Augmentation of youth cognitive behavioral and pharmacological interventions with attention modification: a preliminary investigation.

Anxiety disorders in youth are prevalent [4], causing distress, disability, and lifelong impairment [5, 6]. Psychological (i.e., cognitive behavioral therapy [CBT]) and pharmacological (selective serotonin reuptake inhibitors [SSRIs]) interventions are effective in treating youth anxiety. However, even when receiving CBT and/or pharmacological intervention, only 60% of clinically-anxious youths lose their diagnosis after monotherapy [7], leaving a substantial proportion unresponsive to current treatments. In order to improve psychological treatments for youths, researchers have attempted to identify core cognitive processes that may be causally linked with pathological anxiety [8, 9]. For example, an early and automatic (i.e., fast, involuntary, outside awareness) [10] attention bias towards threatening information [11, 12] with downstream effects on higher-level cognitive processes (e.g., memory) may be a candidate cognitive process involved in the pathogenesis of anxiety. Indeed, there is now ample evidence that anxious youths have an attention bias toward threat-relevant information [13]. More recently, researchers have developed computerized attention modification programs (AMP) [1, 14] that direct attention away from threatening information in anxious adults. If attention bias is causally involved in the maintenance of anxiety, such modification of basic attentional processes should result in reduction of anxiety symptoms. At least four randomized double-blind clinical trials support the efficacy of AMP in adults with social anxiety [15-17] and generalized anxiety disorder [18]. Similarly, there are a number of studies of AMP in youths under the age of 18 [2, 3, 19, 20]. Rozenman et al. [3] found that after completing four weeks of AMP, 75% of youths with a primary anxiety disorder (12 of 16 youths) no longer met diagnostic criteria for any anxiety disorder. Additionally, both youths and primary caregivers indicated that AMP was a feasible and acceptable treatment. However, conclusions based on reported diagnostic change within the four-week period reported by Rozenman et al. are limited given that diagnostic criteria for anxiety disorders are generally based on a longer time frame. Moreover, this study did not include a control group. Bar-Haim and colleagues [19] examined the effects of a similar cognitive bias modification (CBM) program in a randomized placebo controlled trial (RCT) with undiagnosed youths reporting elevated levels of anxiety (N = 35). The authors found that CBM resulted in reduced stress reactivity and reduced attentional bias compared to a control condition. Most recently, Eldar and colleagues [2] completed the first RCT of AMP in a sample of clinically anxious youths. In this study, youths with a primary anxiety diagnosis of separation anxiety disorder, generalized anxiety disorder, social phobia, or specific phobia completed four weeks of AMP (n = 15) or one of two control conditions (ns = 15 and 10). At post-treatment, the group completing AMP experienced a larger decrease in anxiety symptoms and attention bias for familiar threat stimuli, relative to control conditions. While this study suggests that AMP may be a useful treatment for youth anxiety, questions remain regarding the use of AMP as treatment of anxious youth in community settings. For example, in the Eldar et al. study participants were excluded if they had obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), depression, or recurrent learning or conduct problems. However, childhood anxiety disorders are commonly comorbid with each other, as well as with other internalizing and externalizing disorders [21-23]. Moreover, participants were included in the study only if they presented with an attention bias towards threat at pre-treatment. Therefore, the results may have limited generalizability to typical clinical settings. In summary, there is some support for the efficacy of AMP in youth. However, there are at least two issues that need further examination. First, current effective treatments for youths often employ a multidimensional treatment model involving CBT and medication [7]. Therefore, it is likely that effective use of AMP in youths would involve a multidimensional approach combining AMP with current treatments. Second, although the majority of youths experiencing anxiety are treated in outpatient settings, anxiety is so debilitating for some youths that it necessitates residential treatment. Therefore, it would be useful to examine the effects of AMP in addition to standard care in such real-world clinical settings where youth anxiety is especially severe. As many youths who receive CBT and pharmacotherapy are not treated to remission, the National Institute of Mental Health called for augmentation treatments for psychotherapy and pharmacotherapy [24]. Similarly, recent reviews of CBM [1, 14, 25] have emphasized the need for research investigating the potential augmentation effects of CBM in conjunction with traditional CBT and/or pharmacotherapy. In the current study we examined the effects of AMP, as compared to an attention control condition (ACC), in a sample of clinically anxious youths admitted to a residential facility that specializes in treating severe and complicated anxiety. Youths completed AMP (or ACC) as an adjunctive service to typical psychosocial and pharmacological intervention.