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.

Family Accommodation and Separation Anxiety: The Moderating Role of Child Attachment.

Family accommodation, or changes in parental behavior aimed at avoiding or alleviating child anxiety-related distress, contributes to the severity of anxiety symptoms, and is most strongly associated with separation anxiety. This study examined whether child attachment security, characterized as the degree to which children perceive their parents to be reliable, available, and communicative, moderates the association between family accommodation and separation anxiety symptoms, and whether this moderation is specific to separation anxiety among other anxiety symptoms. In a sample of clinically anxious children (N = 243, 6-12 years), family accommodation was significantly positively associated with separation anxiety symptoms across levels of attachment security. Family accommodation was more strongly associated with parent-reported separation anxiety symptoms in children with lower attachment security compared with those with higher attachment security. No significant moderation effect emerged for other anxiety symptoms. Findings enhance understanding of the role of attachment within family accommodation of child anxiety.

Brain Functional Connectivity and Anatomical Features as Predictors of Cognitive Behavioral Therapy Outcome for Anxiety in Youths.

Background: Because pediatric anxiety disorders precede the onset of many other problems, successful prediction of response to the first-line treatment, cognitive-behavioral therapy (CBT), could have major impact. However, existing clinical models are weakly predictive. The current study evaluates whether structural and resting-state functional magnetic resonance imaging can predict post-CBT anxiety symptoms. Methods: Two datasets were studied: (A) one consisted of n=54 subjects with an anxiety diagnosis, who received 12 weeks of CBT, and (B) one consisted of n=15 subjects treated for 8 weeks. Connectome Predictive Modeling (CPM) was used to predict treatment response, as assessed with the PARS; additionally we investigated models using anatomical features, instead of functional connectivity. The main analysis included network edges positively correlated with treatment outcome, and age, sex, and baseline anxiety severity as predictors. Results from alternative models and analyses also are presented. Model assessments utilized 1000 bootstraps, resulting in a 95% CI for R2, r and mean absolute error (MAE). Outcomes: The main model showed a mean absolute error of approximately 3.5 (95%CI: [3.1-3.8]) points a R2 of 0.08 [-0.14 - 0.26] and r of 0.38 [0.24 - 0.511]. When testing this model in the left-out sample (B) the results were similar, with a MAE of 3.4 [2.8 - 4.7], R2-0.65 [-2.29 - 0.16] and r of 0.4 [0.24 - 0.54]. The anatomical metrics showed a similar pattern, where models rendered overall low R2. Interpretation: The analysis showed that models based on earlier promising results failed to predict clinical outcomes. Despite the small sample size, the current study does not support extensive use of CPM to predict outcome in pediatric anxiety.

Responding to threat: Associations between neural reactivity to and behavioral avoidance of threat in pediatric anxiety.

BACKGROUND: Despite broad recognition of the central role of avoidance in anxiety, a lack of specificity in its operationalization has hindered progress in understanding this clinically significant construct. The current study uses a multimodal approach to investigate how specific measures of avoidance relate to neural reactivity to threat in youth with anxiety disorders. METHODS: Children with anxiety disorders (ages 6-12 years; n = 65 for primary analyses) completed laboratory task- and clinician-based measures of avoidance, as well as a functional magnetic resonance imaging task probing neural reactivity to threat. Primary analyses examined the ventral anterior insula (vAI), amygdala, and ventromedial prefrontal cortex (vmPFC). RESULTS: Significant but distinct patterns of association with task- versus clinician-based measures of avoidance emerged. Clinician-rated avoidance was negatively associated with right and left vAI reactivity to threat, whereas laboratory-based avoidance was positively associated with right vAI reactivity to threat. Moreover, left vAI-right amygdala and bilateral vmPFC-right amygdala functional connectivity were negatively associated with clinician-rated avoidance but not laboratory-based avoidance. LIMITATIONS: These results should be considered in the context of the restricted range of our treatment-seeking sample, which limits the ability to draw conclusions about these associations across children with a broader range of symptomatology. In addition, the limited racial and ethnic diversity of our sample may limit the generalizability of findings. CONCLUSION: These findings mark an important step towards bridging neural findings and behavioral patterns using a multimodal approach. Advancing understanding of behavioral avoidance in pediatric anxiety may guide future treatment optimization by identifying individual-specific targets for treatment.

Assessing Anxiety-Related Impairment in Children and Adolescents.

Anxiety disorders (ADs) frequently lead to significant impairment across important domains of youth functioning. Yet until recently, clinical research and assessment have largely neglected the measurement of anxiety-related impairment. In this article, we review the evidence for five extant rating scales of youth anxiety-related impairment, guided by widely used evaluative criteria. Emerging psychometric data show the potential utility of these rating scales for achieving different assessment functions. Of the five scales, the Child Anxiety Impact Scale, particularly the parent-report version, has been the most researched one. Promising psychometric data support its use for assessing anxiety-related impairment in school, social, and family/home domains of functioning. We conclude with recommendations for growing this research base and for incorporating these rating scales into the youth AD clinical and research assessment process.

Randomized trial comparing standard versus light intensity parent training for anxious youth.

OBJECTIVE: To examine the efficacy of the parent-led intervention Supportive Parenting for Anxious Childhood Emotions (SPACE) relative to a low-dose version of the protocol among children and adolescents with clinically significant anxiety and/or obsessive-compulsive disorder (OCD). METHOD: 68 youth (7-17) with anxiety/OCD and their parents were randomized to receive 12 weekly telehealth SPACE sessions (SPACE-Standard) or bibliotherapy plus 4 telehealth sessions over 12 weeks (SPACE-light). After screening, assessments were conducted via videoconferencing at baseline, post-treatment, and one-month follow-up. Independent evaluators were blind to treatment condition. RESULTS: Treatment condition did not predict whether a participant responded to the intervention (SPACE-Standard = 70%; SPACE-Light = 68%), nor was treatment condition a predictor of anxiety severity, parent-reported anxiety, or parent-/child-reported functional impairment at post-treatment or one-month follow-up. Youth in SPACE-Light self-reported higher post-treatment anxiety than youth in SPACE-standard, though this was no longer significant at one-month follow-up. Parent-reported family accommodation total change scores were associated with anxiety severity at post-treatment across both arms. CONCLUSION: This is the second randomized controlled trial (RCT) evaluating SPACE and provides further support for the efficacy of this intervention both in standard and low-dose formats. This study provides support for parent-led anxiety treatment targeting family accommodation as a primary mechanism of change and extends evidence of efficacy to a more clinically diverse sample. TRIAL REGISTRATION: ClinicalTrials.gov Registry: NCT04922502.https://classic. CLINICALTRIALS: gov/ct2/show/NCT04922502.

Transactional associations of child irritability and anxiety with parent psychological control in Taiwanese school-aged children.

Background: Child irritability and anxiety are associated with parent psychological control; yet their transactional relations over time are not well-characterized at the within-person level. Research addressing generalizability of past Western-based literature in non-Western, collectivist community samples is lacking. Methods: Sample comprised 285 children aged 8.8-11.4 years (145 girls; Mage = 9.9 years, SD = 0.6) in Northern Taiwan. Participants were assessed at baseline (T1), 6-month (T2), and 12-month (T3) follow-ups. Child irritability and anxiety symptoms were assessed using parent-rated Child Behavior Checklist. Parent psychological control was assessed using the parent- and child-rated Psychological Control Scale. Within-person processes were specified using the random-intercept cross-lagged panel models. Results: Models showed that psychological control predicted increased child irritability when analyzing parenting data from parents and children. However, the lagged effect from psychological control to child anxiety was only seen in parent-rated parenting data. We found limited evidence for a back-and-forth transactional pathway among constructs. Child irritability predicted increased child anxiety in all models. Conclusions: Directional effects from psychological control to child irritability and anxiety support parent-involved interventions that prioritize collaborative parenting and positive reinforcement techniques. Future validations in combined clinical and typically developing samples and direct cross-cultural comparisons are warranted.

Family Accommodation and Separation Anxiety: The Moderating Role of Child Attachment.

Family accommodation, or changes in parental behavior aimed at avoiding or alleviating child anxiety-related distress, contributes to the severity of anxiety symptoms, and is most strongly associated with separation anxiety symptoms. This study examined whether child attachment security, characterized as the degree to which children perceive their parents to be reliable, available, and communicative, moderates the association between family accommodation and separation anxiety symptoms, and whether this moderator is specific to separation anxiety among other anxiety symptoms. In a sample of clinically anxious youth (N = 243, 6-12 yrs), family accommodation was significantly positively associated with separation anxiety symptoms across levels of attachment security. Family accommodation was more strongly associated with separation anxiety symptoms in children with lower attachment security compared with those with higher attachment security. No significant moderation effect emerged for other anxiety symptoms. Findings enhance understanding of the role of attachment within family accommodation of child anxiety.

Does Cognitive-Behavioral Therapy for Youth Anxiety Disorders Improve Social Functioning and Peer Relationships?

Child and adolescent anxiety disorders (ADs) contribute to impairment in social functioning and peer relationships, exacerbating anxiety and related difficulties. The extent to which the AD treatment with the strongest evidence-base, cognitive-behavioral therapy (CBT), improves social functioning and peer relationships is unclear. In this article, we report results of the first systematic narrative review of this topic. Randomized clinical trials of CBT for child and/or adolescent ADs were included if they used at least one measure of social functioning or peer relationships as a treatment outcome. Sixteen studies met our inclusion criteria. From each study, we extracted the sample characteristics, treatment arms, social and/or peer outcome measures, and statistical findings. Results show that social functioning and/or peer relationships improved over time in the majority of studies, highlighting an important aspect of treatment efficacy beyond anxiety reduction. There were also several treatment-specific effects, but considerable variability across studies' samples, methods, and findings, makes it difficult to draw firm conclusions about which specific treatments improve specific outcomes. We recommend next steps for research to reconcile these findings, including improved operationalization and standardization of social and peer outcomes, and research on treatment specificity and mechanisms.

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.

A Pilot Trial of SPACE (Supportive Parenting for Anxious Childhood Emotions) in Autism.

Family accommodation describes changes parents make to their behavior, intended to alleviate their child's distress, which stems from a psychopathology. In anxiety, studies show that accommodation alleviates distress in the short term but is associated with increased symptom severity, greater functional impairment, poorer treatment outcomes, increased caregiver burden and disruption to family functioning longitudinally. Research shows high prevalence of family accommodation of anxiety in autism. While the most common treatments for anxiety in autism are cognitive-behavior therapy and pharmacology, research is limited and other approaches must be considered. Supportive Parenting for Anxious Childhood Emotions (SPACE) is a parent-based, manualized treatment for anxiety targeting family accommodation, which has been found to be acceptable and efficacious in treating childhood anxiety. This pilot trial examined the feasibility, acceptability, treatment-satisfaction, and preliminary efficacy of SPACE for anxiety in autism. Parents of 15 autistic children (ages 6-10 years) with at least average cognitive abilities exhibiting high levels of anxiety participated in 13 weekly sessions of SPACE. Feasibility and acceptability were assessed through enrollment, attrition rates, and adverse events. Of 26 eligible families, 22 (84.62%) elected to participate, 15 of whom (68.18%) completed treatment. Parents rated the treatment as highly satisfactory. Anxiety symptom severity and family accommodation were significantly reduced following treatment, with 86.66% of participants showing reliable change post-treatment, and this reduction was preserved at 2-month follow-up. This study provides preliminary evidence that SPACE is feasible, acceptable, satisfactory, and produces improvement in anxiety in the autistic population.Trial registration number: NCT04747262 Date of registration: February 10, 2021.

Oxytocin as a Biomarker of Differential Effects to SPACE vs. CBT Treatment of Child Anxiety Disorders.

OBJECTIVE: Two lines of research, on outcome moderators and on novel treatment targets, seek to improve the overall efficacy of child anxiety treatment, with mixed results. We propose that an integration of both lines of research can lead to improved treatment efficacy. In a first proof of concept of this approach, we studied whether the interaction between baseline levels and targeted changes in peripheral oxytocin (OT) can predict differential responses to two childhood anxiety treatments. METHOD: A total of 124 mother-child dyads participated in the study. Children's salivary OT levels were measured at baseline and again, immediately after an experimental dyadic interaction in the lab. Dyads were subsequently randomized to receive one of two treatments, differing in their targets: SPACE (Supportive Parenting for Anxious Childhood Emotions) and CBT (cognitive-behavioral therapy). Treatment outcomes were assessed using the Childhood Anxiety Related Emotional Disorders scale, reported by both mother and child. RESULTS: The findings suggest that in SPACE, where the mother is the main agent of change, higher baseline levels of child OT, coupled with increases in OT following a positive mother-child interaction, predicted greater treatment efficacy. By contrast, in CBT, where the child is the main agent of change, higher baseline levels of child OT, coupled with a decrease in OT following the interaction, predicted greater treatment efficacy. CONCLUSIONS: The findings highlight the importance of the integration between moderators and targets of treatments for progress toward improving treatment efficacy through precision medicine.

The Role of Pediatric Sensory Over-responsivity and Anxiety Symptoms in the Development of Family Accommodations.

Sensory over-responsivity (SOR) is linked with elevated anxiety and reduced family wellbeing. Family accommodation of anxiety relates with greater symptom severity and reduced intervention outcome. This study examined the contribution of child SOR and co-occurring anxiety symptoms to family accommodation and its consequences. Ninety families of typically developing children (ages 4-13 years), completed an online survey including the Sensory Profile 2, Screen for Child Anxiety Related Emotional Disorders (SCARED), and Family Accommodation Sensory Scale (FASENS). FASENS scores include frequency of accommodation, child impact, and family impact.Children with elevated anxiety symptoms had significantly higher sensory and FASENS scores. Stepwise linear regression indicated that only SOR symptoms significantly predicted the frequency of sensory family accommodation, while both SOR and anxiety symptoms predicted the impact of family accommodation upon child and family well-being.Both SOR and anxiety symptoms in children predict the impact of sensory family accommodations on child and family well-being.

Affective language spreads between anxious children and their mothers during a challenging puzzle task.

Humans influence each other's emotions. The spread of emotion is well documented across behavioral, psychophysiological, and neuroscientific levels of analysis, but might this influence also be evident in language (e.g., are people more likely to use emotion words after hearing someone else use them)? The current study tests whether mothers and children influence each other's use of affective language. From 2018 to 2020, children aged 6-12 who met diagnostic criteria for anxiety disorders and their mothers (N = 93 dyads) completed a challenging puzzle task while being video recorded. Analyses of transcriptions revealed that mothers and children indeed influenced each other's language. Bidirectional influence was observed for use of negative affect words: Mothers were more likely to use negative affect words if their child had just used negative affect words (over and above mothers' own language on their previous turn), and children were similarly influenced by mother affect word use. A similar bidirectional relation emerged for linguistic distance, a measure related to effective emotion regulation and mental health. However, the significance of the child-to-mother direction of influence for these two variables varied depending on correction threshold and should thus be verified in future research. Nonetheless, these findings extend understanding of emotional influence by showing turn-by-turn relations between the use of affective language. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

Maternal FGF2 levels associated with child anxiety and depression symptoms through child FGF2 levels.

BACKGROUND: Recent research implicates fibroblast growth factor 2 (FGF2) in anxiety and depressive symptoms of childhood. This study is the first to examine an intergenerational pathway linking FGF2 levels in mothers to FGF2 levels in children, and to the children's anxiety and depressive symptoms. METHODS: We assayed serum FGF2 in 259 mothers and their children, with a range of anxiety and depressive symptoms: 194 were mothers of clinic-referred anxious and depressed children; 65 were mothers of non-referred children. We examined associations between FGF2 levels in mothers and children, and anxiety and depression symptoms. We used structural equation modeling (SEM) to examine associations between maternal and child FGF2 levels, and between maternal and child FGF2 levels and symptoms of anxiety and depression in and children. RESULTS: FGF2 levels in mothers and children were significantly positively correlated. Children's FGF2 levels were significantly negatively correlated with their ratings of anxiety and depression. Results of the SEM model showed that increases in maternal FGF2 levels were significantly associated with increases in child FGF2, which in turn was associated with decreases in child anxiety and child depression, controlling for maternal anxiety and depression. LIMITATIONS: We relied on self-reported ratings of anxiety and depression, and on a single measurement of FGF2 levels for each participant. CONCLUSIONS: Our results point to a role for FGF2 in the intergenerational transmission of risk for, and resilience to, anxiety and depression in youth.

Clinical Update: The Role of Family Accommodation in Youth Anxiety Treatment Outcomes.

Over the past several years, family accommodation (FA) has gained increasing recognition for its role in child and adolescent anxiety disorders. Recent clinical trials highlight the importance of assessing and addressing FA within the context of treatment, with findings showing that FA is a significant predictor of treatment success. This clinical update was prompted by such findings, and specifically findings from a study by Zilcha-Mano and colleagues (2020) which suggest that the level of agreement between child- and parent-reports of FA has differential effects on outcomes for child- and parent-based treatments. In this article we aim to provide (1) a brief overview of the research pointing to the reduction of FA as a critical ingredient of youth anxiety treatment, and (2) a summary and in-depth discussion of the study by Zilcha-Mano et al. (2020) that speaks to the potential importance of leveraging multi-informant reports of FA. With regard to the latter aim, we offer preliminary suggestions for how clinicians might incorporate measures of FA into their practice to maximize benefits for anxious youth and their families. We also offer suggestions for how future research can build on these novel findings, advance methods of FA assessment, and promote its clinical utility.

Youth social functioning interacts with treatment arm, diagnosis, and gender to predict anxiety treatment outcome.

Research has uncovered a wide range of predictors of youth anxiety treatment outcome (i.e., symptom severity and diagnostic remission). Youth's social functioning is one predictor that has been rarely studied, however, which is a significant gap given its importance to development and clinical functioning. We address this gap by examining two aspects of youth's social functioning as predictors of anxiety treatment outcome: (1) positive social interactions and (2) social skills. We further examined the moderating roles of treatment arm (child- or parent-based treatment), diagnosis (presence or absence of social anxiety disorder), and youth gender, between each of the two predictors and treatment response and remission. Participants were 96 youths with anxiety disorders (6-16 years; 54% girls) and their mothers, who completed diagnostic interviews and questionnaires at baseline and posttreatment. Multiple regression models revealed that higher baseline parent-reports of their child's social skills predicted lower posttreatment anxiety symptom severity for youth with social anxiety disorder. Modified linear probability models revealed that baseline youth-reports of their social skills predicted remission from anxiety diagnoses for youths assigned to the parent-based treatment. Baseline youth-reports of their positive social interactions and parent-reports of youth social skills predicted remission from anxiety diagnoses for girls. Results contribute to the predictor literature by highlighting the importance of youth social functioning to anxiety treatment outcome.