ReviewTowards a cognitive-learning formulation of youth anxiety: A narrative review of theory and evidence and implications for treatment
Introduction
Anxiety disorders are common, debilitating conditions that affect approximately 10–20% of children and adolescents (hereafter referred to as ‘youth’) and are associated with significant impairment (Rapee, Schniering, & Hudson, 2009 for a review). Anxiety disorders that onset during childhood predict mental health problems in adolescence and adulthood, including depression and substance abuse (Bittner et al., 2007, Pine et al., 1998), and the risk for long-term impairment means that anxiety disorders are costly to national economies and health care systems (Bodden et al., 2008, Mathews et al., 2011).
Although enormous strides have been made in our knowledge of the origins and maintenance of anxiety disorders (see Waters, Farrell, & Schilpzand, 2013 for review), we remain unable to fully explain why some youth and not others develop these disorders. Modern approaches grounded in fear conditioning and learning (e.g., Bouton et al., 2001, Craske, 1999, Lissek, 2012, Mineka and Zinbarg, 2006) and cognitive models emphasising differences in attention allocation and appraisal processes have provided influential accounts of anxiety over the past four decades (e.g., Bar-Haim et al., 2007, Mogg and Bradley, 1998, Williams et al., 1997) and continue to evolve with new evidence (e.g., Crocker et al., 2013, Grupe and Nitschke, 2013, Pessoa, 2009).
Cognitive and conditioning perspectives of youth anxiety have emerged far more slowly, primarily over the past two decades, and largely as separate accounts of youth anxiety (e.g., Dadds et al., 2001, Field and Lester, 2010, Kindt and van den Hout, 2001, Weems and Watts, 2005). There are numerous reasons why it is time for an updated and integrated formulation. First, there has been a significant increase in empirical research on cognitive and conditioning mechanisms underlying youth anxiety in the past 10 years that needs to be integrated into updated theoretical models. Second, within the conditioning literature, there is accumulating evidence that anxious youth display elevated fear responses to threat and safety cues as well as impairments in reducing fear responses to these cues relative to healthy controls (see Jovanovic et al., 2014). This work lags behind research with adults and a conceptual framework is needed that can guide further research on threat generalisation to safety cues. Third, within the cognitive literature, there is substantial evidence of theory-consistent attention biases towards threat in anxious youth (e.g., Roy et al., 2008) as well as theory-inconsistent evidence that many anxious youth avoid attending to threat stimuli relative to healthy controls (e.g., Salum et al., 2013, Waters et al., 2014). Such findings cannot be accounted for in previous developmental cognitive perspectives which uniformly predict attention biases towards threat stimuli (Field and Lester, 2010, Kindt and van den Hout, 2001, Weems and Watts, 2005). Fourth, recent data suggest that attention avoidance relative to vigilance for threat might contribute to overgeneralised responding from threat to safety cues during fear conditioning and impaired fear extinction in anxious youth (Waters & Kershaw, 2015). Greater integration of experimental evidence derived from cognitive and conditioning perspectives is needed to advance knowledge beyond what each perspective can offer alone. Fifth, contemporary models have begun to incorporate the neural circuitry underpinning cognitive biases as well as fear conditioning and extinction in adults (Grupe and Nitschke, 2013, Milad and Quirk, 2012). Associated age-typical neurocognitive changes that might modify anxiety-related differences in conditioning and cognitive processes across development need to be incorporated into integrative models of youth anxiety (Britton et al., 2012, Lau et al., 2011). Sixth, given high rates of comorbidity among anxiety disorders and depression that emerge during childhood and exacerbate during adolescence (see Waters et al., 2013), integrative formulations must consider mechanisms that cut across diagnoses as traditionally defined, consistent with the Research Domain Criteria initiative (Sanislow et al., 2010). Finally, given that cognitive behavioural therapy (CBT) for anxious youth results in remission rates that hover around 50% (Rapee et al., 2009) and relapse in as many as 48% of acute responders (Ginsburg, Becker, Keeton, Sakolsky, & Piacentini, 2014), an updated model that integrates knowledge about cognitive and conditioning processes could lead to more effective treatments.
The major aim of this review is to integrate the theoretical and empirical literatures relating to cognitive and conditioning processes in anxious youth in order to develop an integrative conceptual framework that can advance theory, research and treatment. These reviews are not intended to be extensive critiques of the theoretical literature or systematic reviews of the empirical literature on cognitive and conditioning processes in anxious youth. The scope of each one of these literatures requires stand-alone reviews and such theoretical and up-to-date meta-analytic reviews are already available (e.g., Cisler and Koster, 2010, Dudeney et al., 2015, Duits et al., 2015, Field, 2006, Mineka and Zinbarg, 2006, Van Bockstaele et al., 2014, Vervliet et al., 2013). Rather, the present review aims to draw from and extend upon these separate literatures to provide an integrative theoretical and empirical backdrop to the cognitive-learning formulation that we propose in order to inspire new directions in research.
This review is organised into three sections. First, in the theoretical and empirical review section, we provide (a) an integrative overview of the main tenets and recent advances in cognitive and conditioning theories of anxiety, emphasising key developmental considerations within each perspective and highlighting the major themes that cut across both perspectives, and (b) a comprehensive review of the associated empirical research on cognitive and conditioning processes, including the underlying neurophysiological basis of these processes in anxious youth. We use the term ‘anxiety’ in the cognitive bias review and ‘fear’ in the conditioning review consistent with the terms used in each literature, but highlight that both terms in this review refer to the broad expression of fear and anxiety in youth. Second, we synthesize these theoretical and empirical literatures to propose a cognitive-learning formulation of youth anxiety. Third, we review the treatment outcome literature derived from cognitive and conditioning perspectives for anxious youth (i.e., CBT and attention bias modification treatments (ABMT)), and provide suggestions for improving outcomes based on the cognitive-learning formulation of youth anxiety.
Section snippets
Cognitive approaches to anxiety
Numerous theoretical models originating from cognitive-experimental research have been proposed to explain the maladaptive patterns of attention deployment and evaluative biases in anxiety (Bar-Haim et al., 2007; Beck, Emery, & Greenberg, 1985; Mogg and Bradley, 1998, Williams et al., 1997). Several key themes can be identified. First, with respect to attention processes, all cognitive models predict disproportionate vigilance or facilitation of attention towards threat stimuli, although models
Threat attention biases
Studies of attention bias have utilised a range of experimental tasks including emotional Stroop, visual search and visual probe tasks to assess attention bias (see MacLeod & Mathews, 2012 for a review). In the most commonly used visual probe task, a threat and neutral stimulus pair is presented simultaneously, a visual probe replaces one stimulus or the other and reaction-time to the probe indexes attention bias. Masked and very short exposure durations are typically used to assess biases in
Overview of the model
The cognitive-learning formulation is based on the key principles of equifinality and multifinality i.e., that unique combinations of factors contribute to varied expressions of pathological anxiety among youth (Ollendick & Hirshfeld Becker, 2002). Therefore, this formulation (see Fig. 2) proposes several key acquisition and maintenance processes derived from the cognitive and learning literatures that interact and form unique pathways to explain why some youth and not others fail to extinguish
Cognitive-behavioural therapy
Within the cognitive-learning formulation (Fig. 2), CBT is likely to be targeting symptom expression of behavioural avoidance (Panel E) through somatic management and exposure therapy, biased stimulus evaluations (Panel D) through cognitive restructuring, and certain risk factors such as parent anxiety (Panel F) through parent management training and family problem-solving (see Rapee et al., 2009). Therefore, biases in the involuntary and voluntary allocation of attention to threat (Panels B
A formulation based on experimental psychopathology research
The cognitive-learning model arises from a foundation in experimental psychopathology in which underlying mechanisms derived from theoretical models have been tested in laboratory research and progressively and systematically applied to clinical populations and treatment outcome research (Waters, LeBeau, & Craske, in press). Therefore, the model is based on findings from widely-used experimental procedures such as Pavlovian conditioning and the visual probe task. As reviewed here, these tasks
Conclusion
The cognitive-learning formulation applied to youth anxiety provides a guiding framework for understanding how conditioning and cognitive processes linked to differences in engagement of underlying neural circuits across development contribute to an expanding internal representation of a wide range of stimuli as threatening to which anxious children and adolescents develop maladaptive attention regulation patterns of predominantly excessive threat monitoring or threat avoidance. These
Acknowledgements
This research was supported by funding from the Australian Research Council (DP1095536, DP120101678, FT130101330) and Griffith University. The authors sincerely thank Professor Karin Mogg, Professor Brendan Bradley, Dr. Daniel Pine and Dr. Michael Treanor for their helpful feedback on earlier drafts of this manuscript.
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