Threat perception predicts cognitive behavioral therapy outcomes in anxious children

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.

Attention Control and Attention to Emotional Stimuli in Anxious Children Before and After Cognitive Behavioral Therapy

“…Given that previous research into the effect of CBT on attentional bias in anxious children is limited, with two studies finding no effect of CBT on bias (Waters et al 2008a;Manassis et al 2013), the present study provides novel findings relating to this issue. Moreover, to our knowledge, no previous research has investigated whether attention control changes over the course of CBT in children with anxiety disorders.…”

“…Previous research into the effect of CBT on attentional bias is very limited. Waters et al (2008b) and Manassis et al (2013) found no effect of CBT on attentional bias in anxious children. Comparison of the present results with these studies is complicated by different experimental methods, as noted earlier.…”

“…One study, which examined the effect of CBT on attentional bias, found a greater attention bias to threat in anxious children before treatment, compared with healthy controls, but this bias was not significantly affected by CBT despite the anxious children showing substantial improvement in anxiety symptoms (Waters et al 2008b). Another recent study found no attentional bias in children with anxiety disorders before treatment, relative to controls, and also did not find an effect of CBT on attentional bias to threat (Manassis et al 2013). However, this research has used varying methodology, as Waters et al (2008a) used a visual probe task presenting pairs of threat and neutral pictures, which included a wide selection of threat images (e.g., snakes, spiders, sharks, guns, dental procedures); whereas Manassis et al (2013) used a modified attentional task displaying a single emotional or neutral face on each trial, and methodological complications with the resulting measure of threat processing can make the findings difficult to interpret (see Mogg et al 2008, for detailed discussion of methodological issues).…”

Cognitive findings in childhood anxiety: Translations for clinical practice

“…Manassis and colleagues [35], however, found no treatment-related changes in a probe position task from pre-to post-CBT in anxious children. One study that may reconcile these findings examined attentional bias on a visual probe task, threat interpretation bias, and selection of avoidant solutions in the same children before and after CBT.…”

“…Intervention with adolescents may need to respect developing executive functions (e.g., focus on hypothesistesting rather than reassuring statements), attend to social as well as physical threats, and involve families less in developing emotion regulation skills [34,35]. Legerstee and colleagues then provided a highly intensive form of CBT to non-responders, with improved treatment response [34].…”