The roles of sex and gender in child and adolescent mental health.

Neurodevelopmental and mental health disorders are common in children and young people, and frequently continue to be impairing into adulthood. Biological sex and gender identity are important factors in the likelihood of the development, referral and diagnosis of these disorders, as well as sources of clinical heterogeneity. In this editorial, we highlight that the aetiology of neurodevelopmental and mental health disorders in young people is complex and multi-faceted. Emerging evidence has implicated sex and gender as playing an important role in understanding the onset and course of psychopathology in childhood and adolescence. Here, we underline the significance of continuing to actively study the roles of sex and gender in the context of outlining potential future research directions and understanding how best to support children and young people.

The Differential Effect of Anxiety and ADHD Symptoms on Inhibitory Control and Sustained Attention for Threat Stimuli: A Go/No-Go Eye-Movement Study.

Objective: This study examined the synergistic effects of ADHD and anxiety symptoms on attention and inhibitory control depending on the emotional content of the stimuli. Method: Fifty-four typically developing individuals (27 children/adolescents and 27 adults) completed an eye-movement based emotional Go/No-Go task, using centrally presented (happy, angry) faces and neutral/symbolic stimuli. Sustained attention was measured through saccade latencies and saccadic omission errors (Go trials), and inhibitory control through saccadic commission errors (No-Go trials). ADHD and anxiety were assessed dimensionally. Results: Elevated ADHD symptoms were associated with more commission errors and slower saccade latencies for angry (vs. happy) faces. In contrast, angry faces were linked to faster saccade onsets when anxiety symptoms were high, and this effect prevailed when both anxiety and ADHD symptoms were high. Conclusion: Social threat impacted performance in individuals with sub-clinical anxiety and ADHD differently. The effects of anxiety on threat processing prevailed when both symptoms were high.

Research Review: A systematic review and meta-analysis of sex/gender differences in social interaction and communication in autistic and nonautistic children and adolescents.

BACKGROUND: Evidence increasingly suggests that ASD manifests differently in females than males. Previous reviews investigating sex/gender differences in social interaction and social communication have focused at the level of broad constructs (e.g. comparing algorithm scores from pre-existing diagnostic instruments) and have typically reported no significant differences between males and females. However, a number of individual studies have found sex/gender differences in narrow construct domains. METHODS: We conducted a systematic review and random effects model meta-analyses (in January 2019 and updated January 2020) that investigated sex/gender differences in narrow construct measures of social communication and interaction in autistic and nonautistic children and adolescents, and adults. Study quality was appraised using the Appraisal Tool for Cross-Sectional Studies (AXIS, BMJ Open, 6, 2016, 1). RESULTS: Across 16 studies (including 2,730 participants), the analysis found that female (vs. male) individuals with ASD had significantly better social interaction and social communication skills (SMD = 0.39, p < .001), which was reflective of a similar sex/gender profile in nonautistic individuals (SMD = 0.35, p < .001). Nonautistic males had significantly better social interaction and communication than males with ASD (SMD = 0.77, p < .001). Nonautistic females also had significantly better social interaction and communication than females with ASD (SMD = 0.72, p  <.001). Nonautistic males had better social interaction and communication than females with ASD, though this difference was not significant (SMD = 0.30, p = .07). CONCLUSIONS: This systematic review and meta-analysis highlighted important sex/gender differences in social interaction and communication for individuals with ASD, likely not captured by pre-existing diagnostic instruments, which potentially contribute to the under recognition of autism in females, and may need to be reflected in the diagnostic process.

Sex/Gender Differences in Camouflaging in Children and Adolescents with Autism.

This study investigated sex/gender differences in camouflaging with children and adolescents (N = 84) with and without an autism diagnosis/increased levels of autistic traits using two conceptualisations/operationalisations of camouflaging. A significant group-by-gender interaction using ANCOVA, with the covariate of verbal IQ, reflected similar levels of social reciprocity in autistic and neurotypical females, whereas autistic males had lower reciprocity than neurotypical males. Autistic females also had higher reciprocity than autistic males, despite similar levels of autistic traits (behavioural camouflaging). Additionally, autistic males and females had similar theory of mind skills, despite females having increased reciprocity (compensatory camouflaging). These findings provide evidence of increased camouflaging in autistic females, which may contribute to delay in the recognition of difficulties and provision of support.

Exploring the Role of Empathy in Understanding the Social-Cognitive Profile for Individuals Referred for Autism Spectrum Disorders Assessment in Adulthood.

This study explored the social-cognitive profile of 173 adults referred for an autism assessment. We considered key dimensional traits (autism, empathy and systemising) to understand social cognition in adults diagnosed with an autism spectrum condition compared with those who were referred for, but did not receive a diagnosis. There were no significant social cognitive differences between groups on measures of emotion recognition and social inference. Adults with a confirmed diagnosis, however, reported fewer empathising traits which were positively associated with social-cognitive understanding. Empathising partially mediated the relationship between diagnostic group and social-cognition. Lower empathising traits in individuals diagnosed in adulthood may be important in understanding challenges with social adaptability. The findings have implications for assessment and highlight the role of empathy in developing social understanding in autism.

Cortisol awakening response in children and adolescents with autism spectrum disorder: a systematic review and meta-analysis.

BACKGROUND: The cortisol awakening response (CAR) is characterised by an increase in cortisol in the 30 to 60 min after waking. Research has found significant associations between an atypical CAR and symptoms of stress and anxiety in typically developing (TD) children and adolescents. A number of studies have explored the CAR in autism spectrum disorder (ASD), but no evidence synthesis is available to date. OBJECTIVE AND METHODS: Based on a preregistered protocol (PROSPERO: CRD42017051187), we carried out a systematic review (SR) and meta-analysis (MA) of CAR studies to explore potential significant differences between children and adolescents with ASD and TD controls. Web of Science, PubMed and PsychInfo were searched until January 2019. A random-effects model was used to pool studies and we used the Newcastle-Ottawa scale (NOS) to assess study quality and risk of bias. FINDINGS: The SR retrieved a total of nine studies, with mixed findings on the comparison of the CAR between children and adolescents with ASD and TD controls. The MA, based on four studies (ASD; n=117 and TD n=118), suggested no differences between the CAR in ASD and TD populations (SMD: -0.21, 95% CI -0.49 to 0.08). In terms of NOS items, no study specified Representativeness of the cases and Non-response rate. DISCUSSION AND CLINICAL IMPLICATIONS: Given the relatively few studies and lack of appropriately matched TD controls, additional research is needed to further understand and recommend the utility of the CAR as a reliable marker to differentiate ASD and TD.

The impact of cognitive load on processing efficiency and performance effectiveness in anxiety: evidence from event-related potentials and pupillary responses.

Anxiety has been associated with poor attentional control, as reflected in lowered performance on experimental measures of executive attention and inhibitory control. Recent conceptualisations of anxiety propose that individuals who report elevated anxiety symptoms worry about performance and will exert greater cognitive effort to complete tasks well, particularly when cognitive demands are high. Across two experiments, we examined the effect of anxiety on task performance and across two load conditions using (1) measures of inhibitory control (behavioural reaction times and eye-movement responses) and (2) task effort with pupillary and electrocortical markers of effort (CNV) and inhibitory control (N2). Experiment 1 used an oculomotor-delayed-response task that manipulated load by increasing delay duration to create a high load, relative to a low load, condition. Experiment 2 used a Go/No-Go task and load was manipulated by decreasing the No-Go probabilities (i.e., 20% No-Go in the high load condition and 50% No-Go in the low load condition). Experiment 1 showed individuals with high (vs. low) anxiety made more antisaccade errors across load conditions, and made more effort during the high load condition, as evidenced by greater frontal CNV and increased pupillary responses. In Experiment 2, individuals with high anxiety showed increased effort (irrespective of cognitive load), as characterised by larger pupillary responses. In addition, N2 amplitudes were sensitive to load only in individuals with low anxiety. Evidence of reduced performance effectiveness and efficiency across electrophysiological, pupillary, and oculomotor systems in anxiety provides some support for neurocognitive models of frontocortical attentional dysfunction in anxiety.

The Moderating Effect of Self-Reported State and Trait Anxiety on the Late Positive Potential to Emotional Faces in 6-11-Year-Old Children.

Introduction: The emergence of anxiety during childhood is accompanied by the development of attentional biases to threat. However, the neural mechanisms underlying these biases are poorly understood. In addition, previous research has not examined whether state and trait anxiety are independently associated with threat-related biases. Methods: We compared ERP waveforms during the processing of emotional faces in a population sample of 58 6-11-year-olds who completed self-reported measures of trait and state anxiety and depression. Results: The results showed that the P1 was larger to angry than neutral faces in the left hemisphere, though early components (P1, N170) were not strongly associated with child anxiety or depression. In contrast, Late Positive Potential (LPP) amplitudes to angry (vs. neutral) faces were significantly and positively associated with symptoms of anxiety/depression. In addition, the difference between LPPs for angry (vs. neutral) faces was independently associated with state and trait anxiety symptoms. Discussion: The results showed that neural responses to facial emotion in children with elevated symptoms of anxiety and depression were most evident at later processing stages characterized as evaluative and effortful. The findings support cognitive models of threat perception in anxiety and indicate that trait elements of anxiety and more transitory fluctuations in anxious affect are important in understanding individual variation in the neural response to threat in late childhood.

Individual differences in search and monitoring for color targets in dynamic visual displays.

Many real-world tasks now involve monitoring visual representations of data that change dynamically over time. Monitoring dynamically changing displays for the onset of targets can be done in two ways: detecting targets directly, post-onset, or predicting their onset from the prior state of distractors. In the present study, participants' eye movements were measured as they monitored arrays of 108 colored squares whose colors changed systematically over time. Across three experiments, the data show that participants detected the onset of targets both directly and predictively. Experiments 1 and 2 showed that predictive detection was only possible when supported by sequential color changes that followed a scale ordered in color space. Experiment 3 included measures of individual differences in working memory capacity (WMC) and anxious affect and a manipulation of target prevalence in the search task. It found that predictive monitoring for targets, and decisions about target onsets, were influenced by interactions between individual differences in verbal and spatial WMC and intolerance of uncertainty, a characteristic that reflects worry about uncertain future events. The results have implications for the selection of individuals tasked with monitoring dynamic visual displays for target onsets. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Pupillometric and saccadic measures of affective and executive processing in anxiety.

Anxious individuals report hyper-arousal and sensitivity to environmental stimuli, difficulties concentrating, performing tasks efficiently and inhibiting unwanted thoughts and distraction. We used pupillometry and eye-movement measures to compare high vs. low anxious individuals hyper-reactivity to emotional stimuli (facial expressions) and subsequent attentional biases in a memory-guided pro- and antisaccade task during conditions of low and high cognitive load (short vs. long delay). High anxious individuals produced larger and slower pupillary responses to face stimuli, and more erroneous eye-movements, particularly following long delay. Low anxious individuals' pupillary responses were sensitive to task demand (reduced during short delay), whereas high anxious individuals' were not. These findings provide evidence in anxiety of enhanced, sustained and inflexible patterns of pupil responding during affective stimulus processing and cognitive load that precede deficits in task performance.

Evaluating the Effectiveness of a School-Based Cognitive Behavioural Therapy Intervention for Anxiety in Adolescents Diagnosed with Autism Spectrum Disorder.

This study evaluated the effectiveness of a school-based Cognitive Behavioural Therapy (CBT) on symptoms of anxiety, social worry and social responsiveness, and indices of attentional control and attentional biases to threat in adolescents diagnosed with Autism Spectrum Disorder. Thirty-five young people (11-14 years; IQ > 70) with ASD and elevated teacher or parent reported anxiety were randomly assigned to 6 sessions of the Exploring Feelings CBT intervention (Attwood in Exploring feelings (anxiety). Future Horizons, Arlington, 2004) (n = 18) or a wait-list control group (n = 17). The intervention (compared to the wait-list control) group showed positive change for parent, teacher and self-reported anxiety symptoms, and more marginal effects of increased teacher-reported social responsiveness. The discussion highlights the potential value and limitations of school-based CBT for young people with ASD.

Working Memory Training and CBT Reduces Anxiety Symptoms and Attentional Biases to Threat: A Preliminary Study.

Research indicates that cognitive processes linked to the detection of threat stimuli are associated with poor attentional control, placing children and adolescents at increased risk for the development of anxious affect. The current study aimed to provide preliminary data to assess whether an intervention designed to improve attentional control (via working memory; WM) would lead to better performance in tests of WM and would be associated with positive changes in symptoms of trait and test anxiety, increased inhibitory control and reduced attention to threat. Forty adolescents aged 11-14 years who reported elevated anxiety and low attentional control were randomly allocated to a WM training or an active cognitive behavioural therapy (CBT) control group. Post intervention, WM training was associated with greater improvements (versus. CBT) in trained WM tasks. Both groups, however, reported fewer anxiety symptoms, demonstrated increased inhibitory control and a reduction in attentional biases to threat post intervention and these results were maintained at follow up. The study provides indicative evidence which suggests that WM training has similar benefits to a more traditional CBT intervention on reduced anxiety and attentional biases for threat. Future research should aim to replicate the findings in a large sample size and explore the broader impact of training on day-to-day functioning. In addition, further research is needed to identify which participants benefit most from different interventions (using baseline characteristics) on treatment compliance and outcome.

Psychometric Properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in a Non-Clinical Sample of Children and Adolescents in Saudi Arabia.

This paper examined the reliability, convergent validity and factor structure of the self-report Screen for Child Anxiety Disorders (SCARED; Birmaher et al. in J Am Acad Child Adolesc Psychiatry 36:545-553, 1997) in a large community sample of children and adolescents in Saudi Arabia. The questionnaire showed moderate to high internal consistency and satisfactory test-retest reliability over a 2 week period. In addition, there were significant positive correlations between reported anxiety symptoms with parent report behavioural difficulties. The five factor structure model of the SCARED also had a good model fit in this population. The results showed that self-report anxiety symptoms decreased with age (for boys and not girls) and were higher in adolescent girls. The results suggest that the SCARED could be useful in this population to identify individuals who are at risk of developing anxiety disorders in childhood with a view to implementing prevention and intervention methods to ensure positive developmental outcome over time.

The development of emotion recognition from facial expressions and non-linguistic vocalizations during childhood.

Sensitivity to facial and vocal emotion is fundamental to children's social competence. Previous research has focused on children's facial emotion recognition, and few studies have investigated non-linguistic vocal emotion processing in childhood. We compared facial and vocal emotion recognition and processing biases in 4- to 11-year-olds and adults. Eighty-eight 4- to 11-year-olds and 21 adults participated. Participants viewed/listened to faces and voices (angry, happy, and sad) at three intensity levels (50%, 75%, and 100%). Non-linguistic tones were used. For each modality, participants completed an emotion identification task. Accuracy and bias for each emotion and modality were compared across 4- to 5-, 6- to 9- and 10- to 11-year-olds and adults. The results showed that children's emotion recognition improved with age; preschoolers were less accurate than other groups. Facial emotion recognition reached adult levels by 11 years, whereas vocal emotion recognition continued to develop in late childhood. Response bias decreased with age. For both modalities, sadness recognition was delayed across development relative to anger and happiness. The results demonstrate that developmental trajectories of emotion processing differ as a function of emotion type and stimulus modality. In addition, vocal emotion processing showed a more protracted developmental trajectory, compared to facial emotion processing. The results have important implications for programmes aiming to improve children's socio-emotional competence.

Emotion-recognition abilities and behavior problem dimensions in preschoolers: evidence for a specific role for childhood hyperactivity.

Facial emotion-recognition difficulties have been reported in school-aged children with behavior problems; little is known, however, about either this association in preschool children or with regard to vocal emotion recognition. The current study explored the association between facial and vocal emotion recognition and behavior problems in a sample of 3 to 6-year-old children. A sample of 57 children enriched for risk of behavior problems (41 were recruited from the general population while 16 had been referred for behavior problems to local clinics) were each presented with a series of vocal and facial stimuli expressing different emotions (i.e., angry, happy, and sad) of low and high intensity. Parents rated children's externalizing and internalizing behavior problems. Vocal and facial emotion recognition accuracy was negatively correlated with externalizing but not internalizing behavior problems independent of emotion type. The effects with the externalizing domain were independently associated with hyperactivity rather than conduct problems. The results highlight the importance of using vocal as well as facial stimuli when studying the relationship between emotion-recognition and behavior problems. Future studies should test the hypothesis that difficulties in responding to adult instructions and commands seen in children with attention deficit/hyperactivity disorder (ADHD) may be due to deficits in the processing of vocal emotions.

When does anxiety help or hinder cognitive test performance? The role of working memory capacity.

Cognitive interference theories (e.g. attentional control theory, processing efficiency theory) suggest that high levels of trait anxiety predict adverse effects on the performance of cognitive tasks, particularly those that make high demands on cognitive resources. We tested an interaction hypothesis to determine whether a combination of high anxiety and low working memory capacity (WMC) would predict variance in demanding cognitive test scores. Ninety six adolescents (12- to 14-years-old) participated in the study, which measured self-report levels of trait anxiety, working memory, and cognitive test performance. As hypothesized, we found that the anxiety-WMC interaction explained a significant amount of variance in cognitive test performance (ΔR(2) .07, p < .01). Trait anxiety was unrelated to cognitive test performance for those adolescents with average WMC scores (ß = .13, p > .10). In contrast, trait anxiety was negatively related to test performance in adolescents with low WMC (ß = -.35, p < .05) and positively related to test performance in those with high WMC (ß = .49, p < .01). The results of this study suggest that WMC moderates the relationship between anxiety and cognitive test performance and may be a determinant factor in explaining some discrepancies found in the literature. Further research is needed to fully understand the mechanisms involved.

Exploring the function of selective attention and hypervigilance for threat in anxiety.

Theoretical frameworks of anxiety propose that attentional biases to threat-related stimuli cause or maintain anxious states. The current paper draws on theoretical frameworks and key empirical studies to outline the distinctive attentional processes highlighted as being important in understanding anxiety. We develop a conceptual framework to make a distinction between two attentional biases: selective attention to threat and hypervigilance for threat. We suggest that these biases each have a different purpose and can account for the typical patterns of facilitated and impaired attention evident in anxious individuals. The framework is novel in its specification of the eye movement behavior associated with these attentional biases. We highlight that selective attention involves narrowing overt attention onto threat to ensure that these stimuli receive processing priority, leading to rapid engagement with task-relevant threat and delayed disengagement from task-irrelevant threat. We show that hypervigilance operates in the presence and absence of threat and involves monitoring for potential dangers via attentional broadening or excessive scanning of the environment with numerous eye movements, leading to improved threat detection and increased distraction from task-irrelevant threat. We conclude that future research could usefully employ eye movement measures to more clearly understand the diverse roles of attention in anxiety.

Isolating N400 as neural marker of vocal anger processing in 6-11-year old children.

INTRODUCTION: Vocal anger is a salient social signal serving adaptive functions in typical child development. Despite recent advances in the developmental neuroscience of emotion processing with regard to visual stimuli, little remains known about the neural correlates of vocal anger processing in childhood. This study represents the first attempt to isolate a neural marker of vocal anger processing in children using electrophysiological methods. METHODS: We compared ERP wave forms during the processing of non-word emotional vocal stimuli in a population sample of 55 6-11-year-old typically developing children. Children listened to three types of stimuli expressing angry, happy, and neutral prosody and completed an emotion identification task with three response options (angry, happy and neutral/'ok'). RESULTS: A distinctive N400 component which was modulated by emotional content of vocal stimulus was observed in children over parietal and occipital scalp regions-amplitudes were significantly attenuated to angry compared to happy and neutral voices. DISCUSSION: Findings of the present study regarding the N400 are compatible with adult studies showing reduced N400 amplitudes to negative compared to neutral emotional stimuli. Implications for studies of the neural basis of vocal anger processing in children are discussed.

The attentional processes underlying impaired inhibition of threat in anxiety: the remote distractor effect.

The current study explored the proposition that anxiety is associated with impaired inhibition of threat. Using a modified version of the remote distractor paradigm, we considered whether this impairment is related to attentional capture by threat, difficulties disengaging from threat presented within foveal vision, or difficulties orienting to task-relevant stimuli when threat is present in central, parafoveal and peripheral locations in the visual field. Participants were asked to direct their eyes towards and identify a target in the presence and absence of a distractor (an angry, happy or neutral face). Trait anxiety was associated with a delay in initiating eye movements to the target in the presence of central, parafoveal and peripheral threatening distractors. These findings suggest that elevated anxiety is linked to difficulties inhibiting task-irrelevant threat presented across a broad region of the visual field.

An experimental investigation of peer influences on adolescent hostile attributions.

Aggression in young people has been associated with a bias toward attributing hostile intent to others. However, little is known about the origin of biased social information processing. The current study explored the potential role of peer contagion in the emergence of hostile attribution in adolescents. One hundred thirty-four adolescents (M age = 13.8 years) were assigned to one of two manipulated "chat-room" conditions, where they believed they were communicating with online peers (e-confederates) who endorsed either hostile or benign intent attributions. Adolescents showed increased hostile attributions following exposure to hostile e-confederates and reduced hostility in the benign condition. Further analyses demonstrated that social anxiety was associated with a reduced tendency to take on hostile peer attitudes. Neither gender nor levels of aggression influenced individual susceptibility to peer influence, but aggressive adolescents reported greater affinity with hostile e-confederates.