Attention Bias Modification for the Improvement of Anxiety in Adolescent and Young Adult Cancer Survivors

Feasibility will be assessed via clinic recruitment rates, defined as (number [#] of adolescent and young adults [AYAs] who enroll in the study) / (total # of AYAs screened as eligible). Attention bias modification (ABM) will be considered feasible with ≥ 50% enrollment.

Uptake will be assessed via retention rates, defined as (# of AYAs who complete 4-week treatment duration of ABM) / (# of AYAs who enroll in the study). ABM will be considered feasible with ≥ 70% retention.

Will be assessed using the Client Satisfaction Questionnaire (CSQ-8). The CSQ-8 is an 8-item questionnaire used to assess level of satisfaction with care. Items are scored on a Likert scale from 1 (low satisfaction) to 4 (high satisfaction) with different descriptors for each response point. Total scores range from 8 to 32, with higher scores indicating greater satisfaction(scores ≥26 indicate satisfaction).

Will be assessed using the System Usability Scale (SUS). The SUS is a well-validated and widely used 10-item scale to evaluate the perceived usability of digital interventions. Items are rated on a 5-point Likert scale for a total score ranging from 0-100, and scores ≥ 70 considered adequate usability.

PROMIS Profile-57: The Patient-Reported Outcomes Measurement Information System (PROMIS) are publicly available, rigorously tested, and well-validated measures supported by the NIH Common Fund. The PROMIS Profile-57 is a self-report measure covering the domains of physical function, anxiety, depression, fatigue, sleep disturbance, social participation, pain interference, and pain intensity.

Connor-Davidson 10 Resilience Scale (CD-RISC-10): The CD-RISC is a well-validated and widely used instrument to measure inherent resiliency. Questions revolve around personal problem-solving and approaches to adversity. The 10-item instrument has high internal consistency (Cronbach's alpha = 0.85), and has been used in diverse populations including adolescents, parents, and cancer patients. Each item consists of a 5-point Likert scale (scored from zero to four) for a total of 40 points, with higher scores reflecting greater resilience.

Kessler-6 Psychological Distress Scale (K6): This 6-item scale measures "level of psychological distress experienced in the past month." It was developed for the US National Health Interview Survey, and is currently being used in Canada, Australia and world-wide as part of the World Health Organization (WHO) world mental health initiative. The instrument strongly discriminates between community cases and non-cases of Diagnostic and Statistical Manual of Mental Disorder (DSM)-V psychiatric disorders such as serious emotional distress or serious mental illness. It has been extensively cross-validated, including among adolescents. Responses are scored on a 5-point Likert scale, generating a range of zero to 24 points. Previous studies have shown that scores ≥ 7 are consistent with "high" distress and those ≥ 13 meet criteria for serious, or debilitating psychological distress.

Hospital Anxiety and Depression Scale (HADS): 14 items assess symptoms of anxiety and depression, respectively, in patients with serious illness. It has been validated in AYAs with chronic illness and cancer survivors, with excellent reliability (α=0.83-0.82). Items are scored 0-3 (subscale range 0-21), with scores ≥8 categorized as borderline abnormal, and ≥11 categorized as abnormal.

Short Health Anxiety Inventory (SHAI): The SHAI contains 14 items that assess health anxiety independent of physical health status. Items assess worry about one's health, awareness of bodily sensations and/or changes, and the feared consequences of having an illness. It can be used in both healthy individuals and physically ill individuals including those who were temporarily sick or diagnosed with a serious and/or chronic illness. The scale has been validated in clinical and non-clinical samples. Total score ranges from 0 to 42, with higher scores indicating greater health anxiety.

Fear of Cancer Recurrence Inventory-SF (FCRI-SF): The FCRI-SF is a widely utilized and validated 9-item measure that evaluates the presence and severity of intrusive thoughts associated with fear of cancer recurrence. Each item is rated on a Likert scale ranging from 0 ("not at all" or "never") to 4 ("a great deal' or "all the time"). A higher score indicates higher levels of fear of cancer recurrence.

The Attention Bias Questionnaire (ABQ) consists of nine items reflecting the subjective experience of attention bias towards threats, with two sub-scales: Engagement with Threat and Difficulty to Disengage from Threat. High ABQ scores are correlated with trait anxiety, social anxiety, PTSD, and depression. It has been validated in ages 18+, with high internal consistency (Cronbach's alpha=0.90). Total score ranges from 0 to 4, with higher scores indicating greater attention bias.

PROMIS Pain Intensity: The Patient-Reported Outcomes Measurement Information System (PROMIS) are publicly available, rigorously tested, and well-validated measures supported by the NIH Common Fund. The PROMIS Pain Intensity (3-item) instrument assesses how much a person hurts.

3 questions will assess pain frequency (6- or 7-item Likert scale from "not at all" to "daily"), pain intensity (11-point NRS, 0-10), and pain interference (11-point NRS, 0-10).

Child Activity Limitations Interview-9 (CALI-9): The CALI-9 is a brief measure for assessing activity limitations in children and adolescents with chronic pain. This measure has demonstrated good internal consistency and high cross-informant reliability. Total score ranges from 0-100, with higher scores indicating greater pain-related activity limitations.

The Adolescent Sleep Wake Scale Short Form (ASWS-SF) is a 10-item measure of behavioral sleep patterns that has been validated in general adolescent populations. The measure provides an overall sleep quality score, and 3 subscale scores: going to bed, falling asleep and reinitiating sleep, and returning to wakefulness. Items are rated on a 6-point Likert scale, and averaged to compute subscale and total measure scores. Total scores range from 1 to 6 with higher scores indicating better sleep quality.

The Adolescent Insomnia Questionnaire (AIQ) is a 13-item screening measure of insomnia in adolescents. The measure has demonstrated strong reliability and high internal inconsistency. Items are rated on a 5-point Likert scale. Total scores range from 0 to 52 with higher scores indicating more insomnia symptoms.

PROMIS NeuroQOL Cognitive Function-SF: The Patient-Reported Outcomes Measurement Information System (PROMIS) are publicly available, rigorously tested, and well-validated measures supported by the NIH Common Fund. The PROMIS NeuroQOL Cognitive Function-SF measures perceived difficulties in everyday cognitive abilities such as memory, attention, and decision-making.

The Dot Probe Task is a well-established and widely utilized digitized reaction time test to measure attention bias towards threat. Attention bias scores will be computed by subtracting the mean reaction time in trials where probes replace negative stimuli from the mean reaction time in trials where probes replace neutral/positive stimuli. Positive attention bias scores will indicate an attentional bias towards threatening stimuli, and negative scores will indicate an attentional bias towards non-threatening stimuli.