Elsevier

Clinical Psychology Review

Volume 40, August 2015, Pages 66-75
Clinical Psychology Review

Attentional bias towards threatening stimuli in children with anxiety: A meta-analysis

https://doi.org/10.1016/j.cpr.2015.05.007Get rights and content

Highlights

  • We examined children's attentional bias to threat.

  • Results showed evidence of an overall effect for children with anxiety.

  • Differences between anxious and control children increase with age.

  • Future research should explore individual differences in attentional bias.

Abstract

Although it is well known that anxious adults show selective attention to threatening stimuli, research investigating attentional bias in children with anxiety has produced mixed results. The purpose of this paper is to provide a comprehensive analysis of studies investigating attentional bias in children with anxiety. Using a systematic search for articles which included both children with anxiety and reported data suitable for a meta-analysis, 38 articles were identified involving 4221 subjects (anxiety n = 2222). We used a random effects meta-analysis with standardized mean difference as our primary outcome to estimate between- and within-group effects of attentional bias towards threat-related information in children with anxiety. Overall, children with anxiety showed a significantly greater bias to threat-related stimuli, compared to controls (d = 0.21). Children with anxiety also showed a significant bias to threat-related stimuli, over neutral stimuli (d = 0.54), which was greater than the bias shown by control children (d = 0.15). Specific variables in attentional bias were also explored, with varying results. The review concluded that anxious children do show a similar bias towards threatening stimuli as has been documented in adults, albeit to a lesser degree and this bias is moderated by age, such that the difference between anxious and control children increases with age. Given the small number of studies in some areas, future research is needed to understand the precise conditions under which anxious children exhibit selective attentional biases to threat-related stimuli.

Introduction

Anxiety disorders are amongst the most common psychopathologies experienced by young people with prevalence rates of 2.5 to 15% for children and adolescents (Rapee, Schniering & Hudson, 2009). Anxiety during childhood can lead to later psychopathologies (Bittner et al., 2007, Roza et al., 2003) and a number of functional and social impairments, both as a child and continuing into adulthood (Rapee, 2002, Rapee et al., 2009), and, as a result, investigation into the aetiology and maintenance of these disorders is important.

To aid our understanding of anxiety in children and adolescents, childhood models of anxiety draw heavily from models of adult anxiety disorders, which have been more thoroughly researched. For example, cognitive models of anxiety propose that attentional biases towards threatening information could be both a vulnerability factor that leads to the development of anxiety disorders (Bar-Haim et al., 2007, Beck and Clark, 1997, Eysenck et al., 2007) and an important contributing factor to the maintenance of anxiety disorders (Beck, 1976, Mogg and Bradley, 1998, Williams et al., 1997).

The relationship between attentional biases towards threat and anxiety was highlighted in the seminal meta-analysis by Bar-Haim, Lamy, Pergamin, Bakermans-Kranenburg, and van IJzendoorn (2007) where they analysed the results of 172 studies that investigated attentional biases in anxiety. Their analysis provided substantive evidence that individuals with anxiety display a bias towards threat-related information (d = 0.45), one which is not seen in individuals without anxiety. Although Bar-Haim et al.'s meta-analysis included studies of childhood anxiety, these constituted only around 10% (n = 17) of the available studies. Since the publication of this influential study, there has been a considerable increase in research investigating attentional bias in children with anxiety.

This increase in child attentional bias research has resulted in studies that differ on a range of both sample and experimental variables. Studies vary on whether children are classified as highly trait anxious or clinically anxious and, for children with clinically diagnosed anxiety, the type of anxiety disorder. There is also variability in the age of the sample, with some studies specifically investigating younger children, children of a specific age or a wide range of children under 18. Further, attentional bias in children with anxiety has been measured with a range of paradigms (e.g., stroop, visual dot-probe, visual search, emotional cueing, masked faces, eye tracking, eye blink), using different types of stimuli (e.g., linguistic and/or pictorial), and stimulus presentation times.

Little is known about how these differences are associated with results, but the pattern of findings across studies is certainly mixed. Some studies have shown children with anxiety have a vigilance to threat (Dalgleish et al., 2003, Eldar et al., 2012, Vasey et al., 1995, Waters et al., 2010), while others have shown the opposite pattern of results with avoidance of threat information (Monk et al., 2006) or no difference in attentional bias between children with or without anxiety (Benoit et al., 2007, Britton et al., 2012, Hadwin et al., 2009). More recently, researchers have found mixed results for attentional bias towards threat even within studies (Salum et al., 2013, Waters et al., 2013), and literature reviews have concluded that the mechanisms underlying attentional bias in the child population may not be as clear as they are for adults with anxiety (Cisler and Koster, 2010, Field et al., 2011, Puliafico and Kendall, 2006).

With the research indicating there may be a difference in how children with anxiety respond on measures of attentional bias, there is a need for a systematic attempt to determine whether an attentional bias for threat-related information is evident for children with anxiety and, if so, under what conditions this bias is present. Accordingly, we have conducted a meta-analysis of studies investigating attentional bias to threat-related information in children with and without anxiety. The meta-analysis has three aims. First, to assess whether the attentional biases identified in adults with anxiety problems are also present in children. That is, we aim to answer the following question: do anxious children demonstrate an attentional bias towards threat-related information compared to non-anxious children? Second, we aim to investigate whether children show an actual or relative attentional bias towards threat-related information. Finally, we will investigate the impact of a range of the potential moderators of attentional bias, including paradigm, stimuli, age, gender, sample and diagnosis in order to elucidate the conditions under which attentional biases occur in children with anxiety.

Section snippets

Literature search

A systematic search was conducted by searching electronic databases PsycINFO, MEDLINE and Web of Science for English language peer-reviewed articles using the search terms selective attention, attentional bias, attention*, intersected with anx*, phob*, GAD, generalised anxiety disorder, panic, separation anxiety disorder; searching PsycINFO with the names of prominent authors in the field of attentional bias research; and, an ancestry approach (Cooper, 1982). Searches were limited to between

Between-group analysis

There were 34 articles in the between group analysis, representing 44 studies, or independent groups (see Table 1 for more details and Appendix A for citations of the included articles). The average sample size for the anxiety groups was 46 (SD = 43.07, N total = 2061) and 69 (SD = 204.28, N total = 1989) for the control, or low anxiety, groups. There was an average of 45.04% (SD = 18.94) males in the anxiety group and 40.67% (SD = 23.35) in the control group. The mean age was 11.26 (SD = 1.94) for the

Discussion

This meta-analysis provides an overview of attentional bias research for children with anxiety. Our first aim was to determine whether or not an attentional bias, similar to that observed in anxious adults towards threatening stimuli (Bar-Haim et al., 2007), was also evident in anxious children. The results of the meta-analysis showed that, overall, children with anxiety display a greater attentional bias towards threat-related information than control children. However, the difference

Limitations and conclusions

The advantage of the meta-analytic method is that we have been able to pool the results of a large number of studies involving large numbers of children. However, it is not without limitations. The main limitation is the heterogeneity of the samples and experimental variables used between studies. In addition, compared to the only prior meta-analysis of attentional biases to threat (Bar-Haim et al., 2007), we had a relatively small number of studies. As a result, some of our null results may

Declaration of interest

None to declare.

The authors have no conflicts of interest to declare. There was no funding for this study. JD and LS conceived the study and conducted article review. JD did the analyses, and LS and CH helped with interpretation of those analyses. JD wrote the first draft of the manuscript and all authors contributed to and approved the final version of the manuscript.

Acknowledgements

The authors would like to acknowledge J. Todd for her assistance with the initial title and abstract screening for interrater reliability. Professor Sharpe is supported by a Senior National Health and Medical Research Council Fellowship.

References (62)

  • L.D. Seligman et al.

    Cognitive-behavioral therapy for anxiety disorders in youth

    Child and Adolescent Psychiatric Clinics of North America

    (2011)
  • E.H. Telzer et al.

    Relationship between trait anxiety, prefrontal cortex, and attention bias to angry faces in children and adolescents

    Biological Psychology

    (2008)
  • A.M. Waters et al.

    Attentional bias towards angry faces in childhood anxiety disorders

    Journal of Behavior Therapy and Experimental Psychiatry

    (2010)
  • A.M. Waters et al.

    Attention training to positive stimuli in childhood anxiety disorders

    Developmental Cognitive Neuroscience

    (2013)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2013)
  • P. Anderson

    Assessment and development of executive function (EF) during childhood

    Child Neuropsychology

    (2002)
  • Y. Bar-Haim et al.

    Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study

    Psychological Bulletin

    (2007)
  • Y. Bar-Haim et al.

    Training anxious children to disengage attention from threat: A randomized controlled trial

    Journal of Child Psychology and Psychiatry

    (2011)
  • A.T. Beck

    Cognitive therapy and the emotional disorders

    (1976)
  • K.E. Benoit et al.

    Processing of emotional faces in children and adolescents with anxiety disorders

    Behaviour Change

    (2007)
  • A. Bittner et al.

    What do childhood anxiety disorders predict?

    Journal of Child Psychology and Psychiatry, and Allied Disciplines

    (2007)
  • J.C. Britton et al.

    Isolating neural components of threat bias in pediatric anxiety

    Journal of Child Psychology and Psychiatry

    (2012)
  • S. Broerena et al.

    Processing biases for emotional faces in 4- to 12-year-old non-clinical children: An exploratory study of developmental patterns and relationships with social anxiety and behavioral inhibition

    Journal of Experimental Psychopathology

    (2011)
  • J.M. Cisler et al.

    Mechanisms of attentional biases towards threat in the anxiety disorders: An integrative review

    Clinical Psychology Review

    (2010)
  • P.J.F. Clarke et al.

    Assessing the role of spatial engagement and disengagement of attention in anxiety-linked attentional bias: A critique of current paradigms and suggestions for future research directions

    Anxiety, Stress, and Coping

    (2013)
  • P.J.F. Clarke et al.

    Absence of evidence or evidence of absence: Reflecting on therapeutic implementations of attentional bias modification

    BMC Psychiatry

    (2014)
  • H.M. Cooper

    Scientific guidelines for conducting integrative research reviews

    Review of Educational Research

    (1982)
  • I.A. Cristea et al.

    Practitioner review: Cognitive bias modification for mental health problems in children and adolescents: A meta-analysis

    (2015)
  • T. Dalgleish et al.

    Patterns of processing bias for emotional information across clinical disorders: A comparison of attention, memory, and prospective cognition in children and adolescents with depression, generalized anxiety, and posttraumatic stress disorder

    Journal of Clinical Child and Adolescent Psychology

    (2003)
  • S. Duval et al.

    A nonparametric trim and fill method of accounting for publication bias in meta-analysis

    Journal of the American Statistical Association

    (2000)
  • S. Duval et al.

    Trim and fill: A simple funnel plot based method of adjusting for publication bias in meta-analysis

    Biometrics

    (2000)
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