disorders. This study examined the extent to which baseline functioning in reward circuitry is associated with response to psychotherapy in youths with anxiety disorders.

METHODS

A randomized clinical trial of cognitive-behavioral therapy compared with supportive therapy was conducted in youths with anxiety disorders. Before treatment, 72 youths (9-14 years old) with anxiety disorders and 37 group-matched healthy comparison youths completed a monetary reward functional MRI task. Treatment response was defined categorically as at least a 35% reduction in diagnostician-rated anxiety severity from pre- to posttreatment assessment. Pretreatment neural activation in the striatum and medial prefrontal cortex (mPFC) during monetary wins relative to losses was examined in relation to treatment response.

RESULTS

Responders, nonresponders, and healthy youths differed significantly in mPFC activation to rewards versus losses at baseline. Youths with anxiety exhibited higher mPFC activity relative to healthy youths, although this may have been driven by differences in depressive symptoms. Planned comparisons between treatment responders (N=48) and nonresponders (N=24) also revealed greater pretreatment neural activation in a cluster encompassing the subgenual anterior cingulate cortex and nucleus accumbens among responders.

CONCLUSIONS

Striatal activation to reward receipt may not differentiate youths with anxiety from healthy youths. However, higher striatal responsivity to rewards may allow youths with anxiety to improve during treatment, potentially through greater engagement in therapy. Function in reward circuitry may guide development of treatments for youths with anxiety.

Examination of developmental pathways from preschool temperament to early adolescent ADHD symptoms through initial responsiveness to reward

To identify sources of phenotypic heterogeneity in attention-deficit/hyperactivity disorder (ADHD) accounting for diversity in developmental/ pathogenic pathways, we examined, in a large sample of youth (N = 354), (a) associations between observed temperamental emotionality at age 3, an electrocortical index (i.e., reward positivity [RewP]) of initial responsiveness to reward at age 9, and ADHD symptoms at age 12, and (b) whether the association between emotionality and ADHD symptoms is mediated by initial responsiveness to reward. Bivariate analyses indicated greater positive emotionality (PE) was associated with enhanced RewP, lower age-9ADHD and lower age-12 inattention (IA). Negative emotionality (NE) was not associated with RewP or ADHD. Mediation analyses revealed the association between PE and hyperactivity/impulsivity (H/I) was mediated by RewP; enhanced RewP was associated with greater H/I. Greater PE was associated with enhanced RewP at a trend level. These effects held accounting for age-9 ADHD, age-12 IA and age-12 oppositional defiant and conduct disorder symptoms. As such, preschool emotionality is associated with adolescent ADHD-H/I symptoms through late childhood initial responsiveness to reward. These relations indicate that individual differences in emotionality and reward responsiveness may be informative for personalizing ADHD interventions.

Altered reward responsiveness and depressive symptoms: An examination of social and monetary reward domains and interactions with rejection sensitivity

BACKGROUND

Alterations in positive valence systems and social processes, including low reward responsiveness and high rejection sensitivity, have been observed in depression. Most reward research focuses on the monetary domain, but social reward responsiveness may be particularly relevant to understanding the etiology of depression, especially in combination with other social processes. Pathways to depression are complex, and research testing interactions between multiple factors is needed. The present study examined the interactive effects of reward responsiveness and rejection sensitivity on depressive symptoms using both social and monetary reward electroencephalogram (EEG) tasks.

METHODS

Emerging adults (N = 120) completed peer interaction and monetary incentive delay tasks while EEG data were recorded, as well as self-report measures of rejection sensitivity and depressive symptoms.

RESULTS

The interaction between social reward responsiveness and self-reported rejection sensitivity was significantly associated with depressive symptoms, such that rejection sensitivity was associated with greater depressive symptoms for those with a relatively reduced response to social reward. The interaction between monetary reward responsiveness and rejection sensitivity was not significant.

LIMITATIONS

The study was cross-sectional and used a non-clinical sample.

CONCLUSIONS

Results suggest a possible pathway for depressive symptoms characterized by the combination of high rejection sensitivity and low social reward responsiveness. Findings highlight the need for consideration of multiple domains of reward responsiveness in clinical neuroscience research. With extension to longitudinal studies and clinical samples, the present findings may inform understanding of targets for intervention.

Great Expectations: A Critical Review of and Suggestions for the Study of Reward Processing as a Cause and Predictor of Depression

Both human and animal studies support the relationship between depression and reward processing abnormalities, giving rise to the expectation that neural signals of these processes may serve as biomarkers or mechanistic treatment targets. Given the great promise of this research line, we scrutinized those findings and the theoretical claims that underlie them. To achieve this, we applied the framework provided by classical work on causality as well as contemporary approaches to prediction. We identified a number of conceptual, practical, and analytical challenges to this line of research and used a preregistered meta-analysis to quantify the longitudinal associations between reward processing abnormalities and depression. We also investigated the impact of measurement error on reported data. We found that reward processing abnormalities do not reach levels that would be useful for clinical prediction, yet the available evidence does not preclude a possible causal role in depression.

Neural Indicators of Anhedonia: Predictors and Mechanisms of Treatment Change in a Randomized Clinical Trial in Early Childhood Depression

BACKGROUND

Early childhood depression is associated with anhedonia and reduced event-related potential (ERP) responses to rewarding or pleasant stimuli. Whether these neural measures are indicators of target engagement or treatment outcome is not yet known.

METHODS

We measured ERP responses to win and loss feedback in a guessing task and to pleasant versus neutral pictures in young (4.0-6.9 years of age) depressed children before and after randomization to either 18 weeks of Parent-Child Interaction Therapy-Emotion Development (PCIT-ED) or waitlist.

RESULTS

Analyses included reward positivity (RewP) data from 118 children randomly assigned to PCIT-ED (n = 60) or waitlist (n = 58) at baseline and late positive potential (LPP) data from 99 children (44 assigned to PCIT-ED vs. 55 assigned to waitlist) at baseline. Children undergoing PCIT-ED showed a greater reduction in anhedonia (F_1,103 = 10.32, p = .002, partial η² = .09). RewP reward responses increased more (F_1,86 = 5.98, p = .02, partial η² = .07) for PCIT-ED, but a greater change in RewP was not significantly associated with a greater reduction in major depressive disorder symptoms (r = -.12, p > .4). Baseline RewP did not predict treatment change. LPPs to positive pictures did not change across treatment, but greater baseline LPPs to positive pictures predicted a higher likelihood of remission from major depressive disorder in children undergoing PCIT-ED (B = 0.14; SE = 0.07; odds ratio = 1.15; p = .03).

CONCLUSIONS

The ERP reward response improved in young children with depression during a treatment designed to enhance emotion development, providing evidence of target engagement of the neural systems associated with reward. Further, greater baseline LPP responses to positive pictures was associated with a greater likelihood of depression remission, suggesting that this ERP measure can predict which children are most likely to respond to treatment.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up-to-date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer-term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments.

OBJECTIVES

To examine the effect of CBT for childhood anxiety disorders, in comparison with waitlist/no treatment, treatment as usual (TAU), attention control, alternative treatment, and medication.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (all years to 2016), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO (each to October 2019), international trial registries, and conducted grey literature searches.

SELECTION CRITERIA

We included randomised controlled trials of CBT that involved direct contact with the child, parent, or both, and included non-CBT comparators (waitlist/no treatment, treatment as usual, attention control, alternative treatment, medication). Participants were younger than age 19, and met diagnostic criteria for an anxiety disorder diagnosis. Primary outcomes were remission of primary anxiety diagnosis post-treatment, and acceptability (number of participants lost to post-treatment assessment), and secondary outcomes included remission of all anxiety diagnoses, reduction in anxiety symptoms, reduction in depressive symptoms, improvement in global functioning, adverse effects, and longer-term effects.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 87 studies and 5964 participants in quantitative analyses. Compared with waitlist/no treatment, CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45, 95% confidence interval (CI) 3.90 to 7.60; n = 2697, 39 studies, moderate quality); NNTB 3 (95% CI 2.25 to 3.57) and all anxiety diagnoses (OR 4.43, 95% CI 2.89 to 6.78; n = 2075, 28 studies, moderate quality). Low-quality evidence did not show a difference between CBT and TAU in post-treatment primary anxiety disorder remission (OR 3.19, 95% CI 0.90 to 11.29; n = 487, 8 studies), but did suggest CBT may increase remission from all anxiety disorders compared to TAU (OR 2.74, 95% CI 1.16 to 6.46; n = 203, 5 studies). Compared with attention control, CBT may increase post-treatment remission of primary anxiety disorders (OR 2.28, 95% CI 1.33 to 3.89; n = 822, 10 studies, low quality) and all anxiety disorders (OR 2.75, 95% CI 1.22 to 6.17; n = 378, 5 studies, low quality). There was insufficient available data to compare CBT to alternative treatments on post-treatment remission of primary anxiety disorders, and low-quality evidence showed there may be little to no difference between these groups on post-treatment remission of all anxiety disorders (OR 0.89, 95% CI 0.35 to 2.23; n = 401, 4 studies) Low-quality evidence did not show a difference for acceptability between CBT and waitlist/no treatment (OR 1.09, 95% CI 0.85 to 1.41; n=3158, 45 studies), treatment as usual (OR 1.37, 95% CI 0.73 to 2.56; n = 441, 8 studies), attention control (OR 1.00, 95% CI 0.68 to 1.49; n = 797, 12 studies) and alternative treatment (OR 1.58, 95% CI 0.61 to 4.13; n=515, 7 studies). No adverse effects were reported across all studies; however, in the small number of studies where any reference was made to adverse effects, it was not clear that these were systematically monitored. Results from the anxiety symptom outcomes, broader outcomes, longer-term outcomes and subgroup analyses are provided in the text. We did not find evidence of consistent differences in outcomes according to delivery formats (e.g. individual versus group; amount of therapist contact time) or amongst samples with and without ASD, and no studies included samples of children with intellectual impairments.

AUTHORS' CONCLUSIONS

CBT is probably more effective in the short-term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.

Blunted neural effects of perceived control on reward feedback in major depressive disorder

BACKGROUND

Blunted reward processing has emerged as an endophenotype of major depressive disorder (MDD), but mechanistic understanding for this deficit remains elusive. The current event-related potential study examined whether this aberration is driven by the blunted effect of perceived control on reward processing.

METHODS

We adapted a well-validated gambling task in which perceived control was exercised by choice in 29 individuals with current MDD and 31 healthy controls. We examined the reward positivity in response to personally chosen versus passively received rewards.

RESULTS

We found that MDD patients relative to healthy controls exhibited a blunted reward positivity when rewards were delivered following voluntary choices but not when they were delivered following passive choices. This pattern was not observed during the relatively late stage, as indexed by the P300, of feedback processing.

LIMITATION

The current findings may be confounded with medication and anxiety.

CONCLUSIONS

These findings suggest that deficient reward processing in MDD is attributable to the deficiency in boosting reward responsivity by perceived control exercised by choice.

Reward-Related Neural Predictors and Mechanisms of Symptom Change in Cognitive Behavioral Therapy for Depressed Adolescent Girls

BACKGROUND

Approximately half of depressed adolescents fail to respond to cognitive behavioral therapy (CBT). Given the variability in response, it is important to identify pretreatment characteristics that predict prognosis. Knowledge of which depressed adolescents are likely to exhibit a positive versus poor outcome to CBT may have important clinical implications (e.g., informing treatment recommendations). Emerging evidence suggests that neural reward responsiveness represents one promising predictor.

METHODS

Adolescents with major depressive disorder (n = 36) received CBT and completed a reward task at 3 time points (pretreatment, midtreatment and posttreatment) while 128-channel electroencephalographic data were acquired. Healthy control participants (n = 29) completed the same task at 3 corresponding time points. Analyses focused on event-related potentials linked to 2 stages of neural processing: initial response to rewards (reward positivity) and later, elaborative processing (late positive potential). Moreover, time-frequency analyses decomposed the reward positivity into 2 constituent components: reward-related delta and loss-related theta activity.

RESULTS

Multilevel modeling revealed that greater pretreatment reward responsiveness, as measured by the late positive potential to rewards, predicted greater depressive symptom change. In addition, a group × condition × time interaction emerged for theta activity to losses, reflecting normalization of theta power in the group with major depressive disorder from baseline to posttreatment.

CONCLUSIONS

An event-related potential measure of sustained (late positive potential)-but not initial (reward positivity)-reward responsiveness predicted symptom improvement, which may help inform which depressed adolescents are most likely to benefit from CBT. In addition to alleviating depression, successful CBT may attenuate underlying neural (theta) hypersensitivity to negative outcomes in depressed youths.

African American Children's Diminished Returns of Subjective Family Socioeconomic Status on Fun Seeking

Background: Reward sensitivity (fun-seeking) is a risk factor for a wide range of high-risk behaviors. While high socioeconomic status (SES) is known to reduce reward sensitivity and associated high-risk behaviors, less is known about the differential effects of SES on reward sensitivity. It is plausible to expect weaker protective effects of family SES on reward sensitivity in racial minorities, a pattern called Minorities' Diminished Returns (MDRs). Aim: We compared Caucasian and African American (AA) children for the effects of subjective family SES on children's fun-seeking. Methods: This was a cross-sectional analysis of 7061 children from the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was subjective family SES. The main outcome was children's fun-seeking measured by the behavioral approach system (BAS) and behavioral avoidance system (BIS). Age, gender, marital status, and household size were the covariates. Results: In the overall sample, high subjective family SES was associated with lower levels of fun-seeking. We also found a statistically significant interaction between race and subjective family SES on children's fun-seeking in the overall sample, suggesting that high subjective family SES is associated with a weaker effect on reducing fun-seeking among AA than Caucasian children. In race-stratified models, high subjective family SES was protective against fun-seeking of Caucasian but not AA children. Conclusion: Subjective family SES reduces the fun-seeking for Caucasian but not AA children.

Clinical, behavioral, and neural measures of reward processing correlate with escitalopram response in depression: a Canadian Biomarker Integration Network in Depression (CAN-BIND-1) Report

Anhedonia is thought to reflect deficits in reward processing that are associated with abnormal activity in mesocorticolimbic brain regions. It is expressed clinically as a deficit in the interest or pleasure in daily activities. More severe anhedonia in major depressive disorder (MDD) is a negative predictor of antidepressant response. It is unknown, however, whether the pathophysiology of anhedonia represents a viable avenue for identifying biological markers of antidepressant treatment response. Therefore, this study aimed to examine the relationships between reward processing and response to antidepressant treatment using clinical, behavioral, and functional neuroimaging measures. Eighty-seven participants in the first Canadian Biomarker Integration Network in Depression (CAN-BIND-1) protocol received 8 weeks of open-label escitalopram. Clinical correlates of reward processing were assessed at baseline using validated scales to measure anhedonia, and a monetary incentive delay (MID) task during functional neuroimaging was completed at baseline and after 2 weeks of treatment. Response to escitalopram was associated with significantly lower self-reported deficits in reward processing at baseline. Activity during the reward anticipation, but not the reward consumption, phase of the MID task was correlated with clinical response to escitalopram at week 8. Early (baseline to week 2) increases in frontostriatal connectivity during reward anticipation significantly correlated with reduction in depressive symptoms after 8 weeks of treatment. Escitalopram response is associated with clinical and neuroimaging correlates of reward processing. These results represent an important contribution towards identifying and integrating biological, behavioral, and clinical correlates of treatment response. ClinicalTrials.gov: NCT01655706.

Reward Responsiveness in the Adolescent Brain Cognitive Development (ABCD) Study: African Americans' Diminished Returns of Parental Education

(1) Background: Reward responsiveness (RR) is a risk factor for high-risk behaviors such as aggressive behaviors and early sexual initiation, which are all reported to be higher in African American and low socioeconomic status adolescents. At the same time, parental education is one of the main drivers of reward responsiveness among adolescents. It is still unknown if some of this racial and economic gap is attributed to weaker effects of parental education for African Americans, a pattern also called minorities' diminished returns (MDRs). (2) Aim: We compared non-Hispanic White and African American adolescents for the effects of parent education on adolescents RR, a psychological and cognitive construct that is closely associated with high-risk behaviors such as the use of drugs, alcohol, and tobacco. (3) Methods: This was a cross-sectional analysis that included 7072 adolescents from the adolescent brain cognitive development (ABCD) study. The independent variable was parent education. The main outcome as adolescents' RR measured by the behavioral inhibition system (BIS) and behavioral activation system (BAS) measure. (4) Results: In the overall sample, high parent education was associated with lower levels of RR. In the overall sample, we found a statistically significant interaction between race and parent education on adolescents' RR. The observed statistical interaction term suggested that high parent education is associated with a weaker effect on RR for African American than non-Hispanic White adolescents. In race-stratified models, high parent education was only associated with lower RR for non-Hispanic White but not African American adolescents. (5) Conclusion: Parent education reduces RR for non-Hispanic White but not African American adolescents. To minimize the racial gap in brain development and risk-taking behaviors, we need to address societal barriers that diminish the returns of parent education and resources in African American families. We need public and social policies that target structural and societal barriers, such as the unequal distribution of opportunities and resources. To meet such an aim, we need to reduce the negative effects of social stratification, segregation, racism, and discrimination in the daily lives of African American parents and families. Through an approach like this, African American families and parents can effectively mobilize their resources and utilize their human capital to secure the best possible tangible outcomes for their adolescents.

Developmental trajectories to reduced activation of positive valence systems: A review of biological and environmental contributions

Reduced activation of positive valence systems (PVS), including blunted neural and physiological responses to pleasant stimuli and rewards, has been shown to prospectively predict the development of psychopathology. Yet, little is known about how reduced PVS activation emerges across development or what implications it has for prevention. We review genetic, temperament, parenting, and naturalistic and laboratory stress research on neural measures of PVS and outline developmentally-informed models of trajectories of PVS activation. PVS function is partly heritable and appears to reflect individual differences in early-emerging temperament traits. Although lab-induced stressors blunt PVS activation, effects of parenting and naturalistic stress on PVS are mixed and depend on the type of stressor, developmental timing, and interactions amongst risk factors. We propose that there may be multiple, dynamic developmental trajectories to reduced PVS activation in which combinations of genes, temperament, and exposure to severe, prolonged, or uncontrollable stress may exert direct and interactive effects on PVS function. Critically, these risk factors may alter PVS developmental trajectories and/or PVS sensitivity to proximal stressors. Distinct factors may converge such that PVS activation proceeds along a typical, accelerated, chronically low, or stress-reactive trajectory. Finally, we present directions for future research with translational implications.

Irritability as a Transdiagnostic Vulnerability Trait:Current Issues and Future Directions

In recent years, irritability has received increasing attention among mental health professionals given its transdiagnostic associations with diverse forms of psychopathology. In contrast to other emotional states and traits, however, literature addressing associations between irritability and related temperament and personality constructs is limited. In addition, those who study irritability have diverse perspectives on its neurobiological substrates. In this comment, we situate irritability in the literatures on child temperament and adult personality, and describe a model in which irritability derives from low tonic dopamine (DA) levels and low phasic DA reactivity in subcortical neural structures implicated in appetitive responding. We note that different findings often emerge in neuroimaging studies when irritability is assessed in circumscribed diagnostic groups versus representative samples. We conclude with directions for future research, and propose that more authors use hierarchical Bayesian modeling, which captures functional dependencies between irritability and other dispositional traits (e.g., trait anxiety) that standard regression models are insensitive too. Treatment implications are also considered.

Age-Related Decline in Children's Reward Sensitivity: Blacks' Diminished Returns

BACKGROUND

It is important to study the correlates of reward sensitivity since it predicts high-risk behaviors. While ageing reduces children's reward sensitivity and its associated risk taking, there is more to find out about racial differences in regard to the effect of age on reward sensitivity. Minorities' Diminished Returns (MDRs) suggest that resources and assets show weaker effects on Black children than White children.

AIM

We compared White children to Black children as for the effects of age on reward sensitivity.

METHODS

This cross-sectional study included 10533 American children who participated in the baseline of the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was age, while the dependent variable was reward sensitivity as captured by the behavioral approach/behavioral avoidance system (BAS-BIS). Gender, parental education, marital status, parental education, and household income were the covariates.

RESULTS

Higher age was associated with less reward sensitivity. A significant interaction was found between race and age when it comes to children's reward sensitivity. It suggested that age is associated with a smaller gain in terms of reduced reward sensitivity in Black children than White children.

CONCLUSION

Age is more likely to reduce reward sensitivity in White children than Black children. This finding is in line with MDRs, and may be due to social racism, segregation, stratification, and discrimination.