Threat perception predicts cognitive behavioral therapy outcomes in anxious children

Katharina Manassis, Kathryn M. Hum, Trevor Changgun Lee, Gloria Zhang, Marc D. Lewis

Behavioral Science Institute, Radboud University, Nijmegen, The Netherlands.
Department of Human Development and Applied Psychology, University of Toronto, Toronto, Canada.
Department of Psychiatry, Hospital for Sick Children, University of Toronto, Toronto, Canada.

DOI: 10.4236/ojpsych.2013.31A009                

Abstract

Objective: Anxiety disorders of childhood are prevalent, debilitating conditions that do not always respond to existing treatments. Attentional biases towards threatening stimuli have been reported in anxious children and hypothesized to interfere with treatment response. Therefore, we examined such biases in children with anxiety disorders in relation to cognitive behavioral therapy (CBT) outcomes. Method: Thirty-eight children diagnosed with anxiety disorders in a specialized clinic (21 girls and 17 boys; age = 10.50 ± 1.11 years) and 36 unaffected community controls (19 girls and 17 boys; age = 10.20 ± 1.07 years) participated. Participants completed standardized questionnaire measures of anxiety and a probe position task (PPT) with facial cues. This task often reveals a response slowing effect related to threatening faces in vulnerable individuals. Children with anxiety disorders repeated these measures after completing CBT. Results: Groups did not differ in performance on the PPT, but angry/calm incongruent difference scores were significantly associated with self-reports of social anxiety and state anxiety. When controlling for pre-CBT anxiety levels, incongruent difference scores involving angry faces predicted post-CBT anxiety disorders index scores on the Multidimensional Anxiety Scale for Children. PPT scores did not change significantly with CBT. Conclusions: Attentional bias towards threat on the PPT task may predict response to CBT and appears linked to social anxiety. Interventions to ameliorate this bias merit further study, as they might improve treatment outcomes for anxious, especially socially anxious, children.

Keywords

Anxiety Disorder; Children; Threat Perception; Emotion; Cognitive Behavioral Therapy

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Connolly, S.D. and Bernstein, G.A. (Work Group on Quality Issues) (2007) Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 267-283. doi:10.1097/01.chi.0000246070.23695.06
[2]	Last, C.G., Hansen, C. and Franco, N. (1997) Anxious children in adulthood: A prospective study of adjustment. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 645-652. doi:10.1097/00004583-199705000-00015
[3]	Compton, S.N., Walkup, J.T., Albano A.M., et al. (2010) Child/adolescent anxiety multimodal study (CAMS): Rationale, design and methods. Child and Adolescent Psychiatry and Mental Health, 4, 1. doi:10.1186/1753-2000-4-1
[4]	Ginsburg, G.S., Kendall, P.C., Sakolsky, D., et al. (2011) Remission after acute treatment in children and adolescents with anxiety disorders: Findings from the CAMS. Journal of Consulting and Clinical Psychology, 79, 806-813. doi:10.1037/a0025933
[5]	Rynn, M., Puliafico, A., Heleniak, C., et al. (2011) Advances in pharmacotherapy for pediatric anxiety disorders. Depression and Anxiety, 28, 76-87. doi:10.1002/da.20769
[6]	Puliafico, A.C. and Kendall, P.C. (2006) Threat-related attentional biases in anxious youth: A review. Clinical Child and Family Psychology Review, 9, 162-180. doi:10.1007/s10567-006-0009-x
[7]	Shechner, T., Britton, J.C., Perez-Edgar, K., et al. (2012) Attention biases, anxiety, and development: Toward or away from threats or rewards? Depression and Anxiety, 29, 282-294. doi:10.1002/da.20914
[8]	Bar-Haim, Y., Lamy, D., Pergamin, L., et al. (2007) Threatrelated attentional bias in anxious and nonanxious individuals: A meta-analytic study. Psychological Bulletin, 133, 1-24. doi:10.1037/0033-2909.133.1.1
[9]	Rutherford, E.M., MacLeod, C. and Campbell, L.W. (2004) Negative selectivity effects and emotional selectivity effects in anxiety: Differential attentional correlates of state and trait variables. Cognition & Emotion, 18, 711-720. doi:10.1080/02699930341000121
[10]	MacLeod, C., Rutherford, E., Campbell, L., et al. (2002) Selective attention and emotional vulnerability: Assessing the causal basis of their association through the experimental manipulation of attentional bias. Journal of Abnormal Psychology, 111, 107-123. doi:10.1037/0021-843X.111.1.107
[11]	Browning, M., Holmes, E.A. and Harmer, C.J. (2010) The modification of attentional bias to emotional information: A review of the techniques, mechanisms, and relevance to emotional disorders. Cognitive, Affective, & Behavioral Neuroscience, 10, 8-20. doi:10.3758/CABN.10.1.8
[12]	Spector, I.P., Pecknold, J.C. and Libman, E. (2003) Selective attentional bias related to the noticeability aspect of anxiety symptoms in generalized social phobia. Journal of Anxiety Disorders, 17, 517-531. doi:10.1016/S0887-6185(02)00232-3
[13]	Waters, A.M., Mogg, K., Bradley, B.P., et al. (2010) Attentional bias for emotional faces in children with generalized anxiety disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 435-442. doi:10.1097/CHI.0b013e3181642992
[14]	Perez-Edgar, K., Reeb-Sutherland, B.C., McDermott, J.M., et al. (2011) Attention biases to threat link behavioral inhibition to social withdrawal over time in very young children. Journal of Abnormal Child Psychology, 39, 885-895. doi:10.1007/s10802-011-9495-5
[15]	Tobon, J.I., Ouimet, A.J. and Dozois, D.J.A. (2011) Attentional bias in anxiety disorders following cognitive behavioral treatment. Journal of Cognitive Psychotherapy, 25, 114-129. doi:10.1891/0889-8391.25.2.114
[16]	Legerstee, J.S., Tulen, J.H.M., Kallen, V.L., et al. (2009) Threat-related selective attention predicts treatment success in childhood anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 196-205. doi:10.1097/CHI.0b013e31819176e4
[17]	Legerstee, J.S., Tulen, J.H.M., Dierckx, B., et al. (2010) CBT for childhood anxiety disorders: differential changes in selective attention between treatment responders and nonresponders. Journal of Child Psychology and Psychiatry, 51, 162-172. doi:10.1111/j.1469-7610.2009.02143.x
[18]	Waters, A.M., Wharton, T.A., Zimmer-Gembeck, M.J., et al. (2008) Threat-based cognitive biases in anxious children before and after cognitive behavioral treatment. Behaviour Research and Therapy, 46, 358-374. doi:10.1016/j.brat.2008.01.002
[19]	Mogg, K., Holmes, A., Garner, M., et al. (2008) Effects of threat cues on attentional shifting, disengagement and response slowing in anxious individuals. Behaviour Research and Therapy, 46, 656-667. doi:10.1016/j.brat.2008.02.011
[20]	Manassis, K., Mendlowitz, S., Scapillato, D., et al. (2002) Group and individual cognitive behavior therapy for childhood anxiety disorders: A randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 1423-1430. doi:10.1097/00004583-200212000-00013
[21]	Mendlowitz, S., Manassis, K., Bradley, S., et al. (1999) Cognitive behavioral group treatments in childhood anxiety disorders: The role of parental involvement. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 1223-1229. doi:10.1097/00004583-199910000-00010
[22]	Silverman, W.K. and Albano, A.M. (1996) The anxiety disorders interview schedule for children and parents— DSM-IV version. Graywind, New York.
[23]	Achenbach, T.M. and Rescorla, L.A. (2001) Manual for the ASEBA school-age forms & profiles. University of Vermont, Research Centre for Children, Youth & Families, Burlington.
[24]	March, J.S. (1998) Multidimensional anxiety scale for children. Multi-Health Systems, Toronto.
[25]	Spielberger, C.D. (1973) Manual for the state trait anxiety inventory for children. Consulting Psychologists Press, Palo Alto.
[26]	Boyle, M.H., Offord, D.R. and Racine, Y. (1993) Evaluation of the revised ontario child health study scales. Journal of Child Psychology and Psychiatry, 43, 189-213. doi:10.1111/j.1469-7610.1993.tb00979.x
[27]	Tottenham, N., Tanaka, J.W., Leon, A.C., et al. (2009) The NimStim set of facial expressions: Judgments from untrained research participants. Psychiatry Research, 168, 242-249. doi:10.1016/j.psychres.2008.05.006
[28]	Manassis, K. (2008) Keys to parenting your anxious child. 2nd Edition, Barron’s Educational Series, Inc., Hauppauge.
[29]	Vasey, M.W. and MacLeod, C. (2001) Information processing factors in childhood anxiety: A developmental perspective. In: Vasey, M.W. and Dadds, M.R. Eds., The Developmental Psychopathology of Anxiety, Oxford University Press, New York, 253-277.
[30]	Blaney, P. (1986) Affect and memory: A review. Psychological Bulletin, 99, 229-246. doi:10.1037/0033-2909.99.2.229
[31]	Bar-Haim, Y., Morag, I. and Glickman, S. (2011) Training anxious children to disengage attention from threat: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 52, 861-869. doi:10.1111/j.1469-7610.2011.02368.x
[32]	Cooper, R.M. and Langton, S.R.H. (2006) Attentional bias to angry faces using the dot-probe task? It depends when you look for it. Behaviour Research and Therapy, 44, 1321-1329. doi:10.1016/j.brat.2005.10.004
[33]	Beidel, D.C., Turner, S.M. and Morris, T.L. (2000) Behavioral treatment of childhood social phobia. Journal of Consulting and Clinical Psychology, 68, 1072-1080. doi:10.1037/0022-006X.68.6.1072
[34]	Kagan, J. and Fox, N. (2006) Biology, culture, and temperamental biases. In: Eisenberg, N., Damon, W. and Lerner, R.M. Eds., Social, Emotional, and Personality Development, Handbook of Child Psychology, Wiley, New York, 167-225.