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