Toward a mechanistic understanding of the role of error monitoring and memory in social anxiety.

Cognitive models state that social anxiety (SA) involves biased cognitive processing that impacts what is learned and remembered within social situations, leading to the maintenance of SA. Neuroscience work links SA to enhanced error monitoring, reflected in error-related neural responses arising from mediofrontal cortex (MFC). Yet, the role of error monitoring in SA remains unclear, as it is unknown whether error monitoring can drive changes in memory, biasing what is learned or remembered about social situations. Motivated by the longer-term goal of identifying mechanisms implicated in SA, in the current study we developed and validated a novel paradigm for probing the role of error-related MFC theta oscillations (associated with error monitoring) and incidental memory biases in SA. Electroencephalography (EEG) data were collected while participants completed a novel Face-Flanker task, involving presentation of task-unrelated, trial-unique faces behind target/flanker arrows on each trial. A subsequent incidental memory assessment evaluated memory biases for error events. Severity of SA symptoms were associated with greater error-related theta synchrony over MFC, as well as between MFC and sensory cortex. Social anxiety also was positively associated with incidental memory biases for error events. Moreover, greater error-related MFC-sensory theta synchrony during the Face-Flanker predicted subsequent incidental memory biases for error events. Collectively, the results demonstrate the potential of a novel paradigm to elucidate mechanisms underlying relations between error monitoring and SA.

Attention Training for Child Anxiety and Its Disorders: Moving from Research to Clinical Implementation.

Attention training is an evidence-based, computerized treatment for anxiety and its disorders rooted in cognitive neuroscience. Though experimental research and clinical trials data on attention training in children span two decades, the literature has focused on attention training's anxiety reduction effects, with little guidance on its implementation in clinical practice. Guidance on implementation is needed given recent efforts to increase accessibility of attention training in clinical practice settings. In this article, we move from research to clinical implementation, providing guidelines with pragmatic clinical steps. We include guidance on psychoeducation, setting and delivery of sessions, potential challenges, and frequently asked questions regarding implementation.

Towards implementation of cognitive bias modification in mental health care: State of the science, best practices, and ways forward.

Cognitive bias modification (CBM) has evolved from an experimental method testing cognitive mechanisms of psychopathology to a promising tool for accessible digital mental health care. While we are still discovering the conditions under which clinically relevant effects occur, the dire need for accessible, effective, and low-cost mental health tools underscores the need for implementation where such tools are available. Providing our expert opinion as Association for Cognitive Bias Modification members, we first discuss the readiness of different CBM approaches for clinical implementation, then discuss key considerations with regard to implementation. Evidence is robust for approach bias modification as an adjunctive intervention for alcohol use disorders and interpretation bias modification as a stand-alone intervention for anxiety disorders. Theoretical predictions regarding the mechanisms by which bias and symptom change occur await further testing. We propose that CBM interventions with demonstrated efficacy should be provided to the targeted populations. To facilitate this, we set a research agenda based on implementation frameworks, which includes feasibility and acceptability testing, co-creation with end-users, and collaboration with industry partners.

Attentional Control Accounts for the Association Between Anxiety Sensitivity and Sleep Efficiency in Clinic-Referred Youth.

Youth with anxiety disorders report difficulty falling asleep and returning to sleep after sleep onset (i.e., poor sleep efficiency). Anxiety sensitivity, the excessive attention to physical symptoms of anxiety and their threatening interpretations, has been linked to poor sleep efficiency. We tested a conceptual model wherein attentional control, attentional focusing and attentional shifting would account for the relationship between anxiety sensitivity and poor sleep efficiency. 255 youths (6-17 years old, 78% Hispanic/Latino) who presented to a university-based research clinic completed measures on anxiety sensitivity, sleep, and attentional control. Poorer sleep efficiency was significantly correlated with higher anxiety sensitivity and lower attentional control, attentional focusing, and attentional shifting. Higher anxiety sensitivity was significantly correlated with lower attentional control and attentional focusing. Attentional control and attentional focusing, not attentional shifting, accounted for the relationship between anxiety sensitivity and poor sleep efficiency. These findings identify attentional control and attentional focusing as variables that may explain the association between anxiety sensitivity and sleep efficiency in youth.

Acculturative Orientations Among Hispanic/Latinx Caregivers in the ABCD Study: Associations With Caregiver and Youth Mental Health and Youth Brain Function.

Background: Population-based neuroscience offers opportunities to examine important but understudied sociocultural factors such as acculturation. Acculturation refers to the extent to which an individual retains their cultural heritage and/or adopts the receiving society's culture and is particularly salient among Hispanic/Latinx immigrants. Specific acculturative orientations have been linked to vulnerability to substance use, depression, and suicide and are known to influence family dynamics between caregivers and their children. Methods: Using data from first- and second-generation Hispanic/Latinx caregivers in the Adolescent Brain Cognitive Development (ABCD) Study (N = 1057), we examined how caregivers' acculturative orientation affects their mental health, as well as the mental health and brain function of their children. Neuroimaging analyses focused on regions associated with self- and affiliation-based social processing (ventromedial prefrontal cortex, insula, and temporoparietal junction). Results: We identified 2 profiles of caregiver acculturation: bicultural (retains heritage culture while adopting U.S. culture) and detached (discards heritage culture and rejects U.S. culture). Bicultural caregivers exhibited fewer internalizing and externalizing problems than detached caregivers; furthermore, youth exhibited similar internalizing effects across caregiver profiles. In addition, youth with bicultural caregivers displayed increased resting-state brain activity (i.e., fractional amplitude of low-frequency fluctuations and regional homogeneity) in the left insula, which has been linked to psychopathology; however, differences in long-range functional connectivity were not significant. Conclusions: Caregiver acculturation is an important familial factor that has been linked to significant differences in youth mental health and insula activity. Future work should examine sociocultural and neurodevelopmental changes across adolescence to assess health outcomes and determine whether localized, corticolimbic brain effects are ultimately translated into long-range connectivity differences.

Therapeutic Alliance, Attendance, and Outcomes in Youths Receiving CBT or Client-Centered Therapy for Anxiety.

OBJECTIVE: Positive associations between therapeutic alliance and outcome (e.g. youth symptom severity) have been documented in the youth anxiety literature; however, little is known about the conditions under which early alliance contributes to positive outcomes in youth. The present study examined the relations between therapeutic alliance, session attendance, and outcomes in youths (N = 135; 55.6% female) who participated in a randomized clinical trial testing the efficacy of cognitive-behavioral therapy or client-centered therapy for anxiety. METHOD: We evaluated a conceptual model wherein: (1) early alliance indirectly contributes to positive outcomes by improving session attendance; (2) alliance-outcome associations differ by intervention type, with stronger associations in cognitive-behavioral therapy compared to client-centered therapy; and (3) alliance-outcome associations vary across outcome measurement timepoints, with the effect of early alliance on outcomes decaying over time. RESULTS: Contrary to hypotheses, provider ratings of early alliance predicted greater youth-rated anxiety symptom severity post-treatment (i.e. worse treatment outcomes). Session attendance predicted positive youth-rated outcomes, though there was no indirect effect of early alliance on outcomes through session attendance. CONCLUSIONS: Results show that increasing session attendance is important for enhancing outcomes and do not support early alliance as a predictor of outcomes.

Towards a mechanistic understanding of the role of error monitoring and memory in social anxiety.

Cognitive models state social anxiety (SA) involves biased cognitive processing that impacts what is learned and remembered within social situations, leading to the maintenance of SA. Neuroscience work links SA to enhanced error monitoring, reflected in error-related neural responses arising from mediofrontal cortex (MFC). Yet, the role of error monitoring in SA remains unclear, as it is unknown whether error monitoring can drive changes in memory, biasing what is learned or remembered about social situations. Thus, we developed a novel paradigm to investigate the role of error-related MFC theta oscillations (associated with error monitoring) and memory biases in SA. EEG was collected while participants completed a novel Face-Flanker task, involving presentation of task-unrelated, trial-unique faces behind target/flanker arrows on each trial. A subsequent incidental memory assessment evaluated memory biases for error events. Severity of SA symptoms were associated with greater error-related theta synchrony over MFC, as well as between MFC and sensory cortex. SA was positively associated with memory biases for error events. Consistent with a mechanistic role in biased cognitive processing, greater error-related MFC-sensory theta synchrony during the Face-Flanker predicted subsequent memory biases for error events. Our findings suggest high SA individuals exhibit memory biases for error events, and that this behavioral phenomenon may be driven by error-related MFC-sensory theta synchrony associated with error monitoring. Moreover, results demonstrate the potential of a novel paradigm to elucidate mechanisms underlying relations between error monitoring and SA.

Parent Accommodation Contemporaneously Mediates the Association Between Youth Irritability and Youth Anxiety Treatment Outcome.

Research documents that child and adolescent (youth) irritability and anxiety have high co-occurrence, and anxious-irritable presentations are associated with greater impairment than anxious nonirritable presentations. This study examines the association between irritability and youth anxiety treatment outcome and tests a conceptual model of the associations among youth irritability, parent accommodation, and youth anxiety severity following cognitive behavioral treatment (CBT). Participants were N = 128 clinic-referred youths ages 6 to 17 years (M = 9.76 years; 57% female) who met criteria for primary anxiety disorder diagnoses and completed a 12- to 14-week CBT anxiety protocol. Parent- and youth-report on youth irritability, parent accommodation of their child's anxiety, and youth anxiety severity were assessed pretreatment and posttreatment. Using parent-report, youth irritability at pretreatment was associated with high parent accommodation of youth anxiety and high youth anxiety severity at posttreatment. The association between irritability and youth anxiety outcome was mediated contemporaneously by parent accommodation at posttreatment. These findings show that parent accommodation of their anxious-irritable children's anxiety may account for high youth anxiety severity following treatment. Developing strategies to target irritability in anxious youth and/or reduce parent accommodation in the presence of youth irritability represent important directions for future research.

Mothers' Psychological Control and Accommodation are Associated with More Severe Anxiety in Hispanic Youth.

Psychological accommodation and control may help explain the finding that anxiety is more severe and common in Hispanic youth. Research with White samples conceptualizes psychological control as part of an authoritarian parenting style; however, research with Hispanic families suggests that psychological control is more likely to be indicative of a protective parenting style. Based on these findings, we hypothesized that in Hispanic families, psychological control would be related to protective parenting behaviors that ultimately maintain child anxiety. We tested a cross-sectional model hypothesizing that in Hispanic families the link between ethnicity and anxiety would be mediated through psychological control and parental accommodation of child anxiety, a parenting behavior which protects the child from the aversive experiences in the moment but ultimately serves to maintain child anxiety. A sample of mothers (n = 145; 48% Hispanic) and fathers (n = 59; 48% Hispanic) of youth from 8 to 18 years of age completed a survey assessing anxiety and parenting. With Hispanic mothers, the relation between ethnicity (Hispanic/non-Hispanic) and child anxiety was mediated through psychological control and accommodation. With fathers, although control was related to accommodation which, in turn, was related to child anxiety, ethnicity was not associated with control, accommodation, or child anxiety. Findings suggest that the context of parenting behavior should be considered in research, and adaptations of child anxiety treatments should consider ways to allow parents to express their desire to communicate warmth and protectiveness while avoiding negative reinforcement of child anxiety.

The Effects of Internet-Based Cognitive Behavioral Therapy for Suicidal Ideation or Behaviors on Depression, Anxiety, and Hopelessness in Individuals With Suicidal Ideation: Systematic Review and Meta-Analysis of Individual Participant Data.

BACKGROUND: Suicide is a global public health problem. Digital interventions are considered a low-threshold treatment option for people with suicidal ideation or behaviors. Internet-based cognitive behavioral therapy (iCBT) targeting suicidal ideation has demonstrated effectiveness in reducing suicidal ideation. However, suicidal ideation often is related to additional mental health problems, which should be addressed for optimal care. Yet, the effects of iCBT on related symptoms, such as depression, anxiety, and hopelessness, remain unclear. OBJECTIVE: We aimed to analyze whether digital interventions targeting suicidal ideation had an effect on related mental health symptoms (depression, anxiety, and hopelessness). METHODS: We systematically searched CENTRAL, PsycInfo, Embase, and PubMed for randomized controlled trials that investigated guided or unguided iCBT for suicidal ideation or behaviors. Participants reporting baseline suicidal ideation were eligible. Individual participant data (IPD) were collected from eligible trials. We conducted a 1-stage IPD meta-analysis on the effects on depression, anxiety, and hopelessness-analyzed as 2 indices: symptom severity and treatment response. RESULTS: We included IPD from 8 out of 9 eligible trials comprising 1980 participants with suicidal ideation. iCBT was associated with significant reductions in depression severity (b=-0.17; 95% CI -0.25 to -0.09; P<.001) and higher treatment response (ie, 50% reduction of depressive symptoms; b=0.36; 95% CI 0.12-0.60; P=.008) after treatment. We did not find significant effects on anxiety and hopelessness. CONCLUSIONS: iCBT for people with suicidal ideation revealed significant effects on depression outcomes but only minor or no effects on anxiety and hopelessness. Therefore, individuals with comorbid symptoms of anxiety or hopelessness may require additional treatment components to optimize care. Studies that monitor symptoms with higher temporal resolution and consider a broader spectrum of factors influencing suicidal ideation are needed to understand the complex interaction of suicidality and related mental health symptoms.

Context and domain matter: the error-related negativity in peer presence predicts fear of negative evaluation, not global social anxiety, in adolescents.

BACKGROUND: Social anxiety symptoms are most likely to emerge during adolescence, a developmental window marked by heightened concern over peer evaluation. However, the neurocognitive mechanism(s) underlying adolescent social anxiety remain unclear. Emerging work points to the error-related negativity (ERN) as a potential neural marker of exaggerated self/error-monitoring in social anxiety, particularly for errors committed in front of peers. However, social anxiety symptoms are marked by heterogeneity and it remains unclear exactly what domain(s) of social anxiety symptoms are associated with ERN variation in peer presence, particularly within the adolescent period. METHODS: To advance and deepen the mechanistic understanding of the ERN's putative role as a neural marker for social anxiety in adolescence, we leveraged a social manipulation procedure and assessed a developmentally salient domain of social anxiety during adolescence - fear of negative evaluation (FNE). Adolescents residing in Hanzhong, a small city in the southwestern region of mainland China, had EEG recorded while performing a flanker task, twice (peer presence/absence); FNE, as well as global social anxiety symptoms, was assessed. RESULTS: Overall ERN increases in peer presence. FNE specifically, but not global levels of social anxiety symptoms, predicted ERN in peer presence. CONCLUSIONS: These data are the first demonstration that the ERN relates to a specific domain of social anxiety in adolescents, as well as the first evidence of such relations within a non-WEIRD (Western, Educated, Industrialized, Rich and Democratic) sample. Results have important implications for theory and research into adolescent social anxiety.

Sleep fails to depotentiate amygdala-reactivity to negative emotional stimuli in youth with elevated symptoms of anxiety.

Sleep-related problems often precede escalating anxiety in early adolescence. Pushing beyond broad sleep-mental health associations and toward mechanistic theories of their interplay can inform etiological models of psychopathology. Recent studies suggest that sleep depotentiates neural (e.g., amygdala) reactivity during reexposure to negative emotional stimuli in adults. Persistent amygdala reactivity to negative experiences and poor sleep characterize anxiety, particularly at the transition to adolescence. We propose that sleep depotentiates amygdala reactivity in youth but fails to do so among youth with anxiety. Participants (n = 34; 18 males; age, mean [M] = 11.35, standard deviation [SD] = 2.00) recruited from the community and specialty anxiety clinics viewed valenced images (positive, negative, and neutral) across two fMRI sessions (Study, Test), separated by a 10-12-hour retention period of sleep or wake (randomized). Mixed linear models regressed basolateral amygdala (BLA) activation and BLA-medial prefrontal cortex (mPFC) functional connectivity to negative images on Time, Condition, and Anxiety Severity. There were greater reductions in BLA activations to negative target images from Study to Test in the Sleep Condition, which was blunted with higher anxiety (b = -0.065, z = -2.355, p = 0.019). No such sleep- or anxiety-related effects were observed for BLA-mPFC functional connectivity (ps > 0.05). Sleep supports depotentiation of amygdala reactivity to negative stimuli in youth, but this effect is blunted at higher levels of anxiety. Disruptions in sleep-related affective habituation may be a critical, modifiable driver of anxiety.

Attention Training as a Low-Intensity Treatment for Concerning Anxiety in Clinic-Referred Youth.

Although youth anxiety treatment research has focused largely on severe and impairing anxiety levels, even milder anxiety levels, including levels that do not meet full criteria for a diagnosis, can be impairing and cause for concern. There is a need to develop and test viable treatments for these concerning anxiety levels to improve functioning and reduce distress. We present findings from a randomized controlled efficacy trial of attention bias modification treatment (ABMT) and attention control training (ACT) for youths with concerning anxiety levels. Fifty-three clinic-referred youths (29 boys, M age = 9.3 years, SD age = 2.6) were randomized to either ABMT or ACT. ABMT and ACT consisted of attention-training trials in a dot-probe task presenting angry and neutral faces; probes appeared in the location of neutral faces in 100% of ABMT trials and 50% of ACT trials. Independent evaluators provided youth anxiety severity ratings; youths and parents provided youth anxiety severity and global impairment ratings; and youths completed measures of attention bias to threat and attention control at pretreatment, posttreatment, and 2-month follow-up. In both arms, anxiety severity and global impairment were significantly reduced at posttreatment and follow-up. At follow-up, anxiety severity and global impairment were significantly lower in ACT compared with ABMT. Attention control, but not attention bias to threat, was significantly improved at follow-up in both arms. Changes in attention control and attention focusing were significantly associated with changes in anxiety severity. Findings support the viability of attention training as a low-intensity treatment for youths with concerning anxiety levels, including levels that do not meet full criteria for a diagnosis. Superior anxiety reduction effects in ACT highlight the critical need for mechanistic research on attention training in this population.

Harmonizing Depression Measures Across Studies: a Tutorial for Data Harmonization.

There has been increasing interest in applying integrative data analysis (IDA) to analyze data across multiple studies to increase sample size and statistical power. Measures of a construct are frequently not consistent across studies. This article provides a tutorial on the complex decisions that occur when conducting harmonization of measures for an IDA, including item selection, response coding, and modeling decisions. We analyzed caregivers' self-reported data from the ADHD Teen Integrative Data Analysis Longitudinal (ADHD TIDAL) dataset; data from 621 of 854 caregivers were available. We used moderated nonlinear factor analysis (MNLFA) to harmonize items reflecting depressive symptoms. Items were drawn from the Symptom Checklist 90-Revised, the Patient Health Questionnaire-9, and the World Health Organization Quality of Life questionnaire. Conducting IDA often requires more programming skills (e.g., Mplus), statistical knowledge (e.g., IRT framework), and complex decision-making processes than single-study analyses and meta-analyses. Through this paper, we described how we evaluated item characteristics, determined differences across studies, and created a single harmonized factor score that can be used to analyze data across all four studies. We also presented our questions, challenges, and decision-making processes; for example, we explained the thought process and course of actions when models did not converge. This tutorial provides a resource to support prevention scientists to generate harmonized variables accounting for sample and study differences.

Implementing Cognitive-Behavioral Therapy in Children and Adolescents with Anxiety Disorders.

This article provides an introduction and overview of the cognitive-behavioral treatment approach to anxiety disorders in children and adolescents. We first provide an introduction to the cognitive-behavioral conceptualization of anxiety, emphasizing the tripartite model of emotions: cognitions, physiological arousal, and avoidance behaviors. We then provide an overview of the basic principles of cognitive behavioral treatment for anxiety disorders in children and adolescents, including generalized, social, and separation anxiety, and specific phobia. We follow this introduction and overview with a discussion of the structure and goals of treatment, including the three phases of treatment (psychoeducation, application, and relapse prevention). In the context of discussing application, we focus primarily on implementation strategies relating to behavioral exposures and cognitive restructuring. We conclude with a summary of different formats wherein cognitive-behavioral treatment can be implemented, including child-only, peer-group, parent-involved, and telehealth.

Digital cognitive-behavioural therapy to reduce suicidal ideation and behaviours: a systematic review and meta-analysis of individual participant data.

QUESTION: Digital interventions based on cognitive-behavioural therapy (iCBT) is associated with reductions in suicidal ideation. However, fine-grained analyses of effects and potential effect-moderating variables are missing. This study aimed to investigate the effectiveness of iCBT on suicidal ideation, effect moderators, effects on suicide attempts and predictors of adherence. STUDY SELECTION AND ANALYSIS: We systematically searched CENTRAL, PsycINFO, Embase and PubMed for randomised controlled trials that investigated iCBT for suicidal ideation or behaviours. Participants reporting baseline suicidal ideation were eligible. We conducted a one-stage individual participant data (IPD) meta-analysis. Suicidal ideation was the primary outcome, analysed as three indices: severity of suicidal ideation, reliable changes and treatment response. FINDINGS: We included IPD from nine out of ten eligible trials (2037 participants). iCBT showed significant reductions of suicidal ideation compared with control conditions across all indices (severity: b=-0.247, 95% CI -0.322 to -0.173; reliable changes: b=0.633, 95% CI 0.408 to 0.859; treatment response: b=0.606, 95% CI 0.410 to 0.801). In iCBT, the rate of reliable improvement was 40.5% (controls: 27.3%); the deterioration rate was 2.8% (controls: 5.1%). No participant-level moderator effects were identified. The effects on treatment response were higher for trials with waitlist-controls compared with active controls. There were insufficient data on suicide attempts. Human support and female gender predicted treatment adherence. The main source of potential bias was missing outcome data. CONCLUSIONS: The current evidence indicates that iCBT is effective in reducing suicidal ideation irrespective of age, gender and previous suicide attempts. Future studies should rigorously assess suicidal behaviour and drop-out reasons.

Parent involvement enhances CBTs for anxiety disorders in Hispanic/Latino youth: Acculturation as a moderator.

OBJECTIVE: Although cognitive behavioral treatments (CBTs) are well-established evidence-based interventions for anxiety disorders in youth, there is long-standing underrepresentation of Hispanic/Latino (H/L) families in youth anxiety clinical trials research. The impact of such underrepresentation is that clinicians who work with H/L youth have minimal evidence-based guidance on best practices. The present study moves toward informing best practices for working with H/L youth with anxiety disorders by examining H/L parents' acculturation and enculturation as moderators of youth anxiety outcomes following CBTs. METHOD: Two hundred eleven H/L youths ages 6-16 (M = 9.41 years, SD = 2.39 years; 43.8% female) and their parents were assigned to individual-youth CBT or one of two parent involvement CBTs: one targeted decreasing parent psychological control, the other targeted decreasing parent use of negative reinforcement. Parent acculturation and enculturation were measured at pretreatment; youth anxiety severity was measured at pretreatment, posttreatment, and 12-month follow-up evaluations. RESULTS: Youth anxiety outcomes were enhanced in both parent involvement CBTs compared with individual-youth CBT. Parent acculturation, but not enculturation, significantly moderated outcomes. At lower levels of parent acculturation, youth anxiety outcomes were enhanced in the parent involvement CBT that targeted negative reinforcement. At higher levels of parent acculturation, youth anxiety outcomes were enhanced in the parent involvement CBT that targeted psychological control. CONCLUSIONS: These findings further support the efficacy of CBTs for anxiety disorders in H/L youth and suggest guidance for tailoring parent involvement treatments based on parent acculturation levels. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Anxious Bullies: Parent Distress and Youth Anxiety Interact to Predict Bullying Perpetration.

Early studies conceptualized the "anxious bully" as different from typical bullies due to their anxiety and home problems. Yet, empirical findings are mixed, and no study has reported associations between youth bullying perpetration, youth anxiety, and parent distress in a clinically anxious sample. We assessed 220 youths' anxiety symptom severity, frequency of the bullying perpetration in the past month, and parent levels of distress. Fifty percent of youths endorsed at least one perpetration act and 17% endorsed six or more. Youth anxiety, but not parent distress, was significantly associated with perpetration. We also found a significant interaction such that youth anxiety was positively associated with bullying perpetration when parent distress was high, but not low. Findings fill a glaring knowledge gap regarding this overlooked group of youth, anxious bullies, and provide novel insights into the interplay between youth distress and parent distress in predicting bullying perpetration.

How Flexible are Treatments for Youth Internalizing Disorders? Examining Modification Guidelines Included across Supported Treatments.

OBJECTIVE: Treatment protocols for youth-internalizing disorders have been developed, however these protocols have yielded mixed findings in routine care settings. Despite increased recognition of the importance of flexibility when delivering evidence-based treatments (EBTs), little is known about the extent to which protocols offer guidance to providers in flexible EBT implementation. The current study examined the extent to which supported EBTs for youth internalizing disorders explicitly incorporate guidance for treatment modification. METHODS: Supported treatment protocols for youth internalizing disorders were identified (N = 44), from which 4,021 modification guidelines were extracted and coded using a structured coding system to classify modification strategies (i.e., the forms that recommended modifications take), and associated tailoring factors (i.e., the rationale for which modifications are recommended). RESULTS: Across all EBTs, modification guidelines were quite common, with the average protocol including almost 91 text passages providing guidance for modification. The majority of modification guidelines functionally increase session or treatment length by recommending the addition or repetition of material, whereas less than 5% of modification guidelines provided strategies for condensing or streamlining care. Strikingly, less than 2% of modification guidelines in EBT protocols address patient cultural factors, and rarely address provider or setting issues that can challenge standard implementation. CONCLUSIONS: Findings highlight critical gaps in the available guidance to modify EBTs for youth internalizing disorders, and suggest EBT protocols may not be optimally poised to flexibly address the broad diversity of children and adolescents across varied settings in need of mental health care.

The role of attentional shifting in the relation between error monitoring and anxiety in youth.

The error-related negativity (ERN), a well-established neural marker of anxiety, reflects enhanced attention to internal threat signals. While attention to threat plays a crucial role in the development and maintenance of anxiety, it is unclear how attentional control influences the ERN-anxiety association. To address this, 37 youths (Mage = 10.89 years) completed self-report measures of attentional control and anxiety symptoms. To obtain ERN amplitude, youth completed a flanker task while simultaneous EEG was collected. Attentional control, specifically attentional shifting rather than focusing, moderated the relation between ERN amplitude and anxiety. Youth who displayed smaller neural responses to making an error and higher ability to shift attention experienced lower levels of anxiety, relative to those who exhibited larger neural responses to making an error or lower attention-shifting ability. These findings highlight that response magnitude to internal threat and ability to flexibly shift attention may jointly contribute to anxiety in youth.