Threat-based cognitive biases in anxious children: comparison with non-anxious children before and after cognitive behavioural treatment

Attention and interpretation biases for threat stimuli were assessed in 19 anxious (ANX) children before and after cognitive behavioural therapy (CBT), and compared with responses from 19 non-anxious (NA) control children collected over the same period. Attentional bias was assessed using a picture version of the visual probe task with threat, neutral and pleasant pictures. Threat interpretation bias was assessed using both a homographs task in which children used homograph words in a sentence and their neutral or threatening meaning was assessed, and a stories task in which children rated their negative emotion, danger judgments, and influencing ability in ambiguous situations. ANX children showed attention biases towards threat on the visual probe task and threat interpretation biases on the stories task but not the homographs task at pre-treatment in comparison with NA children. Following treatment, ANX children's threat interpretation biases as assessed on the stories task reduced significantly to within levels comparable to NA children. However, ANX children continued to show larger attentional biases towards threat than pleasant pictures on the visual probe task at post-treatment, whereas NA children did not show attentional biases. Moreover, a residual threat interpretation style on the stories task at post-treatment was associated with higher anxiety symptoms in both ANX and NA children.     

Do anxious parents interpretive biases towards threat extend into their child's environment?

Anxiety disorders are known to run in families [Turner, S. M., Beidel, D. C., & Costello, A. (1987). Psychopathology in the offspring of anxiety disorder patients. Journal of Consulting and Clinical Psychology, 55(2), 229–235] and environmental factors may largely account for the concordance between parental and child anxieties. Cognitive psychology models emphasise the importance of interpretive biases towards threat in the maintenance of anxiety and it is well established that anxious adults and children display similar interpretive biases and that these biases in anxious parents and their children are correlated. This raises the question of whether anxious cognitions/cognitive style may be transmitted from parent to child. We propose that this is more likely if anxious parents demonstrate interpretive biases not only about potential threats in their own environment but also about potential threats in their child's environment. Forty parents completed a recognition memory measure of interpretation bias adapted from Eysenck, Mogg, May, Richards, and Mathews (1991) [Bias in interpretation of ambiguous sentences related to threat in anxiety. Journal of Abnormal Psychology, 100(2), 144–150] to measure biases in response to potentially threat provoking situations involving themselves and their child. The interpretive biases demonstrated by parents were similar across situations involving themselves and their children. As expected, parental interpretive biases were further modified by anxiety with higher levels of parental anxiety associated with more negative interpretive biases about situations in their own and their child's environment, although this association was significantly stronger for potentially threat provoking situations in their own environment. These results are consistent with parent's interpretive biases extending beyond their own environment into their child's environment, although future research should continue to consider the mechanisms by which anxious parents may transmit fear cognitions to their children.     

Threat interpretation bias as a vulnerability factor in childhood anxiety disorders

The present study examined threat interpretation biases in children 7-12 years of age with separation, social and generalised anxiety disorders (N=15), non-anxious offspring at risk due to parental anxiety (N=16) and non-anxious controls of non-anxious parents (N=14). Children provided interpretations of ambiguous situations to assess cognitive, emotional and behavioural responses. In comparison with non-anxious control children and at-risk children who did not differ from each other, anxious children reported stronger negative emotion and less ability to influence ambiguous situations. These results suggest that threat interpretation bias may be a cognitive factor associated with ongoing childhood anxiety but not a vulnerability factor associated with parental anxiety.     

The impact of mothers' trait anxiety on their expectations of approach‐avoidance behaviour in anxious and non‐anxious children

This study investigated estimates of approach and avoidance behaviour in clinically anxious and non‐anxious children, and whether mothers' expectations of their children's avoidance differed as a function of high trait anxiety (HTA) versus low trait anxiety (LTA). Participants were 62 clinically anxious and 60 non‐anxious children aged 7–12 years and their mothers. Estimates of avoidance were obtained using an analogue task in which children and mothers were given threat and pleasant information about two novel animals and were asked to estimate children's avoidance of the threat animal's habitat when the threat animal was present (threat condition) and absent (safe condition) from the habitat and when its presence was uncertain (ambiguous condition). Contrary to expectation, anxious children did not differ from controls in estimates of avoidance in any condition. However, relative to HTA mothers of anxious children and LTA mothers of non‐anxious children, HTA mothers estimated greater approach behaviour by their non‐anxious children in the threat condition. Findings suggest that mothers' expectations of children's approach‐avoidance behaviour is influenced by both maternal and child factors.     

Differentiating between memory and interpretation biases in socially anxious and nonanxious individuals

Although individual cognitive biases toward threat in social anxiety are well established, few studies have examined the manner in which cognitive biases work in conjunction. In the present study, socially anxious ( n = 54 ) and nonanxious ( n = 58 ) individuals read 10 passages consisting of positive social or evaluative, negative social or evaluative, and neutral content and completed two cognitive tasks assessing memory of factual details and interpretation immediately and after 48 h. Socially anxious and nonanxious individuals did not differ in their memory for details presented in the passages. However, they made less positive and more negative interpretations of details included in the passages, particularly in positive passages that were self-relevant and particularly in positive passages after the delay. After including depression, state anxiety, and trait anxiety as covariates, biased interpretation of positive passages after the time delay remained significant, but biased interpretation of the self-relevant, positive passages did not. It is concluded that socially anxious individuals are characterized by accurate memory of threatening, factual material, but that they impose a biased interpretation upon that material, especially after some time has passed.     

Interpretation of Ambiguity in Children: A Prospective Study of Associations With Anxiety and Parental Interpretations

Interpretation of ambiguity is consistently associated with anxiety in children, however, the temporal relationship between interpretation and anxiety remains unclear as do the developmental origins of interpretative biases. This study set out to test a model of the development of interpretative biases in a prospective study of 110 children aged 5–9 years of age. Children and their parents were assessed three times, annually, on measures of anxiety and interpretation of ambiguous scenarios (including, for parents, both their own interpretations and their expectations regarding their child). Three models were constructed to assess associations between parent and child anxiety and threat and distress cognitions and expectancies. The three models were all a reasonable fit of the data, and supported conclusions that: (i) children’s threat and distress cognitions were stable over time and were significantly associated with anxiety, (ii) parents’ threat and distress cognitions and expectancies significantly predicted child threat cognitions at some time points, and (iii) parental anxiety significantly predicted parents cognitions, which predicted parental expectancies at some time points. Parental expectancies were also significantly predicted by child cognitions. The findings varied depending on assessment time point and whether threat or distress cognitions were being considered. The findings support the notion that child and parent cognitive processes, in particular parental expectations, may be a useful target in the treatment or prevention of anxiety disorders in children.     

Anxious cognitions in children: An exploration of associations and mediators

To investigate sources of influences connecting mothers' and their children's anxious cognitions, 65 children (aged 10 to 11 years) completed self‐report measures of anxiety. Children and mothers responded to an ambiguous scenario questionnaire and measures of parenting style and life events. Mothers also reported expectations about their child's reaction to ambiguous situations. Mothers' and children's threat cognitions were significantly correlated (r = .31), and partially mediated by mothers' expectations about their child. Mothers' anticipated distress was associated with expectations for their child's distress, which was associated with the child's own anticipated distress. Parenting and life events were significantly associated with children's interpretative bias, but did not mediate the intergenerational association in interpretative bias. The results suggest influences on children's ‘anxious cognitive style’ and potential targets for preventing and reducing maladaptive cognitions in children.     

Interpretation and Expectation in Childhood Anxiety Disorders: Age Effects and Social Specificity

Theory and treatment for childhood anxiety disorders typically implicates children’s negative cognitions, yet little is known about the characteristics of thinking styles of clinically anxious children. In particular, it is unclear whether differences in thinking styles between children with anxiety disorders and non-anxious children vary as a function of child age, whether particular cognitive distortions are associated with childhood anxiety disorders at different child ages, and whether cognitive content is disorder-specific. The current study addressed these questions among 120 7–12 year old children (53% female) who met diagnostic criteria for social anxiety disorder, other anxiety disorder, or who were not currently anxious. Contrary to expectations, threat interpretation was not inflated amongst anxious compared to non-anxious children at any age, although older (10–12 year old) anxious children did differ from non-anxious children on measures of perceived coping. The notion of cognitive-content specificity was not supported across the age-range. The findings challenge current treatment models of childhood anxiety, and suggest that a focus on changing anxious children’s cognitions is not warranted in mid-childhood, and in late childhood cognitive approaches may be better focussed on promoting children’s perceptions of control rather than challenging threat interpretations.     

Intergenerational transmission of attentional bias and anxiety

Earlier evidence has revealed a bi‐directional causal relationship between anxiety and attention biases in adults and children. This study investigated the prospective and concurrent relations between anxiety and attentional bias in a sample of 89 families (mothers, fathers, and first‐born children). Parents’ and children's attentional bias was measured when children were 7.5 years old, using both a visual probe task and visual search task with angry versus happy facial expressions. Generalized and social anxiety symptoms in parents and children were measured when children were 4.5 and 7.5 years old. Anxiety in parents and children was prospectively (but not concurrently) related to their respective attentional biases to threat: All participants showed a larger attentional bias to threat in the visual search (but not in the visual probe) task if they were more anxious at the 4.5 (but not at the 7.5) year measurement. Moreover, parents’ anxiety levels were prospectively predictive of the visual search attentional bias of their children after controlling for child anxiety. More anxiety in mothers at 4.5 years was related to a faster detection of angry among happy faces, while more anxiety in fathers predicted a faster detection of happy among angry faces in children at 7.5 years. We found no direct association between parental and child attentional biases. Our study contributes to the recently emerging literature on attentional biases as a potential mechanism in the intergenerational transmission of anxiety by showing that parents’ anxiety rather than parents’ attentional bias contributes to the intergenerational transmission of risk for child anxiety.     

Autobiographical memory in angry and anxious individuals

Recent studies have found that angry individuals are characterized by more pronounced attentional and interpretation biases toward threat than anxious individuals. The present study examined anger-related, anxiety-related, and neutral autobiographical memories in 35 angry participants, 33 anxious participants, and 29 non-angry/non-anxious, or healthy participants. Objective indices of autobiographical memories (i.e., retrieval latency, coding of specificity and affective tone) suggested that groups retrieved memories with similar properties. However, both angry and anxious participants rated their memories as less pleasant than healthy participants. These results indicate that memory biases are not part of the cognitive sequelae associated with anger and anxiety, although aspects of the appraisal of these personal memories are distorted.     

Effects of threat cues on attentional shifting, disengagement and response slowing in anxious individuals

According to cognitive models of anxiety, attentional biases for threat may cause or maintain anxiety states. Previous research using spatial cueing tasks has been interpreted in terms of difficulty in disengaging attention from threat in anxious individuals, as indicated by contrasts of response times (RTs) from threat cue versus neutral cue trials. However, on spatial cueing tasks, differences in RT between threat cue and neutral cue trials may stem from a slowing effect of threat on RT, as well as effects on allocation of visuospatial attention. The present study examined the effects of threat cues on both attentional cueing and response slowing. High and low anxious individuals completed a central cue task, which assessed threat-related response slowing, and a spatial cueing task, which assessed attentional biases for angry, happy and neutral faces. Results indicated that interpretation of the anxiety-related bias for threat depended on whether the effect of response slowing was taken into account. The study illustrates an important problem in using the modified spatial cueing task to assess components of threat-related attentional bias. As this experimental method may reflect both threat-related attentional cueing and response slowing effects, it cannot be assumed to provide pure measures of shift or disengagement components of attention bias.     

Forced choice reaction time paradigm in children with separation anxiety disorder, social phobia, and nonanxious controls

Cognitive distortions refer to cognitive processes that are biased and therefore yield dysfunctional and maladaptive products (e.g., interpretation bias). Automatic aspects of information processing need to be considered and investigating these aspects requires forms of assessment other than self-report. Studies focussing on the specificity of cognitive biases across different types of anxiety disorders in childhood are rare. Thus, a forced choice reaction time paradigm with picture stimuli was used to assess the interpretation bias in anxious children online. The study investigated disorder-specific interpretation bias in 71 children with separation anxiety disorder (SAD), 31 children with social phobia, and 42 children without mental disorders, aged 5–13 years. Results indicated that children with SAD rated ambiguous separation pictures as significantly more unpleasant and more arousing than nonanxious children. However, no support was found that children with SAD and social phobia interpret ambiguous separation or social pictures in a more negative way than nonanxious children. Furthermore, no group differences were found in reaction times to all picture categories.     

Direction of threat attention bias predicts treatment outcome in anxious children receiving cognitive-behavioural therapy

BackgroundA bias to selectively direct attention to threat stimuli is a cognitive characteristic of anxiety disorders. Recent studies indicate that individual differences in pre-treatment threat attention bias predict treatment outcomes from cognitive-behavioural therapy (CBT) in anxious individuals. However, there have been inconsistent findings regarding whether attention bias towards threat predicts better or poorer treatment outcome.MethodThis longitudinal study examined treatment outcomes in 35 clinically-anxious children following a 10-week, group-based CBT program, as a function of whether children showed a pre-treatment attention bias towards or away from threat stimuli. The effect of CBT on attention bias was also assessed.ResultsBoth groups showed significant improvement after receiving CBT. However, anxious children with a pre-treatment attention bias towards threat showed greater reductions not only in anxiety symptom severity, but also in the likelihood of meeting diagnostic criteria for anxiety disorders at post-treatment assessment, in comparison with anxious children who showed a pre-treatment attention bias away from threat. Children who had a pre-treatment bias away from threat showed a reduction in this bias over the course of CBT.ConclusionsFindings suggest that pre-existing differences in the direction of attention towards versus away from threat could have important implications for the treatment of anxious children.     

A multi-session interpretation modification program: changes in interpretation and social anxiety symptoms

Previous research suggests that socially anxious individuals interpret ambiguous social information in a more threatening manner compared to non-anxious individuals. Recently, studies have experimentally modified interpretation and shown that this subsequently affected anxiety in non-anxious individuals. If similar procedures can modify interpretation biases in socially anxious individuals, they may lead to a reduction in social anxiety symptoms. In the current study, we examined the effect of a computerized Interpretation Modification Program (IMP) on interpretation bias and social anxiety symptoms. Twenty-seven socially anxious individuals were randomly assigned to the IMP or a control condition. Participants completed eight computer sessions over four weeks. The IMP modified interpretation by providing positive feedback when participants made benign interpretations and negative feedback in response to threat interpretations. The IMP successfully decreased threat interpretations, increased benign interpretations, and decreased social anxiety symptoms compared to the control condition. Moreover, changes in benign interpretation mediated IMP's effect on social anxiety. This initial trial suggests that interpretation modification may have clinical utility when applied as a multi-session intervention.     

Maternal Sensitivity and Anxiety: Impacts on Child Outcome

ABSTRACT

Children of anxious parents have been shown to be at an increased risk of developing an anxiety disorder. Thus, it is critically important to identify factors that increase or decrease that risk. The depression literature has shown that maternal sensitivity decreases negative child outcome associated with maternal depression. The current study was designed to determine whether maternal sensitivity may buffer children of anxious mothers in a similar way. Three hypotheses were tested. First, that anxious mothers would display less sensitivity than nonanxious mothers in interactions with their children; that there would be an interaction between sensitivity and anxiety on child outcome; and that sensitivity would account for variance in child outcome beyond that attributed to anxiety. One hundred and twenty-five mothers (75 anxious) and their children (ages 3–12) completed the study. Mothers were administered the Anxiety Disorders Interview Schedule-IV and Parent, and a subset also completed the Beck Anxiety Inventory. Children completed the Anxiety Disorders Interview Schedule-Child. Dyads also engaged in two interaction tasks (one cognitive, one social) which were coded for maternal sensitivity and three child outcome behaviors. Results showed that anxious mothers displayed less sensitivity in the social task but not in the cognitive task. An interaction between anxiety and sensitivity was found only when predicting child negativity in the social task. Finally, maternal sensitivity was found to account for variance in child outcome beyond that of anxiety. Implications and directions for future research are discussed.     

An examination of the cognitive processes involved in childhood obsessive-compulsive disorder

The cognitive theory of obsessive-compulsive disorder (OCD) is the most widely accepted account of the aetiology and maintenance of this disorder in adults. This paper investigated whether cognitive processes were evident in a sample of children with a primary diagnosis of OCD. Using an idiographic approach, as proposed by the Obsessive-Compulsive Cognitions Working Group, this paper assessed cognitive appraisals of responsibility, probability, severity, thought-action fusion, self-doubt and cognitive control. Ratings of these cognitive appraisals were obtained across a sample of children with OCD, and were compared with ratings from a clinical control group of anxious children and a non-clinic control group. It was hypothesised that consistent with the cognitive theory of OCD, children in the OCD group would display higher estimations of these cognitive processes in comparison to anxious and non-clinic children. Results of this investigation provide preliminary support for a cognitive conceptualisation of OCD during childhood. OCD children reported significantly higher ratings of responsibility, severity, thought action fusion and less cognitive control in comparison to non-clinic children. OCD children could also be clearly differentiated from anxious children on ratings of cognitive control. Implications of this investigation are discussed and directions for future research are highlighted.     

Effects of stress and anxiety on the processing of threat stimuli

Two experiments extended the work of MacLeod and Mathews (1988) and examined whether a cognitive bias for threat information is a function of state or trait anxiety. Color-naming and attention deployment tasks were used to assess the effects of a stress manipulation procedure on attentional responses in high and low trait anxious subjects. Subjects under high stress selectively allocated processing resources toward threat stimuli, irrespective of their trait anxiety level. There was no consistent evidence of a cognitive bias associated with trait anxiety, and the effect of the stress manipulation did not appear to be mediated by state anxiety. It was suggested that trait factors do not modify attentional biases associated with acute stress, but may influence such biases when stress is prolonged.     

Interactions between mothers and children: impacts of maternal and child anxiety

This study, an expansion of an earlier study of parenting behaviors of anxious mothers, examined the relationship of both mother and child anxiety disorders to mother behavior in parent--child interactions. Participants were 68 mother--child dyads with children ranging in age from 7 to 15 years. Mothers and children completed diagnostic evaluations and engaged in conversational tasks; behaviors were rated by coders who were blind to diagnosis. Mothers of anxious children, regardless of their own anxiety, were less warm (p <.05) toward their children. They also granted less autonomy (p <.01). There was an interaction between mother and child anxiety in predicting maternal catastrophizing (p <.01), with anxious mothers and nonanxious mothers of anxious children likely to catastrophize. Theoretical and research implications are discussed.     

A Single-Session Online Cognitive Bias Modification of Interpretations Modified for Adults With Anxiety and Depressive Symptoms

Anxiety and depression are common, co-occurring, and costly mental health disorders. Cognitive bias modification aims to modify biases to reduce associated symptoms. Few studies have targeted multiple biases associated with both anxiety and depression, and those that have lacked a control condition. This study piloted a single-session online cognitive bias modification (known as CBM-IA) designed to target two biases associated with anxiety and depression—interpretation bias and attribution style—in adults with varying levels of anxiety and depressive symptoms. Participants (18–26 years) with at least mild levels of anxiety/stress and depressive symptoms on the DASS-21 were randomly allocated to an intervention (n = 23) or a control (n = 22) condition. The training consisted of a single-session online CBM-IA to encourage positive interpretations and a positive attribution style.Interpretation bias, attribution style, anxious and depressive mood states, and anxiety, stress and depressive symptoms improved at posttraining and at follow-up, irrespective of condition. Changes in interpretation bias from pre- to posttraining were significantly associated with changes in anxious mood state. CBM-IA, as implemented in this single-session pilot study, did not significantly reduce targeted biases and symptoms compared to a control condition. This adds to the mixed evidence on the efficacy of single-session CBM-I for altering biases and symptoms.     

Factors in the referral of children for behavioral treatment: A comparison of mothers of clinic-referred deviant,clinic-referred non-deviant and non-c

The purpose of this study was to compare a non-clinic sample of mothers and children to two groups of clinic-referred children and their mothers. The two clinic-referred groups differed from one another in that the selection criterion for one group of children (Clinic Deviant) was that they were significantly more deviant and non-compliant than the non-clinic group whereas the selection criterion for the second group of children (Clinic Non-deviant) was that they did not differ significantly from the non-clinic group on deviant and non-compliant behavior. Home observations by independent observers and parent questionnaires examining parental adjustment and parental perceptions of child adjustment were completed. The results indicated that both clinic groups perceived their children as more maladjusted than parents in the non-clinic groups perceived their children. Parents of the children in the Clinic Non-deviant group were significantly more depressed than those in the remaining two groups, whereas parents in the Clinic Deviant group issued more vague, interrupted commands than those in the Clinic Non-deviant group. Implications of the findings are discussed.