Cognitive bias modification of interpretations: A viable treatment for child and adolescent anxiety?

doi:10.1016/j.brat.2013.07.001

Behaviour Research and Therapy

Volume 51, Issue 10, October 2013, Pages 614-622

https://doi.org/10.1016/j.brat.2013.07.001 Get rights and content

Highlights

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Training benign interpretations has been used to treat adult anxiety problems.
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Extending these training packages to anxious youth may be beneficial.
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Studies to date suggest that benign interpretations can be trained in this age group.
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Outstanding questions to realise the therapeutic benefits of training are discussed.

Abstract

Anxiety disorders in children and adolescents are common and impairing. As many patients do not benefit from – or have difficulties accessing – frontline treatments, novel, effective and easy-to-deliver interventions are needed. Cognitive Bias Modification of Interpretations (CBM-I) training has been used to treat adult anxiety disorders. CBM-I methods train individuals to endorse benign rather than negative resolutions of ambiguous cues. Developmental extensions of CBM-I are important for several reasons. First, implementing CBM-I in symptomatic children and adolescents may facilitate early preventative gains. Second, as training uses simple learning mechanisms, CBM-I may reflect a developmentally-suitable strategy for shaping adaptive processing styles. Third, as this age range involves protracted neurocognitive maturation and associated plasticity, administering CBM-I early could drive powerful, long-lasting benefits for emotional development. Finally, data from CBM-I studies could inform the cognitive mechanisms involved in the genesis of early-emerging anxiety. This paper provides the first organised review of CBM-I studies conducted in children and adolescents, and contains suggestions for future research that may help realise the therapeutic potential of early CBM-I interventions.

Section snippets

CBM-I principles and study designs

Cognitive Bias Modification of Interpretations (CBM-I) training was first developed to test the causal relationship between negative interpretational style and anxiety (Mathews & Mackintosh, 2000), as hypothesised by early cognitive theories of anxiety (Beck, Emery, & Greenberg, 1985). Extant data had already implicated the tendency to select negative interpretations of ambiguous cues in anxious individuals (Eysenck, Mogg, May, Richards, & Mathews, 1991). However, as the majority of these

CBM-I studies of symptomatic adults

Using this basic methodological set-up, a number of studies have assessed the effectiveness of CBM-I at training benign interpretational styles and boosting anxiety responses in individuals who meet criteria for clinically-significant anxiety problems or those selected on high levels of anxiety symptoms or trait anxiety (Table 1). Most of these studies have assessed the effectiveness of a single session of CBM-I (in comparison to neutral or no training conditions) with a few studies assessing

Developmental considerations

Perhaps the most obvious reason why one would extend CBM-I interventions to non-adult samples is for prevention. Extensive data implicate early-life as a period of onset for many anxiety disorders (Gregory et al., 2007, Kessler et al., 2007). Intervening when conditions first emerge may therefore attenuate lifelong problems such as persistent anxiety (Sahakian, Malloch, & Kennard, 2010). But why adopt CBM-I as an early intervention when there are other options? There is now ample data to

CBM-I studies of children and adolescents

There are now at least 15 studies that have implemented CBM-I methods in children and adolescents (Table 2). Most of these have focussed on children and adolescents recruited through the community, with a few targeting participants selected for high levels of anxiety and/or those with a clinical diagnosis. Developmental differences in the capacity to engage with CBM-I have warranted the creation of a range of training tasks, deviating in their interface to adult paradigms. For most adolescent

Outstanding questions

Developmental extensions of CBM-I have so far yielded promising results: adaptive interpretational styles can be trained in non-adult samples using simple tasks. However, before these tools are implemented in clinical settings, there are several remaining issues that need to be addressed. First, although data from Table 2 are encouraging, as with adult data, it is unclear whether training effects on interpretational style emerge through demand effects. This may be particularly likely if the

Conclusions

Cognitive Bias Modification of Interpretations (CBM-I) training has emerged as a potential clinical tool for treating adult anxiety disorders. Although data attesting to its effectiveness in adults continues to be debated, and its underlying assumptions sometimes challenged (e.g. Longmore and Worrell, 2007), its' potential as an early interventive tool in children and adolescents is just becoming apparent. However, ‘basic’ questions need to be addressed over the generalizability and persistence

Acknowledgements

I have received funding from the British Academy, Nuffield Trust and the Calleva Research Centre for Evolution and Human Sciences for work in this area.

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Child labourers are more likely to have experienced physical victimisation, which may increase risk for anxiety/depression, by shaping threat biases in information-processing. To target threat biases and vulnerability for anxiety/depression, we evaluated whether Cognitive Bias Modification (CBM) training could be feasibly and acceptably delivered to rescued youth labourers. Seventy-six physically abused rescued labourers aged 14–17 (40 from Nepal, 36 from India) in out-of-home care institutions received either multi-session computerised CBM or control training. Training targeted attention away from threat to positive cues and the endorsement of benign over threat interpretations. Feasibility and acceptability data were gathered along with pre and post intervention measures of attention and interpretation bias and emotional and behavioural symptoms. In terms of feasibility, uptake (proportion of those who completed the pre-intervention assessment from those who consented) and retention (proportion of those who completed the post-intervention assessment from those who completed the pre-intervention assessment) were above 75% in both countries. Average acceptability ratings were mostly ‘moderate’ on most indices for both countries, and none of the participants reported experiencing serious adverse events or reactions in response to or during the trial. Secondarily, CBM participants showed increased attention to positive and decreased attention to threatening stimuli, as well as increased endorsement of benign interpretation and decreased endorsement in negative interpretations of ambiguous social situations. Symptom changes were less clear. Delivering CBM to former child labourers in out-of-home care institutions has interventive potential.
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Citation Excerpt :
If parent bias is a function of parent anxiety, it is possible that macro-level factors related to parent anxiety (or other mechanistic processes) are responsible for transmission of bias and anxiety from parent to child. Such work may provide useful information about which youth (and which parents) may be appropriate candidates for computerized interventions aimed at modifying interpretation bias (Beard and Amir, 2008; Cristea et al., 2015; Lau, 2013; Rozenman et al., 2020). To our knowledge, only one study has investigated this relationship longitudinally (Creswell et al., 2006), and found evidence supporting associations between mother expectations of child interpretation bias at the first measurement time point, with child interpretation bias six months later.
Anxiety disorders are the most prevalent psychiatric problem across the lifespan, with typical onset during the pediatric period. Prior literature has examined cognitive mechanisms associated with youth anxiety and identified interpretation bias, the threatening appraisal of ambiguity, as a ubiquitous correlate and likely mechanism. A small set of studies have examined interpretation bias and anxiety in parent-child dyads, although results about this potential relationship are conflicted. This systematic review and meta-analysis investigates the association between parent interpretation bias with child interpretation bias and child anxiety.
Eight studies met the rigorous inclusion criteria, which required direct assessment of interpretation bias in both youth and parent.
Meta-analysis with a random effects model indicated a small and significant correlation between parent and child interpretation biases (r = 0.14, p < .01), as well as a small and significant correlation between parent interpretation bias and child anxiety (r = = 0.20, p = .01).
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Cognitive bias modification of interpretations: A viable treatment for child and adolescent anxiety?

Highlights

Abstract

Section snippets

CBM-I principles and study designs

CBM-I studies of symptomatic adults

Developmental considerations

CBM-I studies of children and adolescents

Outstanding questions

Conclusions

Acknowledgements

Journal of Anxiety Disorders

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental

Developmental Cognitive Neuroscience

Journal of Adolescent Health

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Clinical Psychology Review

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Journal of Anxiety Disorders

Behaviour Research and Therapy

Lancet

Journal of Anxiety Disorders

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Psychiatry Research

Journal of Anxiety Disorders

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Interpretation training in individuals with generalized social anxiety disorder: a randomized controlled trial

Journal of Consulting and Clinical Psychology

The effects of attentional training on physiological stress recovery after induced social threat

Anxiety Stress Coping

Research review: attention bias modification (ABM): a novel treatment for anxiety disorders

Journal of Child Psychology and Psychiatry

Cognitive bias modification for anxiety: current evidence and future directions

Expert Review of Neurotherapeutics

Anxiety disorders and phobias. A cognitive perspective

Chronic childhood adversity and onset of psychopathology during three life stages: childhood, adolescence and adulthood

Journal of Psychiatric Research

Clinical course of Tourette syndrome

Journal of Psychosomatic Research

Child anxiety in primary care: prevalent but untreated

Depression and Anxiety

Bias in interpretation of ambiguous sentences related to threat in anxiety

Journal of Abnormal Psychology

A preliminary investigation of the effectiveness of single session cognitive bias modification of interpretations training in high-anxious adolescents