Perceived acceptability and appropriateness of a web-based program targeting risk for anxiety in young children and their parents.

OBJECTIVE: This mixed-methods study examined perceived acceptability and appropriateness of a novel digital mental health program targeting anxiety risk (i.e., perfectionism or error sensitivity) in 5-to-7-year-old children and their parents. METHODS: Parent-child dyads participated in a modular, web-based cognitive-behavioral program targeting negative overreactions to making mistakes. The program, "Making Mistakes", consisted of a 6-month series of short video clips, journaling activities, and weekly reminders, and modules were delivered to caregivers and children separately. 86 dyads completed self-report measures, 18 of whom participated in semi-structured interviews, following completion of the primary program module. A standard thematic analysis was used to elucidate themes from the parent and child interview content. RESULTS: Our quantitative and qualitative results were generally aligned. Children and parents viewed the novel digital mental health program as acceptable and appropriate, favoring the cognitive behavioral strategies such as modeling positive reactions to mistakes, responding positively to child mistakes, and emphasizing effort over outcome. Participants also provided helpful feedback related to program content, delivery, and engagement, as well as suggestions to enhance the program. CONCLUSIONS: Findings have implications for design and content features of parent-based and dyad-based programs, as well as digital mental health programs focused on reducing anxiety risk.

The impact of punishment on error-related brain activity in children.

The error-related negativity (ERN) is sensitive to individual differences relating to anxiety and is modulated by manipulations that increase the threat-value of committing errors. In adults, the ERN magnitude is enhanced when errors are followed by punishment, especially among anxious individuals. Punitive parenting is related to an elevated ERN in children; however, the effects of task-based punishment on the ERN in children have yet to be understood. Furthermore, there is a need to assess developmental periods wherein the ERN might be especially prone to modulation by punishment. We examined the impact of punishment on the ERN in a sample of children and assessed whether the impact of punishment on the ERN was moderated by age and anxiety. Punishment potentiated the ERN in children, especially among higher trait-anxious individuals; the punishment potentiation of the ERN was also associated with older age. The interaction between child age and anxiety symptoms did not significantly predict the punishment potentiation of the ERN; however, both child age and anxiety symptoms uniquely predicted the punishment potentiation of the ∆ERN. Anxious children may be especially prone to punishment-related alterations in error monitoring, and the impact of punishment on the ERN may become more pronounced as children age.

Error-related negativity predicts increases in anxiety in a sample of clinically anxious female children and adolescents over 2 years.

BACKGROUND: An increased neural response to making errors has emerged as a biomarker of anxiety. Error negativity (Ne) or errorrelated negativity (ERN) is an event-related potential generated when people commit errors; the Ne/ERN is greater among people with anxiety and predicts increases in anxiety. However, no previous study has examined whether the Ne/ERN can be used as a prognostic indicator among people with current anxiety. The present study addressed this gap by examining whether the Ne/ERN prospectively predicts increases in anxiety symptoms in clinically anxious children and adolescents. METHODS: The sample included 34 female participants between the ages of 8 and 14 years who met the criteria for a clinical anxiety disorder based on clinical interview. The Ne/ERN was measured using a flanker task. RESULTS: Increased Ne/ERN at baseline predicted increases in total anxiety symptoms 2 years later, even when accounting for baseline symptoms. The Ne/ERN predicted increases in the symptom domains of generalized anxiety, social anxiety and harm avoidance/perfectionism, but not panic, separation anxiety, school avoidance or physical symptoms. LIMITATIONS: The sample size was small, which may have inflated the false discovery rate. To mitigate this possibility, we used multiple self-report measures, and the results for the 2 measures (as well as their symptom domains) converged. CONCLUSION: These data suggest that the Ne/ERN can delineate specific risk trajectories, even among those who already meet the criteria for a clinical anxiety disorder. Considering the need for prognostic markers among people with clinical anxiety, the current findings are an important and novel extension of previous work.

Psychometric properties of threat-related attentional bias in young children using eye-tracking.

Anxiety is one of the most common forms of child psychopathology associated with persistent impairment across the lifespan. Therefore, investigating mechanisms that underlie anxiety in early childhood may improve prevention and intervention efforts. Researchers have linked selective attention toward threat (i.e., attentional bias to threat) with the development of anxiety. However, previous work on attentional bias has used less reliable, reaction time (RT)-based measures of attention. Additionally, few studies have used eye-tracking to measure attentional bias in young children. In the present study, we investigated the psychometric properties of an eye-tracking measure of attentional bias in a sample of young children between 6- and 9-years-old and explored if trait and clinical anxiety were related to attentional biases to threat. Results showed good psychometric properties for threat and neutral attentional biases, comparable to those found in adult eye-tracking studies. Temperamental and clinical anxiety did not significantly relate to threat/neutral dwell time and attentional biases. The significance of these null findings was discussed in relation to existing developmental theories of attentional biases. Future studies should explore if temperamental or clinical anxiety prospectively predict threat attentional bias and the onset of anxiety in older children using a longitudinal design.

COVID-related fear maintains controlling parenting behaviors during the pandemic.

The direct threat posed by the 2019 novel coronavirus (COVID-19), uncertainty surrounding best safety practices, and secondary consequences of the virus have led to widespread stress and declining mental health across communities and individuals. These stresses may impact parenting behaviors, potentially leading to negative consequences for children. Controlling parenting behaviors increase in the face of perceived environmental threat and are associated with adverse mental health outcomes for children; however, determinants of parenting behaviors have not been investigated during the COVID-19 pandemic. The current study prospectively evaluated parenting behaviors during the pandemic (N=87). Results indicated that all negative affect emotions investigated were positively associated with controlling parenting behaviors. However, only COVID-related fear predicted changes in controlling parenting behaviors across timepoints. Specifically, although controlling parenting behaviors decreased in the overall sample from time 1 to time 2, higher COVID-related fear scores at time 1 predicted maintenance of high levels of controlling parenting behaviors at time 2. Additionally, this effect was specific to controlling, as opposed to more adaptive, parenting behaviors. Future studies should investigate the association between parents' COVID-related fear, controlling parenting behaviors, and adverse mental health outcomes for children in the context of the COVID-19 pandemic.

A brief, computerized intervention targeting error sensitivity reduces the error-related negativity.

Research has identified the neural response to errors (the error-related negativity; ERN) as a marker of current anxiety, as well as risk for future anxiety. Previous work found that traditional cognitive behavioral therapy approaches do not impact the ERN. However, none of these approaches directly target the psychological constructs linked to an increased ERN (e.g., error sensitivity). In the current study, we examine the extent to which a brief, computerized intervention ("Treating the ERN"; i.e., TERN) might impact the ERN by reducing error sensitivity. Results suggest that TERN reduced the ERN and that the impact of the intervention was larger amongst individuals with an increased baseline ERN. This study is an important first step in the development of a novel intervention approach that directly targets error sensitivity, and thereby the ERN.

The Utility of Event-Related Potentials in Clinical Psychology.

Event-related potentials (ERPs) are direct measures of brain activity that can be leveraged for clinically meaningful research. They can relate robustly both to continuous measures of individual difference and to categorical diagnoses in ways that clarify similarities and distinctions between apparently related disorders and traits. ERPs can be linked to genetic risk, can act as moderators of developmental trajectories and responses to stress, and can be leveraged to identify those at greater risk for psychopathology, especially when used in combination with other neural and self-report measures. ERPs can inform models of the development of, and risk for, psychopathology. Finally, ERPs can be used as targets for existing and novel interventions and prevention efforts. We provide concrete examples for each of these possibilities by focusing on programmatic research on the error-related negativity and anxiety, and thus show that ERPs are poised to make greater contributions toward the identification, prediction, treatment, and prevention of mental disorders.

Parenting style moderates the effects of exposure to natural disaster-related stress on the neural development of reactivity to threat and reward in children.

Little is known about the effect of natural disasters on children's neural development. Additionally, despite evidence that stress and parenting may both influence the development of neural systems underlying reward and threat processing, few studies have brought together these areas of research. The current investigation examined the effect of parenting styles and hurricane-related stress on the development of neural reactivity to reward and threat in children. Approximately 8 months before and 9 months after Hurricane Sandy, 74 children experiencing high and low levels of hurricane-related stress completed tasks that elicited the reward positivity and error-related negativity, event-related potentials indexing sensitivity to reward and threat, respectively. At the post-Hurricane assessment, children completed a self-report questionnaire to measure promotion- and prevention-focused parenting styles. Among children exposed to high levels of hurricane-related stress, lower levels of promotion-focused, but not prevention-focused, parenting were associated with a reduced post-Sandy reward positivity. In addition, in children with high stress exposure, greater prevention-focused, but not promotion-focused, parenting was associated with a larger error-related negativity after Hurricane Sandy. These findings highlight the need to consider contextual variables such as parenting when examining how exposure to stress alters the development of neural reactivity to reward and threat in children.

A neural biomarker, the error-related negativity, predicts the first onset of generalized anxiety disorder in a large sample of adolescent females.

OBJECTIVE: An increased neural response to making mistakes has emerged as a potential biomarker of anxiety across development. The error-related negativity (ERN) is an event-related potential elicited when people make mistakes on simple laboratory-based reaction time tasks that has been associated with risk for anxiety. This study examined whether the ERN prospectively predicted the first onset of generalized anxiety disorder (GAD) over 1.5 years in adolescent girls. METHODS: The sample included 457 girls between the ages of 13.5 and 15.5 years, with no history of GAD. At baseline, the ERN was measured using a flankers task. Psychiatric history of the adolescent and biological parent was assessed with diagnostic interviews, and the adolescent completed a self-report questionnaire regarding anxiety symptoms. Approximately 1.5 years later, adolescents completed the same interview. RESULTS: An increased neural response to errors at baseline predicted first-onset GAD over 1.5 years. The ERN was a significant predictor independent of other prominent risk factors, including baseline anxiety and depression symptoms and parental lifetime psychiatric history. Jointly the ERN and social anxiety symptoms provided the greatest power for predicting first-onset GAD. CONCLUSIONS: This study provides evidence for the utility of the ERN as a biomarker of risk for GAD during a key developmental period.

Examining the relationships between error-related brain activity (the ERN) and anxiety disorders versus externalizing disorders in young children: Focusing on cognitive control, fear, and shyness.

OBJECTIVE: We examine the relationship between individual differences in temperament (cognitive control, fear, and shyness) and the error-related negativity (i.e., the ERN) in a large sample of young children. Furthermore, we explore to what extent variation in temperament may underlie the associations between the ERN and anxiety disorders versus externalizing disorders. METHOD: Using the Children's Behavior Questionnaire (CBQ), we focus on scales related to cognitive control (attentional focusing, attentional shifting, and inhibitory control) and a fearful/anxious temperament (fearfulness and shyness). We use diagnostic interviews to assess anxiety (specific phobia, separation anxiety disorder, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, and agoraphobia) and externalizing disorders (attention deficit hyperactivity disorder; ADHD, and oppositional defiant disorder; ODD). A go/no-go task was used to measure the ERN. RESULTS: Results suggest that while shyness was related to an increased ERN, fearfulness was associated with a decreased ERN. Moreover, increased cognitive control was related to an increased ERN, and an exploratory model suggested that while shyness displayed an independent relationship with the ERN, the relationship between fear and the ERN was accounted for by deficits in cognitive control. Additionally, we found that the ERN was increased in children with anxiety disorders, and that this association was explained by shyness, but not fear or cognitive control. In contrast, the ERN was blunted in children with externalizing disorders (ADHD or ODD), and this association was accounted for by lower levels of both shyness and cognitive control. CONCLUSIONS: Overall, these results are novel insofar as they suggest that the temperamental factors of shyness and cognitive control may underlie the associations between the ERN and internalizing versus externalizing disorders.

A genetic variant brain-derived neurotrophic factor (BDNF) polymorphism interacts with hostile parenting to predict error-related brain activity and thereby risk for internalizing disorders in children.

The error-related negativity (ERN) is a negative deflection in the event-related potential occurring when individuals make mistakes, and is increased in children with internalizing psychopathology. We recently found that harsh parenting predicts a larger ERN in children, and recent work has suggested that variation in the brain-derived neurotrophic factor (BDNF) gene may moderate the impact of early life adversity. Parents and children completed measures of parenting when children were 3 years old (N = 201); 3 years later, the ERN was measured and diagnostic interviews as well as dimensional symptom measures were completed. We found that harsh parenting predicted an increased ERN only among children with a methionine allele of the BDNF genotype, and evidence of moderated mediation: the ERN mediated the relationship between parenting and internalizing diagnoses and dimensional symptoms only if children had a methionine allele. We tested this model with externalizing disorders, and found that harsh parenting predicted externalizing outcomes, but the ERN did not mediate this association. These findings suggest that harsh parenting predicts both externalizing and internalizing outcomes in children; however, this occurs through different pathways that uniquely implicate error-related brain activity in the development of internalizing disorders.

Maternal Depression Is Related to Reduced Error-Related Brain Activity in Child and Adolescent Offspring.

Chronic parental depression is associated with an increased likelihood of depression in offspring. One mechanism by which parental depression may increase risk is through physiological or cognitive tendencies in offspring. Error processing has been studied using the error-related negativity (ERN), an event-related potential that occurs around the time someone commits an error, and has previously been shown to be heritable and blunted in depressed individuals. The current study examined the ERN as a potential biomarker of risk in a sample of never-depressed children whose mothers had a history of recurrent major depressive disorder (MDD), a single episode of MDD, or no lifetime history of any mood disorder. Seventy-eight mother-child dyads participated. The average age for children was 13.13 years (SD = 2.07) and 50% were female. Diagnostic interviews and self-report questionnaires were used to assess depression in both mothers and children. A flankers task was used to elicit the ERN and the correct response negativity (CRN) in children. Children of mothers with a history of recurrent MDD exhibited a reduced difference between the ERN and CRN compared to children of mothers with no depression history, even after controlling for children's current depression symptoms. Furthermore, current maternal depression symptoms related to a smaller difference between ERN and CRN in children. This pattern of findings suggests that blunted neural activity differentiating error from correct responses may be one mechanism by which recurrent maternal depression increases risk for depression in offspring and may be useful biomarker of risk.

Linking puberty and error-monitoring: Relationships between self-reported pubertal stages, pubertal hormones, and the error-related negativity in a large sample of children and adolescents.

The error-related negativity (ERN) is a negative deflection in the event-related potential occurring when individuals make mistakes. The ERN has been proposed as a biomarker for anxiety and a substantial amount of research suggests the ERN increases across development. Further, the ERN may relate to individual differences and the development of cognitive control. Despite the large quantity of research on this topic, there have been no studies focusing on the relationship between pubertal hormones and the ERN. Previous work suggests developmental increases may begin sooner for girls than for boys, suggesting that puberty may impact the ERN. The current study examined the relationship between pubertal hormones and the ERN amplitude in a sample of 99 females between 8 and 14 years old. Each participant and the parent who accompanied them completed the Pubertal Developmental Scale (PDS) to assess the degree to which pubertal indicators are present. Participants also completed a Go/NoGo Task while EEG was recorded and participants provided saliva samples for hormone assays. Results indicated that ERN was significantly related to both the dehydroepiandrosterone (DHEA) hormone and PDS scores. A simultaneous multivariate regression suggested that DHEA levels significantly predict the ERN, even when controlling for age, behavioral variables, and PDS. These findings suggest that ERN amplitude is related to DHEA levels, further linking puberty to developmental increases in the ERN. Future research should examine this relationship in the context of developmental increases in anxiety symptoms.

Early temperamental fearfulness and the developmental trajectory of error-related brain activity.

The error-related negativity (ERN) is a negative deflection in the event-related potential waveform that occurs when an individual makes a mistake, and an increased ERN has been proposed as a biomarker for anxiety. However, previous work suggests that fearful children are characterized by a smaller ERN. We have proposed that this may reflect the changing phenomenology of anxiety across development. In the current study, we investigate this possibility using a longitudinal within-subject design. In 271 children, we completed observational measures of fear when the children were 3 years old, and then measured the ERN when the children were 6 and 9 years old. Fearful children were characterized by a decreased ERN when they were 6-year-old; by age 9, the same children who were fearful at age 3 had increased ERNs-a pattern that closely resembles that of anxious adolescents and adults.

The Parent Sensitivity to Child Anxiety Index.

Anxiety sensitivity (AS) is the perception that anxiety symptoms and experiences have negative consequences, and has been identified as a risk factor for the development of anxiety disorders. AS has been measured in adults and in children, but to date, the construct of parent's sensitivity to their children's anxiety symptoms has not been identified, measured, or evaluated. The current study presents a novel measure of this construct, the Parent Sensitivity to Child Anxiety Index (PSCAI), and an initial evaluation of its psychometric properties. Factor analysis revealed a three-factor structure consisting of parents' concern for physical symptoms, concern of social evaluation, and fear of anxiety symptoms. The PSCAI demonstrated good internal consistency, and was positively correlated with relevant parental constructs such as parental accommodation, anxiety sensitivity, and trait anxiety. This new measurement system opens new avenues for researching the early development of anxiety disorders and the possibility for novel targeted interventions.

Pubertal development and anxiety risk independently relate to startle habituation during fear conditioning in 8-14 year-old females.

Reduced habituation to aversive stimuli has been observed during adolescence and may reflect an underlying mechanism of vulnerability for anxiety disorders. This study examined the startle reflex during a fear-learning task in 54 8-14-year-old girls. We examined the relationship between mean startle, startle habituation, pubertal development, and two measures linked to risk for anxiety: behavioral inhibition system (BIS) and the error-related negativity (ERN). Puberty, BIS, and the ERN were unrelated to mean startle; however, each measure modulated startle habituation. Greater pubertal development was associated with reduced startle habituation across the CS+ and CS-. Higher BIS related to a larger ERN, and both were associated with reduced startle habituation specifically to the CS+. All effects were independent of each other. Findings suggest that puberty alters habituation of defense system activation to both threat and safety cues, and this is independent of risk for anxiety, which uniquely impacts habituation to threat cues.

Transdiagnostic factors and pathways to multifinality: The error-related negativity predicts whether preschool irritability is associated with internalizing versus externalizing symptoms at age 9.

There is increasing interest among developmental psychopathologists in broad transdiagnostic factors that give rise to a wide array of clinical presentations (multifinality), but little is known about how these processes lead to particular psychopathological manifestations over the course of development. We examined whether individual differences in the error-related negativity (ΔERN), a neural indicator of error monitoring, predicts whether early persistent irritability, a prototypical transdiagnostic construct, is associated with later internalizing versus externalizing outcomes. When children were 3 years old, mothers were interviewed about children's persistent irritability and completed questionnaires about their children's psychopathology. Three years later, EEG was recorded while children performed a go/no-go task to measure the ΔERN. When children were approximately 9 years old, mothers again completed questionnaires about their children's psychopathology. The results indicated that among children who were persistently irritable at age 3, an enhanced or more negative ΔERN at age 6 predicted the development of internalizing symptoms at age 9, whereas a blunted or smaller ΔERN at age 6 predicted the development of externalizing symptoms. Our results suggest that variation in error monitoring predicts, and may even shape, the expression of persistent irritability and differentiates developmental trajectories from preschool persistent irritability to internalizing versus externalizing outcomes in middle to late childhood.

The stability of the feedback negativity and its relationship with depression during childhood and adolescence.

Feedback negativity (FN) is an event-related potential elicited by monetary reward and loss; it is thought to relate to reward-related neural activity and has been linked to depression in children and adults. In the current study, we examined the stability of FN, and its relationship with depression in adolescents, over 2 years in 45 8- to 13-year-old children. From Time 1 to Time 2, FN in response to monetary loss and in response to monetary gain showed moderate to strong reliability (rs = .64 and .67, respectively); these relationships remained significant even when accounting for related variables. FN also demonstrated high within-session reliability. Moreover, the relationship between a blunted FN and greater depression observed at Time 1 was reproduced at Time 2, and the magnitude of FN at Time 1 predicted depressive symptomatology at Time 2. These findings are consistent with the hypothesis that FN and its relationship with depression remain consistent over the course of development, and that FN may prospectively predict later depressive symptomatology. The current results suggest that FN may be suitable as a biomarker of depressive symptoms during adolescence.

Differentiating anxiety and depression in children and adolescents: evidence from event-related brain potentials.

The current study, which was a reanalysis of previous data, focused on the error-related negativity (ERN)-an event-related potential (ERP) associated with error monitoring-and the feedback negativity (FN)-an ERP associated with reward processing. Two objectives motivated this study: first, to illustrate the relationship between the ERN and anxious symptoms, and the relationship between the FN and depressive symptoms; second, to explore whether the ERN and the FN relate uniquely to anxiety and depression, respectively, in children. EEG was collected from twenty-five 11- to 13-year-old participants (12 female; 23 Caucasian, 1 Asian, 1 of Caucasian and Hispanic ethnicity) during tasks designed to elicit an ERN and an FN. Participants and a parent completed questionnaires assessing the participant's anxious and depressive symptomatology. Increasing anxiety was related to a larger ERN, and increasing depression was related to a smaller FN. Further analysis demonstrated that these relationships remained significant when controlling for the contribution of other variables; that is, the ERN continued to predict anxiety when controlling for the FN and depression, and the FN continued to predict depression when controlling for the ERN and anxiety. Thus, in late childhood and early adolescence, the ERN and the FN appear to relate uniquely to anxious and depressive symptoms, respectively. Although this research is still in early stages, the ERN and the FN have the potential to inform trajectories of risk for anxiety and depression, and could be utilized in clinical settings as cost- and labor-efficient neural biomarkers.

The associations among sleep-related difficulties, anxiety, and error-related brain activity in youth.

Given the high prevalence of anxiety disorders and their associated impairment, elucidating neural mechanisms related to these disorders has been increasingly prioritized. The error-related negativity (ERN) has been identified as a neural marker that indexes risk for anxiety across development. The ERN seems to confer risk for developing anxiety, especially in the context of stressful life events. The present study sought to examine sleep-related difficulties as another stressful factor that might impact the ERN. In a sample of 221 girls, aged 8 to 15 years old, we first examined the relationship between longer-term (i.e., over the past month) and shorter-term (i.e., over the past week) sleep difficulties and the ERN. We then investigated whether specific sleep difficulties uniquely predict the ERN. In exploratory analyses, we assessed whether sleep difficulties moderate the relationship between the ERN and anxiety. Results indicated that youth who report longer-term lower sleep duration, longer-term worse sleep, and shorter-term lower sleep duration on school days over the past week have a larger (i.e., more negative) ERN. Additionally, only shorter-term sleep duration on school days over the past week uniquely predicted the ERN. Finally, an elevated ERN predicted greater clinical anxiety in the context of longer-term sleep difficulties. Future studies should clarify the direction of these associations via longitudinal designs.