Investigating the genetic and environmental bases of biases in threat recognition and avoidance in children with anxiety problems

Anxiety disorders in children and adolescents: A summary and overview of the literature

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Understanding anxiety symptoms as aberrant defensive responding along the threat imminence continuum

Threat-anticipatory defensive responses have evolved to promote survival in a dynamic world. While inherently adaptive, aberrant expression of defensive responses to potential threat could manifest as pathological anxiety, which is prevalent, impairing, and associated with adverse outcomes. Extensive translational neuroscience research indicates that normative defensive responses are organized by threat imminence, such that distinct response patterns are observed in each phase of threat encounter and orchestrated by partially conserved neural circuitry. Anxiety symptoms, such as excessive and pervasive worry, physiological arousal, and avoidance behavior, may reflect aberrant expression of otherwise normative defensive responses, and therefore follow the same imminence-based organization. Here, empirical evidence linking aberrant expression of specific, imminence-dependent defensive responding to distinct anxiety symptoms is reviewed, and plausible contributing neural circuitry is highlighted. Drawing from translational and clinical research, the proposed framework informs our understanding of pathological anxiety by grounding anxiety symptoms in conserved psychobiological mechanisms. Potential implications for research and treatment are discussed.

A gene-environment cascade theoretical framework of developmental psychopathology

Previous theories have emphasized genetic effects "inside the skin" via endophenotypes within the broader developmental psychopathology theory. Expanding on the mechanisms of gene-environment correlation, we propose a new integrative framework emphasizing how genetic effects "outside the skin" (Reiss & Leve, 2007) accumulate due to individual variation in social information processing in negative environments and sociocultural contexts as part of developmental cascades to psychopathology. In this gene-environment cascade theoretical framework, genetic predisposition for psychopathology, as well as stable traits and behaviors, can lead to negative environments via gene-environment correlations that can be exacerbated or buffered by an individual's social information processing. Moreover, these "environments" range from dyadic social relationships to broader sociocultural contexts. Over time, these processes exacerbate one another as part of developmental cascades, resulting in accumulating risk for psychopathology. By focusing on gene-environment correlations and integrating disparate social-emotional, cognitive, and sociocultural research domains, this framework delineates key processes by which early genetic predisposition can contribute to developmentally distinct and accumulating risk for psychopathology over the life course. Implications for intervention and methodological advances that facilitate testing models are presented. This new framework moves the field further away from genetic determinism by informing targets of early psychosocial prevention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Reduction of costly safety behaviors after extinction with a generalization stimulus is determined by individual differences in generalization rules

Exposure-based treatment involves repeated presentation of feared stimuli or situations in the absence of perceived threat (i.e., extinction learning). However, the stimulus or situation of fear acquisition (CS+) is highly unlikely to be replicated and presented during treatment. Thereby, stimuli that resemble the CS+ (generalization stimuli; GSs) are typically presented. Preliminary evidence suggests that depending on how one generalizes fear (i.e., different generalization rules), presenting the same GS in extinction leads to differential effectiveness of extinction learning. The current study aimed to extend this finding to safety behaviors. After differential fear and avoidance conditioning, participants exhibited discrete generalization gradients that were consistent with their reported generalization rules (Similarity vs Linear). The Linear group showed stronger safety behaviors to a selected GS compared to the Similarity group, presumably due to higher threat expectancy. After extinction learning to this GS, the Linear group exhibited stronger reduction in safety behaviors generalization compared to the Similarity group. The results show that identifying distinct generalization rules allows one to predict expectancy violation to the extinction stimulus, in addition to corroborating the idea that strongly violating threat expectancy leads to better extinction learning and its generalization. With regard to clinical implications, identifying one's generalization rule (e.g., threat beliefs) help designing exposure sessions that evoke strong expectancy violation, enhancing the reduction in the generalization of maladaptive safety behaviors.

The role of anxiety and gender in anticipation and avoidance of naturalistic anxiety-provoking experiences during adolescence: An ecological momentary assessment study

Objective

Anxiety symptoms often increase in late childhood/early adolescence, particularly among girls. However, few studies examine anxiety-relevant gender differences during anticipation and avoidance of naturalistic experiences during adolescence. The current study uses ecological momentary assessment (EMA) to examine associations among clinical anxiety, gender, anticipation, and attempted avoidance of person-specific anxiety-provoking experiences in youth ages 8-18.

Method

124 youth (73 girls) completed 7 consecutive days of EMA. Seventy participants (42 girls) met criteria for one or more anxiety disorders, while the remaining 54 were healthy controls (31 girls). Participants reported the experience that they were "most worried about happening that day" and completed ratings about that event including whether they attempted to avoid that experience. Multilevel models examined whether diagnostic group (anxious, healthy), gender (boys, girls), or their interaction predicted anticipatory ratings or avoidance of these experiences.

Results

Analyses revealed significant diagnostic group by gender interactions for anticipatory ratings. Specifically, anxious girls reported greater worry and predicted more negative outcomes related to future experiences. However, only a main effect of diagnostic group emerged for attempted avoidance. Finally, anticipatory worry predicted higher rates of attempted avoidance, but this association did not vary by diagnostic group, gender, or their interaction.

Conclusion

These findings extend the literature on the interplay of anticipation and avoidance to person-specific naturalistic experiences in pediatric anxiety. They reveal that anxious girls report more anticipatory anxiety and worry, while avoidance of real-world anxiety-provoking scenarios is a key concern for anxious youth independent of gender. By using EMA to examine person-specific anxiety-inducing experiences we can begin to understand how these processes and experiences unfold in the real world.

Fear learning, avoidance, and generalization are more context-dependent for adults than adolescents

This study examined developmental differences in contextual and perceptual generalization of fear and avoidance learning. Adults (N = 39) and adolescents (N = 44) completed differential fear acquisition wherein each conditional stimulus (CS) appeared in a background context. In the dangerous context, one stimulus (CS+) predicted an aversive sound, and the other stimulus (CS-) did not. In the safe context, the aversive sound was never administered with either CS. During fear generalization, participants were presented with three generalization stimuli (GSs), ranging on a perceptual continuum from threat to safety stimuli, in both contexts. Participants then completed avoidance conditioning and avoidance generalization phases, allowing them to actively avoid the upcoming aversive sound by pressing an avoidance button. Developmental differences emerged in threat perception, physiological arousal, avoidance behavior, and eye movements during contextual fear learning and generalization. Adolescents showed less discrimination between stimuli and contexts than adults, resulting primarily from their elevated fear responses to safety and generalized stimuli. Developmental differences in fear learning should be further explored in future research, as they could explain why adolescence is a sensitive developmental period for anxiety.

High avoidance despite low fear of a second-order conditional stimulus

This study examined avoidance learning using a second-order threat conditioning paradigm. Participants completed fear acquisition wherein a second-order threat cue (preCS+) was paired with a threat cue (CS+) followed by an aversive sound (US); another stimulus was never associated with the US (CS-). During avoidance conditioning, participants could press a button when the preCS + or the CS- was presented, preventing upcoming events. During response prevention and extinction, the avoidance button was removed. Avoidance persistence was then examined in the absence of the actual threat. Results revealed that although the preCS+ and CS- elicited low levels of fear following Pavlovian fear acquisition, during avoidance conditioning, participants showed more avoidance of the preCS+ than the CS-. They also reported the preCS+ as more dangerous than the CS-. Following extinction, participants returned to actively avoid the preCS+ and rated it as more dangerous than the CS-. Finally, the association between avoidance learning and persistence of avoidance was mediated by self-reported threat expectancy during extinction. Our findings suggest avoidance behavior can be triggered by low levels of experienced fear, and this avoidance may play a role in the development and maintenance of threat beliefs.

Executive functioning, adaptive skills, emotional and behavioral profile: A comparison between autism spectrum disorder and phenylketonuria

INTRODUCTION

Influential theories maintain that some of Autism Spectrum Disorder (ASD) core symptoms may arise from deficits in executive functions (EF). EF deficits are also considered a neuropsychological marker of early treated individuals with phenylketonuria (PKU). Aims of this study were: to verify the occurrence and patterns of specific EF impairments in both clinical groups; to explore the coexistence of EF alterations with adaptive, behavioral and emotional problems in each clinical condition.

MATERIAL AND METHODS

We assessed EF, adaptive, behavioral and emotional profile in 21 participants with ASD, 15 early treated PKU individuals, comparable for age and IQ, and 14 controls, comparable for age to the clinical groups (age range: 7-14 years).

RESULTS

ASD and PKU participants presented two different, but partially overlapping patterns of EF impairment. While ASD participants showed a specific deficit in cognitive flexibility only, PKU individuals showed a more extensive impairment in EF with a weaker performance in two core EF domains (inhibition, cognitive flexibility) as compared to healthy controls. Psychological and adaptive profile was typical in PKU participants, while ASD participants experienced behavioral (externalizing symptoms), emotional (internalizing symptoms) and adaptive disorders (general, practical, social domains).

CONCLUSIONS

Present results support the view of a relative disengagement of adaptive and emotional-behavioral profile with respect to EF skills and suggest that other dysfunctions contribute to the multidimensional phenotype of ASD participants.

An Embodied Neurocomputational Framework for Organically Integrating Biopsychosocial Processes: An Application to the Role of Social Support in Health and Disease

OBJECTIVE

Two distinct perspectives-typically referred to as the biopsychosocial and biomedical models-currently guide clinical practice. Although the role of psychosocial factors in contributing to physical and mental health outcomes is widely recognized, the biomedical model remains dominant. This is due in part to (a) the largely nonmechanistic focus of biopsychosocial research and (b) the lack of specificity it currently offers in guiding clinicians to focus on social, psychological, and/or biological factors in individual cases. In this article, our objective is to provide an evidence-based and theoretically sophisticated mechanistic model capable of organically integrating biopsychosocial processes.

METHODS

To construct this model, we provide a narrative review of recent advances in embodied cognition and predictive processing within computational neuroscience, which offer mechanisms for understanding individual differences in social perceptions, visceral responses, health-related behaviors, and their interactions. We also review current evidence for bidirectional influences between social support and health as a detailed illustration of the novel conceptual resources offered by our model.

RESULTS

When integrated, these advances highlight multiple mechanistic causal pathways between psychosocial and biological variables.

CONCLUSIONS

By highlighting these pathways, the resulting model has important implications motivating a more psychologically sophisticated, person-specific approach to future research and clinical application in the biopsychosocial domain. It also highlights the potential for quantitative computational modeling and the design of novel interventions. Finally, it should aid in guiding future research in a manner capable of addressing the current criticisms/limitations of the biopsychosocial model and may therefore represent an important step in bridging the gap between it and the biomedical perspective.

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.

Attentional avoidance of fearful facial expressions following early life stress is associated with impaired social functioning

BACKGROUND

Early life stress is associated with poorer social functioning. Attentional biases in response to threat-related cues, linked to both early experience and psychopathology, may explain this association. To date, however, no study has examined attentional biases to fearful facial expressions as a function of early life stress or examined these biases as a potential mediator of the relation between early life stress and social problems.

METHODS

In a sample of 154 children (ages 9-13 years) we examined the associations among interpersonal early life stressors (i.e., birth through age 6 years), attentional biases to emotional facial expressions using a dot-probe task, and social functioning on the Child Behavior Checklist.

RESULTS

High levels of early life stress were associated with both greater levels of social problems and an attentional bias away from fearful facial expressions, even after accounting for stressors occurring in later childhood. No biases were found for happy or sad facial expressions as a function of early life stress. Finally, attentional biases to fearful faces mediated the association between early life stress and social problems.

CONCLUSIONS

Attentional avoidance of fearful facial expressions, evidenced by a bias away from these stimuli, may be a developmental response to early adversity and link the experience of early life stress to poorer social functioning.

Psychophsyiological reactivity during uncertainty and ambiguity processing in high and low worriers

BACKGROUND AND OBJECTIVES

Intolerance of uncertainty (IU) has been linked to Generalized Anxiety Disorder (GAD), but studies experimentally manipulating uncertainty have mostly failed to find differences between GAD patients and controls, possible due to a lack of distinction between uncertainty and ambiguity. This study therefore investigated reactivity to ambiguity in addition to uncertainty in high worriers (HW) and low worriers (LW). We hypothesized an interpretation bias between the groups during ambiguity tasks, while uncertainty would facilitate threat processing of subsequent aversive stimuli.

METHODS

HW (N = 23) and LW (N = 23) completed a paradigm comprising the anticipation and perception of pictures with dangerous, safe, or ambiguous content. Anticipatory cues were certain (always correct information about the following picture) or uncertain (no information). Subjective ratings, reaction times and skin conductance responses (SCRs) were recorded.

RESULTS

HW rated particularly ambiguous pictures as more aversive and showed longer reaction times to all picture conditions compared to LW. SCRs were also larger in HW compared to LW, particularly during uncertain but also safe anticipation. No group differences were observed during perception of stimuli.

LIMITATIONS

All participants were female. HW was used as subclinical phenotype of GAD.

CONCLUSIONS

Intolerance of ambiguity seems to be related to individual differences in worry and possibly to the development of GAD. Threat-related interpretations differentiating HW and LW occurred particularly for ambiguous pictures but were not accompanied by increased autonomic arousal during the picture viewing. This disparity between subjective rating and arousal may be the result of worrying in response to intolerance of uncertainty, restraining physiological responses.

Memory cueing during sleep modifies the interpretation of ambiguous scenes in adolescents and adults

The individual tendency to interpret ambiguous situations negatively is associated with mental disorders. Interpretation biases are already evident during adolescence and due to the greater plasticity of the developing brain it may be easier to change biases during this time. We investigated in healthy adolescents and adults whether stabilizing memories of positive or negative scenes modulates the later interpretation of similar scenes. In the evening, participants learnt associations between ambiguous pictures and words that disambiguate the valence of the pictures in a positive or negative direction. Half of the words were acoustically presented (i.e. cued) during post-learning sleep which is known to benefit memory consolidation by inducing reactivation of learned information. Cued compared to un-cued stimuli were remembered better the next morning. Importantly, cueing positively disambiguated pictures resulted in more positive interpretations whereas cueing negatively disambiguated pictures led to less positive interpretations of new ambiguous pictures with similar contents the next morning. These effects were not modulated by participants' age indicating that memory cueing was as efficient in adolescents as in adults. Our findings suggest that memory cueing during sleep can modify interpretation biases by benefitting memory stabilization and generalization. Implications for clinical settings are discussed.

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.

Impaired Facial Affect Perception in Unaffected Children at Familial Risk for Panic Disorder

Recent studies suggest that impaired processing of facial affect has a familial component and may reflect a marker of liability to psychopathology. This study investigated whether facial affect processing is impaired in offspring with parental panic disorder (PD). Psychiatrically healthy children with parental PD (n = 51) and age and sex matched control children with no parental psychopathology (n = 51) completed a standard facial recognition task. High-risk children made more errors recognizing fearful faces than controls and misattributed fear and angry facial affect as surprised. High-risk females also made more errors recognizing sad faces compared to low risk females and misattributed sadness as fear. No difference emerged for self-rated anxiety while viewing facial expressions. However, self-rated anxiety correlated moderately with misrecognition of fearful facial affect in high-risk children. Overall, our data suggest that the ability to correctly recognize negative facial emotions is impaired in children with parental PD. Further research is needed to confirm if these deficits represent a trait marker of liability for PD and elucidate the contribution of genetic and family environmental influences.

Conduct disorder and callous-unemotional traits in youth

The term “conduct problems” refers to a pattern of repetitive rule-breaking behavior, aggression, and disregard for others. Such problems have received increased attention recently, owing to violent events perpetrated by youth and modifications in the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for conduct disorder, a syndrome involving recurrent conduct problems in children and adolescents. Youth conduct problems are predictive of an increased risk of substance abuse, criminal behavior, and educational disruption; they also incur a considerable societal burden from interpersonal suffering and financial costs. This review summarizes current data on youth conduct problems and highlights promising avenues for research. Prior reviews have summarized either the clinical literature on outcome, treatment, and familial aggregation or the neurocognitive literature on mechanisms and pathophysiology.^– The current review differs by more tightly integrating clinical and neurocognitive perspectives.

The association between social cognition and executive functioning and symptoms of anxiety and depression in adolescents with autism spectrum disorders

While high levels of anxiety and depression are now recognized as major co-occurring problems in children and young people with an autism spectrum disorder (ASD), research examining possible associations with individual differences in neurocognitive functioning has been limited. This study included 90 adolescents with an ASD aged 14-16 years with a full-scale IQ > 50. Using structural equation modeling, we examined the independent relationships between multiple measures of executive functioning and social cognition on severity of anxiety or depressive symptoms. Results indicated a significant association between poorer executive functioning and higher levels of anxiety, but not depression. In contrast, social cognition ability was not associated with either anxiety or depression. This study is the first to report significant associations between executive functions and anxiety in ASD. This may suggest that poor executive functioning is one factor associated with the high prevalence of anxiety disorder in children and adolescents with ASD.

Reducing negative interpretations in adolescents with anxiety disorders: a preliminary study investigating the effects of a single session of cognitive bias modification training

Anxiety disorders are globally prevalent, debilitating and onset in early life. Cognitive bias modification of interpretations (CBM-I) training has emerged as a targeted intervention for early emerging anxiety problems. While CBM-I can alter interpretational styles in unselected and clinical-analogue samples of adolescents, no studies have assessed its capacity to change biases in clinical samples. Here, we assessed training efficacy in ameliorating interpretation biases and anxious mood in adolescents with anxiety disorders. Twenty-eight Chinese adolescents meeting criteria for a current anxiety disorder were randomly assigned to receive positive or neutral CBM-I training. Training involved completing a word-fragment to resolve the outcomes of sixty ambiguous scenarios. During positive training, scenarios ended with benign/positive resolutions, but during neutral training, half of the scenarios were resolved positively and half negatively. Positively trained patients interpreted new ambiguous scenarios less negatively than the neutral training group although training effects were not observed on a questionnaire measure of interpretation bias. Training effects on mood were also absent. Before the clinical implications of CBM-I can be considered in adolescents, research needs to establish optimal training parameters for symptom-changes to occur.

The relationship between attentional bias and anxiety in children and adolescents with autism spectrum disorders

Young people with an autism spectrum disorder (ASD) are more likely to have heightened levels of anxiety compared with their typically developing (non-ASD) peers. The reasons for this are poorly understood, and there has been little research investigating the cognitive correlates of anxiety in individuals with ASD. Typically developing youth with anxiety disorders have frequently been found to show an attentional bias toward threatening information. In this study, we examined whether such a bias was also found in young people with ASD and anxiety symptoms. The protocol utilized two versions of the dot-probe paradigm, the first with emotional faces and the second with emotional words. Participants comprised 38 boys with an ASD and 41 typically developing controls aged 10-16 years of age. Those with an ASD displayed higher levels of parent- and child-rated anxiety (both P < 0.001) and depression (P < 0.001) compared with controls. However, there were no significant group differences in attentional bias scores and no significant relationship between anxiety and attentional bias in either the face or word tasks, for either group. Our findings suggest that, for young people with ASD, unlike non-ASD individuals with an anxiety disorder, high levels of anxiety may not be associated with attentional bias to threat. This may indicate that anxiety in ASD has different cognitive correlates from anxiety in the typically developing population. Further conclusions, study limitations, and future directions are discussed.