Threat Interpretation Bias as Cognitive Marker and Treatment Target in Pediatric Anxiety: R33 Phase

Anxiety is chronic, debilitating, and the most common mental health problem across development, costing the U.S. over $42 billion annually. As anxiety disorders most commonly onset before age 18, the period from childhood through adolescence offers a critical window within which to intervene. Unfortunately, evidence-based interventions are costly, not widely available, and ineffective for upwards of 50% of youth. In response, pediatric anxiety experts and the National Institute of Mental Health (NIMH) have called for approaches that directly target underlying mechanisms to improve treatments for anxious youth. One such putative mechanism is interpretation bias - the appraisal of environmental ambiguity as threatening. Interpretation bias has been identified as a mechanism underlying the development and maintenance of youth anxiety. We have found that interpretation bias for threat, objectively measured with a paradigm that assesses whether and how quickly youth respond to ambiguous stimuli with threatening appraisals, occurs in 90% of clinically anxious youth, predicts anxiety severity above and beyond clinical characteristics, and differentiates anxious from non-anxious youth. CBM-I is a computerized intervention that attempts to reduce anxiety by directly targeting and reducing interpretation bias. While findings in the child literature are preliminary, studies with adults provide initial support that CBM-I at high dose (i.e., more than a few trainings) may reduce anxiety. This phased innovation grant tests personalized CBM-I in youth ages 10 to 17 who meet diagnostic criteria for a primary anxiety disorder (Generalized, Separation, Social). In the previous R61 Phase (N=50), a randomized clinical trial (RCT) examined whether CBM-I personalized to youth anxiety symptoms significantly reduced interpretation bias compared to a computerized interpretation control condition (ICC) and identified the optimal dose for reduction in interpretation bias. The R61 trial results indicated that CBM-I outperforms ICC on interpretation bias reduction, so the current R33 phase will proceed. In this R33 Phase, an RCT (N=72) will validate whether CBM-I significantly reduces interpretation bias, and conducts a mechanism test (i.e., does bias reduction precede and predict anxiety reduction?), by comparing CBM-I to CR, a clinically relevant psychosocial intervention that also targets anxious cognition.

Inclusion criteria

• Provision of signed and dated informed consent form by parent/legal guardian and signed youth assent. If youth turns 18 after study entry (i.e., Visit 1), they will need to reconsent as an adult to continue participation. Youth and consenting parent/legal guardian agree to 6-week study participation as part of consent/assent process.
• Youth and parent/legal guardian speak sufficient English to engage in study procedures.
• Youth is aged 10 to 17 inclusive, at time of signing consent/assent and completion of Visit 1 procedures.
• Youth meets full diagnostic criteria for primary Generalized Anxiety Disorder, Separation Anxiety Disorder, or Social Anxiety Disorder as assessed by the Anxiety Disorders Interview Schedule-IV (ADIS-IV) during Visit 1. Note: the ADIS diagnostic criteria are only valid for two weeks. For the purposes of our study, a youth should be randomized, have randomization revealed, and be in treatment (i.e., complete Visit 2) within 14 days of Visit 1 diagnostic/clinical interview. If this timeline is not met, clinical measures may need to be updated with the youth and parent/legal guardian, although consent does not need to be re-obtained. Parent and youth versions of the Screen for Child Anxiety Related Emotional Disorders, as well as the Pediatric Anxiety Rating Scale and Clinician's Global Impressions - Severity/Improvement Scale might also be re-administered. The ADIS will need to be reviewed to assess whether there have been any diagnostic changes during the elapsed time period. If more than one month has elapsed from the time of baseline, all measures within baseline procedures would be readministered, including reconsenting parent/legal guardian and youth. All such cases must be triaged in the next immediate weekly Project Management meeting.
• Youth otherwise meeting study entry criteria, who are receiving treatment for a stable medical or psychiatric condition, may be included providing that medication and dose have been stable for at least six weeks (e.g., stable dose of stimulant medication for Attention-Deficit/Hyperactivity Disorder) prior to study entry and remain stable on that medication and dose throughout their study participation. Changes to medication during study participation following randomization at Visit 2 will be considered non-urgent protocol deviations and will be tracked in the Protocol Deviations Form. Youth would not be removed from the study in this case, but their data may be excluded from sensitivity analyses.
• Youth must have a standard score of at least 85 on the Wechsler Abbreviated Scale of Intelligence, Vocabulary and Matrix Reasoning subtests, as well as the Wide Range Achievement Test-4 Reading subtest (administered during Visit 1) to ensure ability to read and understand stimuli during interpretation bias assessments and CBM-I.
• Youth must have access to a desktop or laptop computer and access to internet at home or can access one at their school or local library for the at-home portion of the computer training program. For youth without access, families can agree to complete all 16 CBM-I trainings (if randomized to CBM-I) at the BRAVE Lab.

Exclusion criteria

• Requires treatment other than CBM-I/CR: namely, youths with severe anxiety indicating need for higher level of care (e.g., psychiatric hospitalization), or primary major depressive disorder, bipolar disorder, psychosis, safety concerns due to recent or current acute suicidal ideation with plan, intent, and/or attempt that warrants alternate intervention, Posttraumatic Stress Disorder, substance dependence, current physical or sexual abuse, or intellectual disability. This will be determined during the Visit 1 ADIS interview. Consultation with the PI will occur in all cases where another mental health concern may be primary and/or warrant more immediate treatment.
• At Visit 1, is currently in alternate psychosocial intervention for any reason or has plans to initiate any psychosocial intervention for any reason.
• Has previously received any type of cognitive bias modification (attention or interpretation bias as target) at the BRAVE Lab or elsewhere.
• The family indicates they are no longer interested or able to participate in the study after Visit 1 (in which it is determined that the family is eligible) but before the family is randomized or told of their randomization. The youth will be excluded and not included in ITT analyses, and the randomization will be "thrown back" into the randomization scheme.
• Has significant uncorrected vision impairment (e.g., uncorrected blindness) that precludes participation in the computerized assessment and intervention components of the study.