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.
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).
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.
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.
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.
•We bridge neural and behavioral findings using a multimodal approach.•Results differed for laboratory- versus clinician-based avoidance measures.•Laboratory-based avoidance was related to increased insula reactivity to threat.•Clinician-rated avoidance was related to reduced insula reactivity to threat.•Clinician-rated avoidance was also related to connectivity between key regions.
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.
We conducted a dismantling design treatment study comparing individual cognitive behavioral therapy (CBT), CBT targeting parents’ reinforcement skills (CBT + Reinf), and CBT targeting parents’ ...relationship skills (CBT+ Relat) in 341 youths with primary anxiety diagnoses. At posttreatment, youths in CBT with parent involvement had lower anxiety than youths in CBT. At 12-month follow-up, youths in CBT + Relat maintained lower anxiety relative to CBT. At posttreatment, negative reinforcement was significantly lower in CBT + Reinf than CBT + Relat and CBT; negative reinforcement partially mediated anxiety reduction in youths. Reducing parental negative reinforcement in CBT + Reinf was associated with lower parental psychological control, which also partially mediated anxiety reduction in youths. Some of these mediational dynamics continued through follow-up. Targeting concrete behavioral parenting skills, especially negative reinforcement, produced treatment specificity and partial mediation relative to less concrete targeting and enhanced CBT. Findings highlight complexities in identifying mechanisms through which targeting of parenting skills produces anxiety reduction in youths and suggest avenues for future research.
•Tested attention training for concerning anxiety in youth.•Attention training led to reductions in anxiety severity and global impairment.•Changes in attention control were associated with changes ...in anxiety.•Findings support the viability of attention training for concerning anxiety.
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.
Children and adolescents demonstrate diverse patterns of symptom change and disorder remission following cognitive behavioural therapy (CBT) for anxiety disorders. To better understand children who ...respond sub-optimally to CBT, this study investigated youths (N = 1,483) who continued to meet criteria for one or more clinical anxiety diagnosis immediately following treatment or at any point during the 12 months following treatment.
Data were collected from 10 clinical sites with assessments at pre-and post-treatment and at least once more at 3, 6 or 12-month follow-up. Participants were assigned to one of three groups based on diagnostic status for youths who: (a) retained an anxiety diagnosis from post to end point (minimal responders); (b) remitted anxiety diagnoses at post but relapsed by end point (relapsed responders); and (c) retained a diagnosis at post but remitted to be diagnosis free at end point (delayed responders). Growth curve models assessed patterns of change over time for the three groups and examined predictors associated with these patterns including demographic, clinical and parental factors, as well as treatment factors.
Higher primary disorder severity, being older, having a greater number of anxiety disorders, having social anxiety disorder, as well as higher maternal psychopathology differentiated the minimal responders from the delayed and relapsed responders at the baseline. Results from the growth curve models showed that severity of the primary disorder and treatment modality differentiated patterns of linear change only. Higher severity was associated with significantly less improvement over time for the minimal and relapsed response groups, as was receiving group CBT, when compared to the delayed response group.
Sub-optimal response patterns can be partially differentiated using variables assessed at pre-treatment. Increased understanding of different patterns of change following treatment may provide direction for clinical decision-making and for tailoring treatments to specific groups of clinically anxious youth. Future research may benefit from assessing progress during treatment to detect emerging response patterns earlier.
•First confirmatory factor analysis on the Attentional Control Scale for Children.•A two-factor model provided the best fit to the data.•The model was invariant across sex and partially invariant ...across ethnic groups.•-Concurrent validity was supported through correlations with anxiety and depression.•Finding support the utility of the ACS-C to measure attentional control in youth.
The Attentional Control Scale for Children (ACS-C) is a widely used self-report questionnaire that measures attentional control in youth. Previous research examined factor-structure and validation of the ACS-C and yielded a 2-factor structure with Attentional Focusing and Attentional Shifting subscales. This study used a confirmatory factor analysis in a large, ethnically diverse sample of clinic-referred anxious youth (N = 442, ages 7–16 years) to compare model fit of three models, the original two-factor model of the ACS-C, a two-factor model of a modified ACS-C (two items re-assigned from Attentional Focusing to Attentional Shifting, three items removed from Attentional Focusing, and two items removed from Attentional Shifting), and a single-factor model. Results reveal best model fit for the two-factor modified ACS-C. This model had strong factorial invariance across sex, partial invariance across ethnicity, and was variant across age. Also, total and subscale scores for the two-factor modified ACS-C correlated with anxiety and depression symptom scale scores, supporting its concurrent validity. Findings confirm the two-factor structure of the modified ACS-C. Future research implications relating to attentional control in children are discussed.
Treatment specificity and long-term recovery mediation of peer-involvement group cognitive behavioral therapy (GCBT) and parent-involvement CBT (PCBT) were investigated for youth anxiety disorders. ...Two hundred forty youths with primary anxiety diagnoses participated in a randomized controlled efficacy trial. Youth anxiety and peer variables/mediators (positive peer–youth relationships; social skills) and parent variables/mediators (psychological control; negative parent–youth relationships) were assessed. At posttreatment and 12-month follow-up, positive peer-youth relationships were significantly higher in GCBT than PCBT (specificity) according to youth and parent ratings. At posttreatment but not follow-up, parental psychological control was significantly lower in PCBT than GCBT (specificity) and findings varied by informants. Parental psychological control and positive peer–youth relationships were putative mediators. The two CBTs produced similar anxiety reductions through different mechanisms. CBT targets show specificity and mediation, providing insight into specific mechanisms through which GCBT and PCBT bring about anxiety reduction and guidance for streamlining these CBTs in practice.
A substantial number of children with anxiety disorders do not improve following cognitive behavioral therapy (CBT). Recent effectiveness studies have found poorer outcome for CBT programs than what ...is typically found in efficacy studies. The present study examined predictors of treatment outcome among 181 children (aged 8–15 years), with separation anxiety, social phobia, or generalized anxiety disorder, who participated in a randomized, controlled effectiveness trial of a 10-session CBT program in community clinics. Potential predictors included baseline demographic, child, and parent factors. Outcomes were as follows: a) remission from all inclusion anxiety disorders; b) remission from the primary anxiety disorder; and c) child- and parent-rated reduction of anxiety symptoms at post-treatment and at 1-year follow-up. The most consistent findings across outcome measures and informants were that child-rated anxiety symptoms, functional impairment, a primary diagnosis of social phobia or separation anxiety disorder, and parent internalizing symptoms predicted poorer outcome at post-treatment. Child-rated anxiety symptoms, lower family social class, lower pretreatment child motivation, and parent internalizing symptoms predicted poorer outcome at 1-year follow-up. These results suggest that anxious children with more severe problems, and children of parents with elevated internalizing symptom levels, may be in need of modified, additional, or alternative interventions to achieve a positive treatment outcome.
•Knowledge of predictors of outcome is important for adapting CBT in community clinics.•Anxiety symptom severity and impairment predicted poorer outcome.•A primary social phobia or separation anxiety disorder predicted poorer outcome.•Parent internalizing symptoms predicted poorer outcome.•Children with these characteristics may need adapted CBT treatment.
Questionnaire measures offer a time and cost-effective alternative to full diagnostic assessments for identifying and differentiating between potential anxiety disorders and are commonly used in ...clinical practice. Little is known, however, about the capacity of questionnaire measures to detect specific anxiety disorders in clinically anxious preadolescent children. This study aimed to establish the ability of the Spence Children's Anxiety Scale (SCAS) subscales to identify children with specific anxiety disorders in a large clinic-referred sample (N = 1,438) of children aged 7 to 12 years. We examined the capacity of the Separation Anxiety, Social Phobia, Generalized Anxiety, and Physical Injury Fears (phobias) subscales to discriminate between children with and without the target disorder. We also identified optimal cutoff scores on subscales for accurate identification of children with the corresponding disorder, and examined the contribution of child, mother, and father reports. The Separation Anxiety subscale was able to accurately identify children with separation anxiety disorder, and this was replicated across all 3 reporters. Mother- and father-reported Social Phobia subscales also accurately identified children with social anxiety disorder, although child report was only able to accurately detect social anxiety disorder in girls. Using 2 or more reporters improved the sensitivity of the Separation Anxiety and Social Phobia subscales but reduced specificity. The Generalized Anxiety and Physical Injury Fears subscales failed to accurately identify children with the corresponding disorders. These findings have implications for the potential use of mother-, father-, and child-report SCAS subscales to detect specific disorders in preadolescent children in clinical settings.
Public Significance Statement
We evaluated the ability of the Spence Children's Anxiety Scale subscales to identify specific anxiety disorders in clinically anxious children aged 7 to 12 years. Findings provide support for the use of the Separation Anxiety and Social Phobia subscales to identify separation anxiety disorder and social anxiety disorder in clinical settings.
Anxiety disorders are common, and cognitive-behavioural therapy (CBT) is a first-line treatment. Candidate gene studies have suggested a genetic basis to treatment response, but findings have been ...inconsistent.
To perform the first genome-wide association study (GWAS) of psychological treatment response in children with anxiety disorders (n = 980).
Presence and severity of anxiety was assessed using semi-structured interview at baseline, on completion of treatment (post-treatment), and 3 to 12 months after treatment completion (follow-up). DNA was genotyped using the Illumina Human Core Exome-12v1.0 array. Linear mixed models were used to test associations between genetic variants and response (change in symptom severity) immediately post-treatment and at 6-month follow-up.
No variants passed a genome-wide significance threshold (P = 5 × 10(-8)) in either analysis. Four variants met criteria for suggestive significance (P<5 × 10(-6)) in association with response post-treatment, and three variants in the 6-month follow-up analysis.
This is the first genome-wide therapygenetic study. It suggests no common variants of very high effect underlie response to CBT. Future investigations should maximise power to detect single-variant and polygenic effects by using larger, more homogeneous cohorts.
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