How to support peer resistance in adolescents with mild-to-borderline intellectual disability? Intervention development and feasibility.

BACKGROUND: Adolescents with mild-to-borderline intellectual disability face peer resistance challenges, risking harmful or dangerous situations. METHOD: We designed a peer resistance group intervention at school for adolescents with mild-to-borderline intellectual disability, tested its feasibility (N = 4, Mage = 14.1, MIQ = 78.8), adapted it, and tested it again (N = 6, Mage = 15.0, MIQ = 72.8). RESULTS: Study 1 demonstrated feasibility in recruitment, resources, and potential benefits on the distal outcome risk taking. However, attendance, obtained knowledge, and potential benefits on peer resistance, peer problems, and prosocial behaviour were suboptimal. Consequently, study 2 contained more learning by doing and individual lessons, resulting in higher attendance and greater personalization. While potential benefits on improved peer resistance measures were not observed, risk taking improved. CONCLUSIONS: Despite finding no potential benefits on peer resistance, running a peer resistance intervention for adolescents with mild-to-borderline intellectual disability at school is considered feasible.

Commentary: Why treatment is the best choice for childhood mental disorders - a commentary on Roest et al. (2022).

An important question in mental healthcare for children is whether treatments are effective and safe in the long run. Here, we comment on a recent editorial perspective by Roest et al. (2022), who argue, based on an overview of systematic reviews, 'that there is no convincing evidence that interventions for the most common childhood disorders are beneficial in the long term'. We believe that the available evidence does not justify this conclusion and express our concern regarding the harmful effects of their message. We show that there is evidence to suggest beneficial longer term treatment effects for each of the disorders and explain why evidence-based treatment should be offered to children with mental disorders.

Biased Maintenance of Attention on Sad Faces in Clinically Depressed Youth: An Eye-Tracking Study.

The role of negative attention biases (AB), central to cognitive models of adult depression, is yet unclear in youth depression. We investigated negative AB in depressed compared to healthy youth and tested whether AB are more pronounced in depressed than at-risk youth. Negative AB was assessed for sad and angry faces with an eye-tracking paradigm [Passive Viewing Task (PVT)] and a behavioural task [Visual Search Task (VST)], comparing three groups of 9-14-year-olds: youth with major depression (MD; n = 32), youth with depressed parents (high-risk; HR; n = 49) and youth with healthy parents (low-risk; LR; n = 42). The PVT revealed MD participants to maintain attention longer on sad faces compared to HR, but not LR participants. This AB correlated positively with depressive symptoms. The VST revealed no group differences. Our results provide preliminary evidence for a negative AB in maintenance of attention on disorder-specific emotional information in depressed compared to at-risk youth.

A computational network perspective on pediatric anxiety symptoms.

BACKGROUND: While taxonomy segregates anxiety symptoms into diagnoses, patients typically present with multiple diagnoses; this poses major challenges, particularly for youth, where mixed presentation is particularly common. Anxiety comorbidity could reflect multivariate, cross-domain interactions insufficiently emphasized in current taxonomy. We utilize network analytic approaches that model these interactions by characterizing pediatric anxiety as involving distinct, inter-connected, symptom domains. Quantifying this network structure could inform views of pediatric anxiety that shape clinical practice and research. METHODS: Participants were 4964 youths (ages 5-17 years) from seven international sites. Participants completed standard symptom inventory assessing severity along distinct domains that follow pediatric anxiety diagnostic categories. We first applied network analytic tools to quantify the anxiety domain network structure. We then examined whether variation in the network structure related to age (3-year longitudinal assessments) and sex, key moderators of pediatric anxiety expression. RESULTS: The anxiety network featured a highly inter-connected structure; all domains correlated positively but to varying degrees. Anxiety patients and healthy youth differed in severity but demonstrated a comparable network structure. We noted specific sex differences in the network structure; longitudinal data indicated additional structural changes during childhood. Generalized-anxiety and panic symptoms consistently emerged as central domains. CONCLUSIONS: Pediatric anxiety manifests along multiple, inter-connected symptom domains. By quantifying cross-domain associations and related moderation effects, the current study might shape views on the diagnosis, treatment, and study of pediatric anxiety.

Dual processes in fear and anxiety: no effects of cognitive load on the predictive value of implicit measures.

Dual process models posit that combinations of impulsive and reflective processes drive behaviour, and that the capacity to engage in effortful cognitive processing moderates the relation between measures of impulsive or reflective processes and actual behaviour. When cognitive resources are low, impulsive processes are more likely to drive behaviour, while when cognitive resources are high, reflective processes will drive behaviour. In our current study, we directly addressed this hypothesis by comparing the capacity of implicit and explicit measures to predict fear and anxiety, either with or without additional cognitive load. In Experiment 1 (N = 83), only explicit measures of spider fear were predictive of spider avoidance, and manipulating cognitive load did not affect these relations. Experiment 2 (N = 70) confirmed these findings, as the capacity of explicit and implicit measures to predict self-reported and physiological responses to a social stressor was not moderated by cognitive load. In two experiments, we thus found no empirical support for the central dual process model assumption that cognitive control moderates the predictive value of implicit and explicit measures. While implicit measures and dual process accounts may still be valuable, we show that results in this field are not necessarily replicable and inconsistent.

Acceptability and Co-Development of an Online Cognitive Bias Modification Intervention for Emerging Adults With Hazardous Alcohol Use and Social Anxiety: A Mixed Methods Study.

BACKGROUND: Approach bias modification (ApBM) and interpretation bias modification (IBM) are two promising adjunct treatments for alcohol use and social anxiety, respectively. However, the acceptability of combining ApBM and IBM into one program for people who experience both of these disorders is unknown. The present study describes the codevelopment of a new, hybrid ApBM + IBM program and provides insight into the perceptions of acceptability from service providers and emerging adults. METHODS: Service providers (n = 14) and emerging adults aged 18 to 25 years with lived experience of hazardous alcohol use and heightened social anxiety (n = 15) were recruited via online advertisements and through existing networks. All participants were shown a beta version of the program and asked to complete qualitative and quantitative questions to ascertain feedback on the program's acceptability and suggestions for improvement. RESULTS: Themes emerged relating to the ApBM + IBM program's quality and usefulness, appropriateness, motivation and engagement, and potential clinical value. The program was well received and deemed acceptable for the target age group. It was rated particularly highly with regard to the overall quality and ease of use. Emerging adults had fewer suggestions for how the intervention might be revised; however, there were suggestions from both groups regarding the need for a compelling rationale at the outset of treatment and a suggestion to include a motivational interviewing and psychoeducational-based module prior to the first training session, to increase user buy-in and engagement. CONCLUSIONS: The current findings reflect positively on the acceptability of a hybrid ApBM + IBM for emerging adults with co-occurring hazardous alcohol use and social anxiety. Service providers and emerging adults identified a number of ways to improve the design and implementation of the program, which will likely improve adherence to, and outcomes of, the intervention when added as an adjunct to treatment as usual.

Modification of hostile attribution bias reduces self-reported reactive aggressive behavior in adolescents.

Aggressive individuals more readily interpret others' motives and intentions in ambiguous situations as hostile. This hostile attribution bias has been argued to be causally involved in the development and maintenance of aggression, making it a target for interventions. In our current study, adolescents selected for high levels of aggression (N = 39) were assigned to either a test-retest control group or a five-session hostile attribution bias modification training, in which they were trained to make more benign interpretations of ambiguously provocative social situations. Before and after the training, we assessed hostile attribution bias and both reactive and proactive self-reported aggression in both groups. The training not only tended to produce the expected reduction in hostile attribution bias but also crucially led to decreased levels of reactive but not proactive aggression compared with the control group. Our results thus support the idea that hostile attribution bias can be targeted using training techniques and that such training-induced changes in bias may reduce aggression. However, future studies using an active control group and multiple outcome measures are needed to address the long-term effects of training.

Reliability and validity of measures of attentional bias towards threat in unselected student samples: seek, but will you find?

Although attentional bias (AB) is considered a key characteristic of anxiety problems, the psychometric properties of most AB measures are either problematic or unknown. We conducted two experiments in which we addressed the reliability, convergent validity, and concurrent validity of different AB measures in unselected student samples. In Experiment 1 (N = 66), the visual probe task and the emotional flanker task yielded unreliable estimates of AB. Both the relevant and irrelevant feature visual search task yielded better reliability estimates, yet AB scores did not correlate significantly with each other nor with self-reported social anxiety. In Experiment 2 (N = 60), we retained only the visual search tasks. The relevant feature visual search task was again highly reliable, but it did not correlate significantly with anxiety measures. The irrelevant feature visual search task yielded only small reliability estimates, yet one of the scores was significantly correlated with implicit (but not self-reported or physiological) measures of social anxiety. Together, our results advocate the use of variants of visual search tasks to measure AB and they underline the importance of fundamental psychometric testing in AB research.

Do implicitly measured math-anxiety associations play a role in math behavior?

The current study examined the role of implicitly measured associations (henceforth referred to as associations) between math and anxiety in adolescents' math anxiety. Previous research has shown that associations predicted behavior independent of explicit measures. In this study, it was investigated whether math-anxiety associations would be related to math anxiety and whether they predicted math behavior as well as state math anxiety independent of explicitly measured math anxiety. In addition, the domain specificity of math-anxiety associations for predicting math behavior was investigated. Adolescents' anxiety associations and self-reported anxiety were assessed for three domains: math anxiety, foreign language (English) anxiety, and trait anxiety. A sample of 189 secondary school students performed three single-target implicit association tests, performed a math problem solving task, and filled out questionnaires. Overall, adolescents showed stronger math-anxiety associations in comparison with math-calmness associations. In contrast to our hypotheses, math-anxiety associations were not related and did not uniquely or specifically predict math behavior and state math anxiety. Explicit anxiety measures demonstrated specificity in predicting math and English grades as well as state math anxiety. The innovative aspects of this study are the investigation of implicitly measured math-anxiety associations and the relation to math anxiety and math behavior. Further research is needed to develop tasks that are better able to capture the most relevant math-threat associations and to investigate which math behavior might be most strongly influenced by these associations.

Association between attention bias to threat and anxiety symptoms in children and adolescents.

BACKGROUND: Considerable research links threat-related attention biases to anxiety symptoms in adults, whereas extant findings on threat biases in youth are limited and mixed. Inconsistent findings may arise due to substantial methodological variability and limited sample sizes, emphasizing the need for systematic research on large samples. The aim of this report is to examine the association between threat bias and pediatric anxiety symptoms using standardized measures in a large, international, multi-site youth sample. METHODS: A total of 1,291 children and adolescents from seven research sites worldwide completed standardized attention bias assessment task (dot-probe task) and child anxiety symptoms measure (Screen for Child Anxiety Related Emotional Disorders). Using a dimensional approach to symptomatology, we conducted regression analyses predicting overall, and disorder-specific, anxiety symptoms severity, based on threat bias scores. RESULTS: Threat bias correlated positively with overall anxiety symptoms severity (ß = 0.078, P = .004). Furthermore, threat bias was positively associated specifically with social anxiety (ß = 0.072, P = .008) and school phobia (ß = 0.076, P = .006) symptoms severity, but not with panic, generalized anxiety, or separation anxiety symptoms. These associations were not moderated by age or gender. CONCLUSIONS: These findings indicate associations between threat bias and pediatric anxiety symptoms, and suggest that vigilance to external threats manifests more prominently in symptoms of social anxiety and school phobia, regardless of age and gender. These findings point to the role of attention bias to threat in anxiety, with implications for translational clinical research. The significance of applying standardized methods in multi-site collaborations for overcoming challenges inherent to clinical research is discussed.

Biases in attention and interpretation in adolescents with varying levels of anxiety and depression.

This is the first study to investigate multiple cognitive biases in adolescence simultaneously, to examine whether anxiety and depression are associated with biases in attention and interpretation, and whether these biases are able to predict unique variance in self-reported levels of anxiety and depression. A total of 681 adolescents performed a Dot Probe Task (DPT), an Emotional Visual Search Task (EVST), and an Interpretation Recognition Task. Attention and interpretation biases were significantly correlated with anxiety. Mixed results were reported with regard to depression: evidence was found for an interpretation bias, and for an attention bias as measured with the EVST but not with the DPT. Furthermore, interpretation and attention biases predicted unique variance in anxiety and depression scores. These results indicate that attention and interpretation biases are unique processes in anxiety and depression. They also suggest that anxiety and depression are partly based on similar underlying cognitive mechanisms.

Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability†.

If meta-analysis is to provide valuable answers, then it is critical to ensure clarity about the questions being asked. Here, we distinguish two important questions concerning cognitive bias modification research that are not differentiated in the meta-analysis recently published by Cristea et al (2015) in this journal: (1) do the varying procedures that investigators have employed with the intention of modifying cognitive bias, on average, significantly impact emotional vulnerability?; and (2) does the process of successfully modifying cognitive bias, on average, significantly impact emotional vulnerability? We reanalyse the data from Cristea et al to address this latter question. Our new analyses demonstrate that successfully modifying cognitive bias does significantly alter emotional vulnerability. We revisit Cristea et al's conclusions in light of these findings.

Exploring the Causal Effect of Interpretation Bias on Attachment Expectations.

Attachment theory implies that children's inclination to interpret attachment figures behavior as supportive and available causally influences children's trust in their attachment figure's availability. An experiment was conducted to test whether training children (8-12 years old) to interpret ambiguous interactions with their mothers in a more secure way increases their trust in their mother's availability. Participants (N = 49) were randomly assigned to either a secure condition to train children to interpret their mother's behavior as supportive or a neutral placebo condition, where interpretations were unrelated to maternal support. Results supported the hypothesis: After the secure training, children interpreted maternal behavior more securely and trusted more in her availability. This suggests that attachment-related processing biases causally affect attachment expectations.

Limited generalisation of changes in attentional bias following attentional bias modification with the visual probe task.

Although attentional bias modification (ABM) can change anxiety, recent studies failed to replicate such effects, possibly because the visual probe ABM failed to induce changes in attentional bias (AB). We investigated whether visual probe ABM generalised to different measures of AB besides the visual probe task (VPT), and thus whether ABM genuinely changes attentional processing. We trained participants (N = 60) to either attend towards or away from angry facial expressions, and we examined training effects on the dot probe task, the exogenous cueing task, and the visual search task. We found a small change in AB in the VPT, but this effect did not transfer to the exogenous cueing task or the visual search task. Our study shows that ABM does not necessarily lead to generalised effects on AB. This finding can be explained by the poor psychometric properties of the AB measures.

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.

Emotional working memory training as an online intervention for adolescent anxiety and depression: A randomised controlled trial.

OBJECTIVE: Anxiety and depression are highly prevalent disorders in adolescence. They are associated with deficits in working memory (WM), which also appears to increase rumination, worry, and negative mood. WM training, especially in an emotional context, might help in reducing or preventing these disorders. The current study investigated the direct effects of online emotional WM training on WM capacity, and short- and long-term effects on symptoms of anxiety and depression, and secondary measures of emotional functioning. METHODS: Unselected adolescents (n = 168, aged 11-18) were randomised over an active or placebo emotional WM training. WM was assessed before and after 4 weeks of bi-weekly training. Emotional functioning was assessed pre- and post-training and at 3, 6, and 12 months follow-up. RESULTS: Improvements in WM capacity and both short- and long-term emotional functioning were found in both training groups, with the only group difference being a trend for a larger increase in self-esteem in the active group compared to the placebo group. CONCLUSIONS: The general improvements irrespective of training condition suggest non-specific training or time effects, or some shared active ingredient in both conditions. Future research is necessary to detect potentially effective components of (emotional) WM training and to increase adolescent engagement with online training.

Executive Functions and Motivation as Moderators of the Relationship Between Automatic Associations and Alcohol Use in Problem Drinkers Seeking Online Help.

BACKGROUND: Dual process models posit that problem drinking is maintained by an imbalance between relatively strong automatic processes and weak controlled processes, a combination of executive functions and motivation. Few studies have examined how the interplay between automatic processes and executive functions is affected by motivation to change. This study examined this relationship in problem drinkers seeking online help to change their alcohol use. It was expected that executive functions (i.e., working memory, response inhibition) would moderate the relationship between automatic (valence and approach) associations and alcohol use and that this effect would be stronger in individuals with strong motivation to change. METHODS: A sample of 302 problem drinkers (mean age: 51.7 years) participated in this study as part of the baseline assessment before an Internet intervention. Participants completed an online version of the brief Implicit Association Test (valence and approach associations), the self-ordered pointing task (working memory), the Stroop task (response inhibition), the Readiness to Change Questionnaire (motivation to change), and the Timeline Follow-Back Questionnaire (alcohol use). Hierarchical moderated regression analysis was used to test the 4 hypothesized 3-way interactions. RESULTS: As expected, the interaction between valence associations and working memory only predicted alcohol use among individuals with strong motivation. This pattern was neither found for response inhibition nor for approach associations. CONCLUSIONS: Results provide partial support for the moderating role of motivation in the interplay between automatic processes and executive functions. Future studies should investigate this relationship in participants with the full range of motivation and alcohol use.

Re-training automatic action tendencies to approach cigarettes among adolescent smokers: a pilot study.

BACKGROUND: This pilot study conducted a preliminary examination of whether Cognitive Bias Modification (CBM), a computerized task to retrain cognitive-approach biases towards smoking stimuli (a) changed approach bias for cigarettes, and (b) improved smoking cessation outcomes in adolescent smokers. METHODS: Sixty adolescent smokers received four weeks of Cognitive Behavioral Therapy (CBT) for smoking cessation, with CBM (90% avoidance/10% approach for smoking stimuli and 10% avoidance/90% approach for neutral stimuli) or sham (50% avoidance/50% approach for smoking and neutral stimuli) training in the Netherlands (n = 42) and the United States (n = 18). RESULTS: While we did not observe changes in action tendencies related to CBM, adolescents with higher smoking approach biases at baseline had greater decreases in approach biases at follow-up, compared to adolescents with smoking avoidance biases, regardless of treatment condition (p = 0.01). Intent-to-treat (ITT) analyses showed that CBM, when compared with sham trended toward higher end-of-treatment, biochemically-confirmed, seven-day point prevalence abstinence, (17.2% vs. 3.2%, p = 0.071). ITT analysis also showed that regardless of treatment condition, cotinine level (p = 0.045) and average number of cigarette smoked (p ≤ 0.001) significantly decreased over the course of treatment. CONCLUSIONS: The findings from this pilot study suggests that re-training approach biases toward cigarettes shows promise for smoking cessation among adolescent smokers. Future research should utilize larger samples and increased distinction between CBM and sham conditions, and examine mechanisms underlying the CBM approach.

Study Preregistration: Targeting Parental Risk Factors for Children's Anxiety: A Factorial Experiment With Three Intervention Components.

Anxiety is one of the most common mental health problems in childhood, and causes severe and persistent impairment in children's lives.1 Parents can play a key role in the development of children's anxiety symptoms2; yet, the evidence of parent-focused interventions is relatively thin.3 This may be because little is known about what the optimal content of these interventions should be. Interventions typically either use parents as lay therapists, or target multiple different family risk factors at the same time.4 Traditional randomized trials of these "package deal" interventions provide little insight into what specific parental risk factors should be targeted to most effectively reduce children's anxiety.5 We will examine the effects of targeting distinct parental risk factors to provide more information on the role of these factors in children's anxiety, and to guide the development of intervention programs.

Codesigned online cognitive bias modification of interpretations for anxiety and depression in children: study protocol of a randomised controlled trial.

INTRODUCTION: Previous research has shown that cognitive bias modification of interpretations (CBM-I) may be a promising intervention for anxiety in youth; however, results are mixed. Given the high comorbidity between anxiety and depression in youth, it is surprising that no child studies have targeted biases associated with both. This study aims to evaluate the effectiveness and acceptability of an online CBM-I intervention (Mindmaster) for children with symptom scores of anxiety or depression above a borderline or clinical threshold. The intervention has been codesigned with children, parents and mental health professionals to promote user engagement. METHODS AND ANALYSIS: The study is a randomised controlled trial, with two parallel arms. Participants are 143 children aged 8-10 years with scores of anxiety and/or depressive symptoms above a borderline or clinical threshold. They will be allocated to either the intervention group or the waitlist control group. The intervention consists of 2 weeks of online CBM-I training, with four sessions (10-15 min) per week. Outcome assessments will be conducted at baseline, 4 weeks after baseline (post-training/post-waitlist) and 8 weeks after baseline (follow-up) for the intervention group only. The primary outcome is interpretation bias. Secondary outcomes are anxiety and depressive symptoms and life interference. Analyses will be conducted within an intention-to-treat framework using mixed models for repeated measures. ETHICS AND DISSEMINATION: The study was approved by the University of New South Wales Human Research Ethics Committee (HC220758). Findings will be reported to (1) participating families; (2) presented at scientific conferences and (3) disseminated to peer-review publications. Data will be available from the corresponding author on request. TRIAL REGISTRATION NUMBER: ACTRN12622001493730.