Cognitive bias modification training in adolescents: effects on interpretation biases and mood

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.

Do markers of daily affect mediate associations between interpretation bias and depressive symptoms? A longitudinal study of early adolescents

INTRODUCTION

Early adolescence represents a time of heightened vulnerability for depression. Negative interpretation biases have been associated with increases in depressive symptoms during this developmental period; however, the mechanisms underlying the association between interpretation biases and depression remain poorly understood. Cognitive theories posit that interpretation biases give rise to depression by modulating daily affect, particularly in the context of stress. However, this has not yet been directly examined. The present study tested affect intensity and instability as mechanisms linking negative interpretation biases with change in adolescent depressive symptoms.

METHODS

Ninety-four adolescents (aged 11-13 years; 51% boys) from Vancouver, Canada, were recruited for this longitudinal study. At baseline (Time 1), participants self-reported depressive symptoms and completed the Scrambled Sentences Task to assess negative interpretation biases. Next, participants completed daily diaries to assess positive affect (PA) and negative affect (NA) during a naturalistic stressor-the first 2 weeks of high school (Time 2). Finally, participants self-reported depressive symptoms 3 months later (Time 3). Path models were conducted to test whether PA and NA intensity and instability mediated prospective associations between negative interpretation biases and depressive symptom changes.

RESULTS

Although NA intensity, NA instability, and PA instability predicted increases in depressive symptoms, only NA intensity mediated associations between interpretation biases and symptom changes. Neither PA intensity nor instability mediated these associations.

CONCLUSIONS

Elevated daily NA represents a specific mechanism through which stronger negative interpretation biases predict increases in depressive symptoms in adolescence.

Developing an interpretation bias modification training task for alleviating loneliness in young people

OBJECTIVE

Loneliness is common among young people and is associated with negative health outcomes. Because loneliness is associated with a bias for interpreting social situations as threatening, cognitive bias modification for interpretation (CBM-I) training is a potential early intervention tool. We developed and delivered a single session of mental imagery enhanced digital CBM-I training, assessing feasibility, acceptability, and magnitude of change in interpretational style and loneliness.

METHOD

CBM-I training materials were developed using a co-creation approach with 18-25-year-olds with experience of loneliness. Another group of 18-25-year-olds with high loneliness received either online CBM-I (n = 29) or control (n = 27) training.

RESULTS

CBM-I training uptake and retention rates were 88% and 92%, respectively. Participants found the training acceptable. The CBM-I group showed a reduction in social threat interpretations (d = 0.77), an increase in social benign interpretations (d = 0.84), and a decrease in loneliness (d = 0.56). The control group showed a small reduction in social threat interpretations (d = 0.21), no change in social benign interpretations (d = 0.04), and an increase in loneliness (d = 0.41).

CONCLUSIONS

Interpretation biases relevant to youth loneliness may be modifiable, and CBM-I training could reduce feelings of loneliness. This informs psychological models of loneliness, and the development of CBM-I interventions targeting loneliness in young people.

The influence of outcome expectancy on interpretation bias training in social anxiety: an experimental pilot study

BACKGROUND

Cognitive bias modification for interpretation (CBM-I) trainings have shown positive effects on interpretation bias in both active interpretation bias training conditions and structurally similar control conditions. Outcome expectations have been suggested to contribute to these placebo effects. The goal of this pilot experimental study was to test the feasibility of positive expectancy induction, to gain preliminary insight into whether this has implications for the efficacy of CBM-I training, and to assess the feasibility of recruitment and the overall study design.

METHODS

Socially anxious individuals aged 18 years and older received a single session (approx. 45 min) of either CBM-I or placebo training preceded by either a positive expectancy induction or no expectancy induction. We first tested whether the expectancy induction had modified participants' expectations of training. We then explored the effects of CBM-I training and expectancy induction on interpretation bias. Finally, we assessed the feasibility of recruitment and further study procedures.

RESULTS

Due to pandemic-related difficulties, fewer participants were recruited than initially planned. Thirty-four (22 females and 12 males) participants were randomly assigned to one of four conditions (interpretation bias training + high expectancy = 10, interpretation bias training + no expectancy = 8, placebo training + high expectancy = 11, placebo training + no expectancy = 5). Participants in the positive expectancy condition had more positive expectations of the training (CBM-I or placebo) than participants in the no expectancy condition. We were unable to conduct the planned 2 × 2 × 2 analysis of interpretation bias due to the small sample size. When looking at these groups individually, we found that participants in the active training condition and participants in the high expectancy condition showed increases in positive interpretation bias and decreases in negative interpretation bias from pre- to post-training, while participants in the placebo and no expectancy conditions showed no change.

CONCLUSIONS

These findings suggest that the expectancy manipulation utilized in this study may be adopted by future studies which investigate outcome expectations as an unspecific mechanism of CBM-I. Preliminary analyses suggest that participants' expectations are likely to play a role in the effect of CBM-I training, although these effects require replication in a larger sample. Several observations about the study feasibility were made which could inform future trials.

TRIAL REGISTRATION

Retrospectively registered on the August 23, 2022, through the German Clinical Trials Register ( DRKS00029768 ).

Fearful Temperament, Catastrophizing, and Internalizing Symptoms in Clinically Anxious Youth

A fearful temperament in childhood is associated with child internalizing symptoms. However, the cognitive mechanisms explaining this association are poorly understood. We examined the effects of child fearful temperament on child internalizing symptoms and the underlying role of catastrophizing cognitions among clinically anxious youth. Children (N = 105; M age = 10.09 years, SD = 1.22; 56.7% female; 62% ethnic minority) completed a diagnostic interview; self-report measures of temperament, catastrophizing, and internalizing symptoms; and behaviorally-indexed measures of catastrophizing and anxiety. Indirect effects were found for child fearful temperament on child self-reported internalizing symptoms by way of self-reported (but not behaviorally-indexed) catastrophizing cognitions. Models predicting behaviorally-indexed child anxiety were not significant. Our findings suggest that targeting fearful temperament during childhood before catastrophizing cognitions develop may have clinical utility. Likewise, among children temperamentally at-risk, addressing catastrophic cognitions may prevent later internalizing psychopathology.

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.

Disentangling the mediating role of modifying interpretation bias on emotional distress using a novel cognitive bias modification program

BACKGROUND

Negative interpretation bias is a potential risk factor for emotional disorders. In this study, we tested a clinically inspired 4-session online Cognitive Bias Modification-Interpretation (CBM-I_Clin) program to modify negative interpretation biases.

METHODS

We randomized one hundred and twenty-one volunteer young adults (Mean age = 21.6 years, SD = 3.5; 85 % women) with varying levels of emotional distress to either an experimental or waitlist control group. Mediation analyses were used to disentangle the associations between the intervention, changes in interpretation biases (assessed by both a self-report and an experimental task), and changes in measures of cognitive vulnerability and symptoms of depression and anxiety.

RESULTS

The results showed that the CBM-I_Clin could change negative interpretation biases. Also, it had a direct effect on the change in negative memory bias, an indirect effect on the change in depression symptoms via the change in interpretation bias, and both direct and indirect effects on the change in self-reported dysfunctional attitudes.

LIMITATIONS

The study included a non-clinical sample of participants and it did not control for some potential confounding factors (e.g., attentional disorders). Furthermore, participants' engagement during the sessions at home was not supervised.

CONCLUSIONS

The CBM-I_Clin is a potential tool to prevent and intervene in emotional disorders in young adults and could complement other traditional CBM procedures or clinical interventions.

Promoting helpful attention and interpretation patterns to reduce anxiety and depression in young people: weaving scientific data with young peoples' lived experiences

BACKGROUND

Anxiety and depression are common, disabling and frequently start in youth, underscoring the need for effective, accessible early interventions. Empirical data and consultations with lived experience youth representatives suggest that maladaptive cognitive patterns contribute to and maintain anxiety and depression in daily life. Promoting adaptive cognitive patterns could therefore reflect "active ingredients" in the treatment and/or prevention of youth anxiety and depression. Here, we described and compared different therapeutic techniques that equipped young people with a more flexible capacity to use attention and/or promoted a tendency to positive/benign (over threatening/negative) interpretations of uncertain situations.

METHODS

We searched electronic databases (PubMed, PsycINFO, EMBASE, and PsycARTICLES) for studies containing words relating to: intervention; youth; anxiety and/or depression and attention and/or interpretation, and selected studies which sought to reduce self-reported anxiety/depression in youth by explicitly altering attention and/or interpretation patterns. Ten young people with lived experiences of anxiety and depression and from diverse backgrounds were consulted on the relevance of these strategies in managing emotions in their daily lives and also whether there were additional strategies that could be targeted to promote adaptive thinking styles.

RESULTS

Two sets of techniques, each targeting different levels of responding with different strengths and weaknesses were identified. Cognitive bias modification training (CBM) tasks were largely able to alter attention and interpretation biases but the effects of training on clinical symptoms was more mixed. In contrast, guided instructions that teach young people to regulate their attention or to evaluate alternative explanations of personally-salient events, reduced symptoms but there was little experimental data establishing the intervention mechanism. Lived experience representatives suggested that strategies such as deliberately recalling positive past experiences or positive aspects of oneself to counteract negative thinking.

DISCUSSION

CBM techniques target clear hypothesised mechanisms but require further co-design with young people to make them more engaging and augment their clinical effects. Guided instructions benefit from being embedded in clinical interventions, but lack empirical data to support their intervention mechanism, underscoring the need for more experimental work. Feedback from young people suggest that combining complimentary techniques within multi-pronged "toolboxes" to develop resilient thinking patterns in youth is empowering.

"I Am a Total…Loser" - The Role of Interpretation Biases in Youth Depression

Negative interpretation biases have been found to characterize adults with depression and to be involved in the development and maintenance of the disorder. However, less is known about their role in youth depression. The present study investigated i) whether negative interpretation biases characterize children and adolescents with depression and ii) to what extent these biases are more pronounced in currently depressed youth compared to youth at risk for depression (as some negative interpretation biases have been found already in high-risk youth before disorder onset). After a negative mood induction interpretation biases were assessed with two experimental tasks: Ambiguous Scenarios Task (AST) and Scrambled Sentences Task (SST) in three groups of 9-14-year-olds: children and adolescents with a diagnosis of major depression (n = 32), children and adolescents with a high risk for depression (children of depressed parents; n = 48), as well as low-risk children and adolescents (n = 42). Depressed youth exhibited substantially more negative interpretation biases than both high-risk and low-risk groups (as assessed with both tasks), while the high-risk group showed more negative interpretation biases than the low-risk group only as assessed via the SST. The results indicate that the negative interpretation biases that are to some extent already present in high-risk populations before disorder onset are strongly amplified in currently depressed youth. The different findings for the two tasks suggest that more implicit interpretation biases (assessed with the SST) might represent cognitive vulnerabilities for depression whereas more explicit interpretation biases (assessed with the AST) may arise as a consequence of depressive symptomatology.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

DISCUSSION

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

Cultural evidence for interpretation bias as a feature of social anxiety in Chinese adolescents

Background and Objectives: Interpretation bias (IB), defined as the tendency to interpret ambiguous social situations in a threatening manner, has increasingly been studied in children and adolescents. Compared to Western samples, the relation between IB and social anxiety in Chinese youth has received little attention. The present study was to mainly examine the relationship between IB and social anxiety among Chinese adolescents. Design: Cross-sectional design was utilized. Methods: IB, measured by the Adolescents' Interpretation Bias Questionnaire (AIBQ), and social anxiety were surveyed among a group of high socially anxious Chinese adolescents (n = 25) and a control group (n = 29). Participants were asked to rate the likelihood of interpretations coming to mind in social/non-social situations and to choose the most believable interpretation. Results: The high social anxiety group had more negative interpretations and beliefs in social situations, and the interpretation bias was particular to social anxiety versus depression. Additionally, the cognitive content-specificity hypothesis was supported; the high anxious group showed interpretation bias in social situations, but didn't have more negative interpretations of non-social situations, after controlling for depression. Conclusions: The present study yielded comparable findings as found in Western samples regarding the relation between IB and social anxiety.

Interpretation Bias Training in Depressed Adolescents: Near- and Far-Transfer Effects

Depressed adolescents are characterized by negative interpretation biases. Although investigators have used cognitive bias modification for interpretation (CBM-I) to experimentally manipulate interpretation biases in depressed adults, the near- and far-transfer effects are not well understood in adolescents diagnosed with Major Depressive Disorder (MDD). In this study, we extend previous research by investigating the near- and far-transfer effects of 6 sessions of Positive versus Neutral CBM-I on independent measures of interpretation bias (near-transfer effects) and on attention biases and clinical symptoms (far-transfer effects) in a sample of adolescents with MDD (n = 46). At post-training, adolescents who received Positive CBM-I interpreted ambiguous scenarios more positively than did participants who received Neutral CBM-I, providing evidence of training effectiveness. There was no evidence, however, of near- or far-transfer effects. These findings raise concerns about the malleability of interpretation biases in adolescent depression and suggest that further work is needed to establish the clinical utility of CBM-I for adolescents with MDD.

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.

Ethnicity's Role in the Relationship Between Anxiety and Negative Interpretation Bias Among Clinically Anxious Youth: A Pilot Study

Negative interpretation bias, a correlate of anxiety, is defined as an individual's tendency to interpret ambiguous events as negative or threatening. The current study examined associations between interpretation bias and anxiety symptoms in clinically anxious youth and potential moderators of these relationships. Thirty anxious youth and their parents participated in a clinical interview and reported on child anxiety symptoms. Youth completed implicit, explicit-personally irrelevant, and explicit-personally relevant interpretation bias measures. Child-reported anxiety was only associated with negative interpretation bias on the explicit-personally relevant measure and parent-reported social anxiety was negatively associated with positive bias on this measure. Hispanic individuals displayed marginally higher anxiety symptoms and significantly more intense negative interpretation on the implicit measure. While this pilot study revealed preliminary findings that Hispanic ethnicity may play a role in relationships between interpretation bias and anxiety, future work may further elucidate associations between interpretation bias, anxiety, and ethnicity in anxious youth.

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

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

A randomized controlled trial of multi-session online interpretation bias modification training: Short- and long-term effects on anxiety and depression in unselected adolescents

Introduction

Negatively biased interpretations play an important role in anxiety and depression, which are highly prevalent in adolescence, and changing such biases might thus reduce or prevent emotional disorders. We investigated the short- and long-term effects of an online interpretation bias modification training in unselected adolescents to explore its potential in preventing anxiety and depression.

Methods

Participants (N = 173) were randomly allocated to eight online sessions of interpretation or placebo training. Interpretation bias was assessed pre- and post-training. Primary outcomes of anxiety and depression, and secondary measures of emotional resilience were assessed pre- and post-training and at three, six, and twelve months follow-up.

Results

Compared to placebo, interpretation training marginally increased positive interpretations. Irrespective of training condition, symptoms of anxiety and depression showed a decline post-training and at follow-up, and indices of resilience showed an increase. Change in interpretation bias, baseline interpretation bias, stressful life events, or number of training sessions completed did not moderate the effects on anxiety or depression.

Conclusions

Results suggest that interpretation training as implemented in this study has no added value in reducing symptoms or enhancing resilience in unselected adolescents.

The effects of a novel hostile interpretation bias modification paradigm on hostile interpretations, mood, and aggressive behavior

BACKGROUND AND OBJECTIVES

Cognitive theories of aggression propose that biased information processing is causally related to aggression. To test these ideas, the current study investigated the effects of a novel cognitive bias modification paradigm (CBM-I) designed to target interpretations associated with aggressive behavior.

METHODS

Participants aged 18-33 years old were randomly assigned to either a single session of positive training (n = 40) aimed at increasing prosocial interpretations or negative training (n = 40) aimed at increasing hostile interpretations.

RESULTS

The results revealed that the positive training resulted in an increase in prosocial interpretations while the negative training seemed to have no effect on interpretations. Importantly, in the positive condition, a positive change in interpretations was related to lower anger and verbal aggression scores after the training. In this condition, participants also reported an increase in happiness. In the negative training no such effects were found. However, the better participants performed on the negative training, the more their interpretations were changed in a negative direction and the more aggression they showed on the behavioral aggression task.

LIMITATIONS

Participants were healthy university students. Therefore, results should be confirmed within a clinical population.

CONCLUSIONS

These findings provide support for the idea that this novel CBM-I paradigm can be used to modify interpretations, and suggests that these interpretations are related to mood and aggressive behavior.

Cognitive bias modification for facial interpretation: a randomized controlled trial of transfer to self-report and cognitive measures in a healthy sample

Cognitive bias modification is a potential low-intensity intervention for mood disorders, but previous studies have shown mixed success. This study explored whether facial interpretation bias modification (FIBM), a similar paradigm designed to shift emotional interpretation (and/or perception) of faces would transfer to: (i) self-reported symptoms and (ii) a battery of cognitive tasks. In a preregistered, double-blind randomized controlled trial, healthy participants received eight online sessions of FIBM (N = 52) or eight sham sessions (N = 52). While we replicate that FIBM successfully shifts ambiguous facial expression interpretation in the intervention group, this failed to transfer to the majority of self-report or cognitive measures. There was, however, weak, inconclusive evidence of transfer to a self-report measure of stress, a cognitive measure of anhedonia, and evidence that results were moderated by trait anxiety (whereby transference was greatest in those with higher baseline symptoms). We discuss the need for work in both larger and clinical samples, while urging caution that these FIBM training effects may not transfer to clinically relevant domains.

Dual Cognitive and Biological Correlates of Anxiety in Autism Spectrum Disorders

Young people with autism spectrum disorder (ASD) have a high prevalence (~40 %) of anxiety disorders compared to their non-ASD peers. It is unclear whether cognitive and biological processes associated with anxiety in ASD are analogous to anxiety in typically developing (TD) populations. In this study 55 boys with ASD (34 with a co-occurring anxiety disorder, 21 without) and 28 male controls, aged 10-16 years and with a full-scale IQ ≥ 70, completed a series of clinical, cognitive (attention bias/interpretation bias) and biological measures (salivary cortisol/HR response to social stress) associated with anxiety in TD populations. Structural equation modelling was used to reveal that that both attentional biases and physiological responsiveness were significant, but unrelated, predictors of anxiety in ASD.

Cognitive bias modification of interpretation in children with social anxiety disorder

Negative (or a lack of positive) interpretation of ambiguous social situations has been hypothesised to maintain social anxiety disorder in children, yet there is currently limited evidence to support this. Cognitive Bias Modification of Interpretation (CBM-I) provides a means to explore the causal influence of interpretation bias on social anxiety disorder, and has been associated with a reduction in social anxiety symptoms in adults. Seven to twelve year old children with a diagnosis of social anxiety disorder completed CBM-I training, adapted from materials designed for socially anxious children in the community, or no training. Effects on interpretation bias and social anxiety were assessed. The adapted CBM-I training was not associated with significant changes in benign or negative interpretation. Unsurprisingly given the lack of successful interpretation training, there were no significant changes in child or parent reported social anxiety symptoms, clinician-rated severity or diagnoses and change in interpretation was not significantly associated with change in social anxiety. These findings contrast with some studies with community populations although it is possible that more intensive CBM-I training is required to fully test this hypothesis among clinical groups.

How children's victimization relates to distorted versus sensitive social cognition: Perception, mood, and need fulfillment in response to Cyberball inclusion and exclusion

This study examined whether victimization is associated with negatively distorted social cognition (bias), or with a specific increased sensitivity to social negative cues, by assessing the perception of social exclusion and the consequences for psychological well-being (moods and fundamental needs). Both self-reported and peer-reported victimization of 564 participants (M_age=9.9years, SD=1.04; 49.1% girls) were measured, and social exclusion was manipulated through inclusion versus exclusion in a virtual ball-tossing game (Cyberball). Children's perceptions and psychological well-being were in general more negative after exclusion than after inclusion. Moreover, self-reported-but not peer-reported-victimization was associated with the perception of being excluded more and receiving the ball less, as well as more negative moods and less fulfillment of fundamental needs, regardless of being excluded or included during the Cyberball game. In contrast, peer-reported victimization was associated with more negative mood and lower need fulfillment in the exclusion condition only. Together, these results suggest that children who themselves indicate being victimized have negatively distorted social cognition, whereas children who are being victimized according to their peers experience increased sensitivity to negative social situations. The results stress the importance of distinguishing between self-reported and peer-reported victimization and have implications for interventions aimed at victimized children's social cognition.

Mental Imagery-Based Training to Modify Mood and Cognitive Bias in Adolescents: Effects of Valence and Perspective

Mental imagery has a powerful impact on emotion and cognitive processing in adults, and is implicated in emotional disorders. Research suggests the perspective adopted in mental imagery modulates its emotional impact. However, little is known about the impact of mental imagery in adolescence, despite adolescence being the key time for the onset of emotional dysfunction. We administered computerised positive versus mixed valence picture-word mental imagery training to male adolescent participants (N = 60, aged 11–16 years) across separate field and observer perspective sessions. Positive mood increased more following positive than mixed imagery; pleasantness ratings of ambiguous pictures increased following positive versus mixed imagery generated from field but not observer perspective; negative interpretation bias on a novel scrambled sentences task was smaller following positive than mixed imagery particularly when imagery was generated from field perspective. These findings suggest positive mental imagery generation alters mood and cognition in male adolescents, with the latter moderated by imagery perspective. Identifying key components of such training, such as imagery perspective, extends understanding of the relationship between mental imagery, mood, and cognition in adolescence.

Cognitive styles and psychological functioning in rural South African school students: Understanding influences for risk and resilience in the face of chronic adversity

Adverse childhood experiences can show lasting effects on physical and mental health. Major questions surround how children overcome adverse circumstances to prevent negative outcomes. A key factor determining resilience is likely to be cognitive interpretation (how children interpret the world around them). The cognitive interpretations of 1025 school children aged 10-12 years in a rural, socioeconomically disadvantaged area of South Africa were examined using the Cognitive Triad Inventory for Children (CTI-C). These were examined in relation to psychological functioning and perceptions of the school environment. Those with more positive cognitive interpretations had better psychological functioning on scales of depression, anxiety, somatization and sequelae of potentially traumatic events. Children with more negative cognitions viewed the school-environment more negatively. Children living in poverty in rural South Africa experience considerable adversity and those with negative cognitions are at risk for psychological problems. Targeting children's cognitive interpretations may be a possible area for intervention.

A review of cognitive biases in youth depression: attention, interpretation and memory

Depression is one of the most common mental health problems in childhood and adolescence. Although data consistently show it is associated with self-reported negative cognitive styles, less is known about the mechanisms underlying this relationship. Cognitive biases in attention, interpretation and memory represent plausible mechanisms and are known to characterise adult depression. We provide the first structured review of studies investigating the nature and causal role of cognitive biases in youth depression. Key questions are (i) do cognitive biases characterise youth depression? (ii) are cognitive biases a vulnerability factor for youth depression? and (iii) do cognitive biases play a causal role in youth depression? We find consistent evidence for positive associations between attention and interpretation biases and youth depression. Stronger biases in youth with an elevated risk of depression support cognitive-vulnerability models. Preliminary evidence from cognitive bias modification paradigms supports a causal role of attention and interpretation biases in youth depression but these paradigms require testing in clinical samples before they can be considered treatment tools. Studies of memory biases in youth samples have produced mixed findings and none have investigated the causal role of memory bias. We identify numerous areas for future research in this emerging field.

Augmentation of Treatment As Usual with online Cognitive Bias Modification of Interpretation training in adolescents with Obsessive Compulsive Disorder: A pilot study

BACKGROUND AND OBJECTIVES

Cognitive Behavioral Therapy for children and adolescents with Obsessive Compulsive Disorder (OCD) is effective. However, since almost half of patients remain symptomatic after treatment, there remains room for improvement. Cognitive Bias Modification training of Interpretations (CBM-I) is a promising new intervention, as it targets misinterpretation of intrusions, which is seen as an important characteristic in OCD. To date, there have been no published studies of CBM-I in adolescents with OCD. The aim of the current pilot study was to examine the added value of online CBM-I training as an adjunctive treatment to the Treatment As Usual (TAU; that included CBT and pharmacotherapy) in adolescents with OCD.

METHODS

Patients receiving TAU were randomly assigned to either an additional CBM-I training (n = 9), or to an additional placebo variant of this procedure (n = 7).

RESULTS

Immediate, on-line interpretations changed in response to the CBM-I training, while no such effects were observed on slower retrospective off-line interpretations. Patients in the CBM-I training condition reported fewer obsessive compulsive symptoms after training, and clinicians rated them as having fewer obsessive symptoms (corresponding to medium-large effect sizes). No such changes were observed in the placebo group.

LIMITATIONS

The small sample size precludes strong conclusions and replication is necessary to test the robustness of the findings.

CONCLUSIONS

This small randomized controlled trial is suggestive, although not conclusive, regarding the promising additive value of OC-related CBM-I training as an adjunctive intervention to TAU in an adolescent clinical population.

Is cognitive bias modification training truly beneficial for adolescents?

BACKGROUND

Cognitive Bias Modification (CBM) has been shown to change interpretation biases commonly associated with anxiety and depression and may help ameliorate symptoms of these disorders. However, its evidence base for adolescents is scarce. Previous results have been hard to interpret because of methodological issues. In particular, many studies have used negative bias training as the control condition. This would tend to inflate any apparent benefits of CBM compared to a neutral control. Most studies also only examined the effects of a single training session and lacked follow-up assessment or ecologically valid outcome measures.

METHOD

Seventy-four adolescents, aged 16-18 years, were randomised to two sessions of CBM training or neutral control. Interpretation bias and mood were assessed three times: at baseline, immediately post-training and 1 week post-training. A controlled experimental stressor was also used, and responses to everyday stressors were recorded for 1 week after training to assess responses to psychological challenges. Feedback for the training programme was collected.

RESULTS

The CBM group reported a greater reduction in negative affect than control participants. However, other hypothesised advantages of CBM were not demonstrated. Regardless of training group, participants reported increased positive interpretations, decreased negative interpretations, reduced depressive symptoms and no change in trait anxiety. The two groups did not differ in their stress reactivity. After controlling for group differences in training performance, all the mood effects disappeared.

CONCLUSIONS

When tested under stringent experimental conditions the effects of CBM in healthy adolescents appear to be minimal. Future studies should concentrate on participants with elevated cognitive biases and/or mood symptoms who may be more sensitive to CBM.

Interpretation modification training reduces social anxiety in clinically anxious children

The present study was designed to examine the effects of training in positive interpretations in clinically anxious children. A total of 87 children between 7 and 12 years of age were randomly assigned to either a positive cognitive bias modification training for interpretation (CMB-I) or a neutral training. Training included 15 sessions in a two-week period. Children with an interpretation bias prior to training in the positive training group showed a significant reduction in interpretation bias on the social threat scenarios after training, but not children in the neutral training group. No effects on interpretation biases were found for the general threat scenarios or the non-threat scenarios. Furthermore, children in the positive training did not self-report lower anxiety than children in the neutral training group. However, mothers and fathers reported a significant reduction in social anxiety in their children after positive training, but not after neutral training. This study demonstrated that clinically anxious children with a prior interpretation bias can be trained away from negative social interpretation biases and there is some evidence that this corresponds to reductions in social anxiety. This study also highlights the importance of using specific training stimuli.

Practitioner Review: Cognitive bias modification for mental health problems in children and adolescents: a meta-analysis

BACKGROUND

Despite accumulating research and bold claims about the efficacy of cognitive bias modification (CBM) for young populations, no meta-analysis has attempted to synthesize the research literature so far. We examined whether there was empirical evidence for the clinical efficacy of CBM interventions in youths, while also considering the methodological quality of this evidence.

METHODS

Studies were identified through systematic searches in bibliographical databases (PubMed, PsychInfo, Cochrane Library and EMBASE to June 2014). We included randomized controlled trials of CBM interventions, and considered both clinical outcomes and targeted biases. We examined the quality of the trials, as well as potential publication bias and possible moderators.

RESULTS

We identified 23 trials that reported on four types of outcomes: mental health, anxiety, depression and bias. Effect sizes were small and nonsignificant for all symptom outcomes considered. We found a moderate significant effect size for bias outcomes (Hedges' g of 0.53), with significant heterogeneity. There were no differences between types of CBM interventions, or between one versus multiple-session applications. A small but significant effect size for mental health problems arose when the intervention was delivered in schools. The quality of almost all of the included studies was suboptimal and the vast majority did not include information needed for allowing quality assessment.

CONCLUSIONS

We conducted the first meta-analysis of CBM interventions for children and adolescents and found no effects for mental health outcomes, but we did find moderate and significant effects on the targeted biases. Our results cast serious doubts on CBM interventions having any clinical utility for nonadult populations. Demand characteristics might play an important part in CBM research.

Single-Session Cognitive Bias Modification of Interpretations Training in High-Anxious Adolescents

Anxiety disorders in youths are globally prevalent and carry impairing, long-lasting effects. Interpreting ambiguous cues negatively may be causally related to adolescent anxiety. Extending cognitive bias modification of interpretations (CBM-I) training, which counters anxiety by encouraging positive interpretations, to anxious adolescents could inform the design of new interventions. The study investigates whether single-session CBM-I training (a) altered interpretation biases and negative mood in adolescents selected for high anxiety and (b) whether these training-associated changes were larger than those reported in low-anxious adolescents. Seventy-seven Chinese adolescents received either positive or control training. Positive training encouraged endorsement of positive interpretations of ambiguous scenarios while on control training trials, half of the scenarios were resolved positively and half negatively. A single session of CBM-I altered interpretation biases across all individuals, F(1, 52) = 10.63, p < .01, η2 = .17. However, no training effects on mood measures emerged (all ps > .05). Training effects were not consistently moderated by baseline trait anxiety. Multisession CBM-I may be needed for mood changes to occur.

How to boost positive interpretations? A meta-analysis of the effectiveness of cognitive bias modification for interpretation

The current meta-analysis explores the strength of effects of cognitive bias modification training for interpretation bias (CBM-I) on positive (i.e., adaptive) interpretations and mood as well as the training and sample characteristics influencing these effects. Data-bases were searched with the key words “interpret* bias AND training” and “interpret* bias AND modif*”. Reference lists of identified articles were checked and authors of identified articles were contacted for further relevant articles and unpublished data. Studies were reviewed for inclusion with eligibility criteria being that the study (a) aimed to target interpretation biases through any kind of training, (b) assessed mood and/or interpretation bias as outcome measures, (c) allocated individuals to training conditions at random, and (d) recruited adult samples. A meta-analytic multilevel mixed-effects model was employed to assess standardized mean changes in interpretation bias, negative mood, and emotional reactivity. In addition, several training and sample characteristics were explored for their potential to enhance benign training effectiveness. On average, benign CBM-I resulted in an increase in positive interpretation bias (p<.01) and a decrease in negative mood state (p<.001), but did not affect emotional reactivity. These effects were not consistently different from control conditions with no or neutral training. However, within benign training conditions imagery instructions and more training sessions were related to larger cognitive and mood effects, whereas feedback about training performance and inclusion of non-benign training items (instead of including benign items only) boosted cognitive effects only. Finally, training was more effective in women (cognitive and mood effects) and presumably samples with symptomatic emotional dysregulation (cognitive effects). Although the effects of emotional dysregulation and number of training sessions could not well be distinguished, there is an indication that when used with imagery instructions and more training sessions, benign CBM-I can be employed as a useful complementary treatment to usual psychotherapies.

Optimizing the ingredients for imagery-based interpretation bias modification for depressed mood: is self-generation more effective than imagination alone?

Negative interpretation is thought to be crucial in the development and maintenance of depression. Recently developed cognitive bias modification paradigms, intending to change these biases towards a more optimistic interpretation tendency (CBM-I), seem to offer new promising implications for cognitive therapy innovation. This study aimed to increase our knowledge of the underlying mechanisms of action of imagery-based CBM-I in the context of depressed mood. We therefore compared the efficacy of CBM-I requiring participants to imagine standardized positive resolutions to a novel, more active training version that required participants to generate the positive interpretations themselves. Fifty-four participants were randomly allocated to (1) standardized CBM-I, (2) self-generation CBM-I or (3) a control group. Outcome measures included self-report mood measures and a depression-related interpretation bias measure. Both positive training variants significantly increased the tendency to interpret fresh ambiguous material in an optimistic manner. However, only the standardized imagery CBM-I paradigm positively influenced mood.

The role of peer rejection in adolescent depression

Adolescence is a period of major risk for depression, which is associated with negative personal, social, and educational outcomes. Yet, in comparison to adult models of depression, very little is known about the specific psychosocial stressors that contribute to adolescent depression, and whether these can be targeted by interventions. In this review, we consider the role of peer rejection. First, we present a comprehensive review of studies using innovative experimental paradigms to understand the role of peer rejection in adolescent depression. We show how reciprocal relationships between peer rejection and depressive symptoms across adolescence powerfully shape and maintain maladaptive trajectories. Second, we consider how cognitive biases and their neurobiological substrates may explain why some adolescents are more vulnerable to the effects of, and perhaps exposure to, peer rejection compared to others. Finally, we draw attention to emerging cognitive and functional magnetic resonance imaging-based neurofeedback training, which by modifying aspects of information processing may promote more adaptive responses to peer rejection. A better understanding of the mechanisms underlying adolescent depression may not only alleviate symptoms during a period of substantial developmental challenges, but may also reduce the burden of the disorder across the lifespan.

Efficacy of Interpretation Bias Modification in Depressed Adolescents and Young Adults

This study evaluated the efficacy of a four-session Cognitive Bias Modification-Interpretation program for 45 depressed adolescents and young adults (14-21 years old; 12 males, 33 females; Beck Depressive Inventory, Second Edition ≥ 14) randomized to an active intervention condition (repeated exposure to positive outcomes of depression-relevant ambiguous scenarios; n=23) or a control condition (n=22). Both conditions experienced reductions on a Test of Interpretation Bias at post-treatment, with no significant between-group differences. When limited to those with negative bias at baseline, the intervention group showed greater improvement in interpretation bias at mid- and post-treatment. In addition, the intervention group overall had greater improvements in self-reported negative cognitions than the control group at post-intervention and two-week follow-up. However, there were no differences between groups in depression or anxiety symptom change. Potential factors contributing to mixed findings are discussed.

The use of cognitive bias modification and imagery in the understanding and treatment of depression

Cognitive models of depression form the natural link between neurobiological and social accounts of the illness. Interest in the role of cognition in depression has recently been stimulated by the advent of simple, computer-based "cognitive bias modification" (CBM) techniques which are able to experimentally alter cognitive habits in clinical and non-clinical populations. In this chapter, we review recent work which has used CBM techniques to address questions of aetiology and treatment in depression with a particular focus on the interface with neurobiological and social processes relevant to the illness. We find that there are early signs that CBM may be a useful tool in exploring the aetiology of depression, particularly in regard to the neural and genetic factors which influence susceptibility to the illness and response to treatment. There is also early evidence suggesting that CBM has promise in the treatment and prevention of depression. This work suggests that the beneficial effects of CBM are mediated by the interaction between cognitive functioning and environmental and social information. In summary, by providing a method for altering habitual cognitive function in experimental and clinical settings CBM techniques have begun to further the understanding of and the treatment for depression.

Mental imagery, emotion and psychopathology across child and adolescent development

Mental imagery-based interventions are receiving increasing interest for the treatment of psychological disorders in adults. This is based on evidence that mental imagery potently influences the experience of emotion in non-clinical samples, and that a number of psychological disorders are marked by syndrome-specific, distressing abnormalities in mental imagery. During childhood and adolescence, neurocognitive development impacting mental imagery processes may moderate its relationship with clinically-relevant emotional symptoms at a number of potential loci. Crucially, these changes could impact vulnerability to distressing mental imagery and the efficacy of mental imagery-based clinical interventions. This review synthesises evidence pertaining to developmental changes in the role and content of mental imagery, and in the cognitive sub-processes required to generate and sustain mental images. Subsequently, we discuss implications for understanding the developmental relationship between mental imagery, emotion and psychopathology. Translational cognitive neuroscience research investigating the content, emotional impact and neurocognitive substrates of mental imagery across development may reveal insights into trajectories of vulnerability to symptoms of a number of psychological disorders. If proper consideration is given to developmental factors, techniques based on mental imagery may be valuable as part of a treatment armoury for child and adolescent clinical populations and those at risk of emotional disorders.

Cognitive bias modification training in adolescents reduces anxiety to a psychological challenge

Many anxiety disorders begin in adolescence. Early interventions that target adolescent anxiety may prevent later disabling consequences. Previous studies show that cognitive bias modification training can generate positive interpretative styles of ambiguous information in adolescents but effects on anxious mood reduction are less clear. Adult studies suggest more consistent training effects on mood when assessed in response to a psychological challenge. Here, we assess whether positive training reduces adolescent anxious responses to a laboratory stressor. A total of 40 adolescents were randomly assigned to positive or negative computerised training. During training, ambiguous scenarios were resolved positively or negatively. After training, adolescents completed a test of interpretation bias and a difficult mental arithmetic task while believing that they were being videotaped for teaching purposes. First, positively-trained adolescents endorsed more positive and fewer negative interpretations of new ambiguous situations than negatively-trained adolescents. Second, positively-trained adolescents also showed attenuated anxiety levels after but not before the challenge. Induced positive interpretations via computerised cognitive training may modify anxious responsivity. Although there are some caveats to these data, in general they justify extensions of computerised training to adolescents with clinical anxiety, to reduce anxious responsivity.