From anxious youth to depressed adolescents: Prospective prediction of 2-year depression ...

13 Pages·2016·0.54 MB·English

UC Berkeley
UC Berkeley Previously Published Works
Title
From anxious youth to depressed adolescents: Prospective prediction of 2-year
depression symptoms via attentional bias measures.
Permalink
https://escholarship.org/uc/item/9m90127k
Journal
Journal of abnormal psychology, 125(2)
ISSN
0021-843X
Authors
Price, Rebecca B
Rosen, Dana
Siegle, Greg J
et al.
Publication Date
2016-02-01
DOI
10.1037/abn0000127

Peer reviewed
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University of California
JournalofAbnormalPsychology ©2015AmericanPsychologicalAssociation
2016,Vol.125,No.2,267–278 0021-843X/16/$12.00 http://dx.doi.org/10.1037/abn0000127
From Anxious Youth to Depressed Adolescents: Prospective Prediction of
2-Year Depression Symptoms via Attentional Bias Measures
Rebecca B. Price, Dana Rosen, Greg J. Siegle, Ronald E. Dahl
Cecile D. Ladouceur, Kevin Tang, BerkeleySchoolofPublicHealth
Kristy Benoit Allen, and Neal D. Ryan
UniversityofPittsburgh
Erika E. Forbes and Jennifer S. Silk
y. UniversityofPittsburgh
s.adl
herbro
publisnated Arengxarioduinsgywouhtihchaarenxaitouhseiygohutethneadreriastkthfoerhsiguhbesestquperonstpdeecvtievleoprimske.nBtioafseddepartetesnsitoionn;ahlopwatetevrenrs,l(iet.tgle.,ivsigkinlaonwcne
dmi andavoidanceofnegativecues)areimplicatedaskeymechanismsinbothanxietyanddepression.Aberrant
salliedisse aotftethnetioennavlirpoanttmerennstmduaryindgisdruevpetloopppmoertnutnaintides/otrotreefafetmcteivnet,lycoemngpaoguenwdiinthg,raisnkdolevaerrntifmroem.,Stihxrteya-steenvienngaansxpieocutss
eofittobe yfeoaurtfhul(–angeeustr9a–l1fa4c;e3p6afiresm.Talhee)ctiommepcloetuerdseaodfoatt-tpernotbioentaalspkattotearnsssebsostbhadsuelriinnegaatntednatifotenratlhpreaatttewrnassparsosveosskeeddvbiya
onnot eye-trackingandpupilometry.Self-reporteddepressiveandanxietysymptomswereassessed2yearsafterthe
oris conclusion of a larger psychotherapy treatment trial. Eye-tracking patterns indicating threat avoidance
ciationerand pproesdttihcrteedatgpreuaptiellra2ry-yeaavroiddeapnrceessi(orenflseccotirnegs,opvreefreraenndtiaablonveeurbaalseelningeagaenmdepnotstwtrietahtmtheentnseyumtrpaltormelsa.tiSvuesttaointehde,
sous previously threatening location) predicted additional variance in depression scores, suggesting sustained
s
Aal avoidanceinthewakeofthreatfurtherexacerbatedrisk.Identicaleye-trackingandpupilindiceswerenot
hologicaleindividu pcoorfentdtheircxettaivtoefcooafunlaxdniexitniyetetmyrfaaeytre2bweyeiatahrgsaa.tcTeqwhueaissyeittibooinodbeoepfhraeavsdsiaoiportnailvaemcraeormkssoertaisokinmeyrpelmgyuatlhtauatritoaatnivoosnkiadillalnwstidanutdtreoinnwtgi.odEnexavlceeplsrosopicvmeesesanivnt,ogcidiunalmnthciee-
ch
yt natinginthebroadbehavioraldeactivationthattypifiesdepression.Preventioneffortsexplicitlytargeting
Psof avoidantattentionalpatternsmaybewarranted.
ne
as
cu
erial
mn
Aso GeneralScientificSummary
heper Thisarticlesuggeststhatanxiousyouthwhoshowattentionalpatternscharacterizedbyavoidanceof
ythe threateninginformationareathigherriskofdepressionsymptoms2yearslater.
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yrightedolelyfor Keywords:attentionalbias,anxiety,depression,adolescence
ps
coed Supplementalmaterials:http://dx.doi.org/10.1037/abn0000127.supp
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docucleis Depression rates increase markedly during the transition to yearsofage)andcontributetothepostpubertalincreaseindepres-
hisarti adolescence(Angold,Costello,&Worthman,1998).Bothbiolog- sionrates(Cyranowski,Frank,Young,&Shear,2000).Hormonal
Ts
hi icalandpsychosocialchangescharacterizethetransitionfromlate changes occurring in adolescence may sensitize the brain to the
T
childhoodtoearlyadolescence(occurringatapproximately9–13 harmful effects of stress and increase vulnerability to depression
ThisarticlewaspublishedOnlineFirstNovember23,2015. DepartmentofPsychiatryandDepartmentofPsychology,Universityof
Rebecca B. Price, Department of Psychiatry, University of Pitts- Pittsburgh.
burgh; Dana Rosen, Department of Psychology, University of Pitts- RebeccaB.PriceandDanaRosencontributedequallytothisarticle.
burgh; Greg J. Siegle, Department of Psychiatry and Department of Theauthorshavenoconflictsofinterest.Thisresearchwassupportedby
Psychology,UniversityofPittsburgh;CecileD.Ladouceur,Department National Institutes of Health Grants MH091327, MH080215, MH18269,
of Psychiatry, University of Pittsburgh; Kevin Tang, Department of and MH082998. Rebecca B. Price is supported by National Institutes of
Neuroscience, University of Pittsburgh; Kristy Benoit Allen and Neal HealthGrant1K23MH100259.
D.Ryan,DepartmentofPsychiatry,UniversityofPittsburgh;RonaldE. CorrespondenceconcerningthisarticleshouldbeaddressedtoRebecca
Dahl, Department of Community Health and Human Development, B. Price, Western Psychiatric Institute and Clinic, 3811 O’Hara Street,
BerkeleySchoolofPublicHealth;ErikaE.ForbesandJenniferS.Silk, Pittsburgh,PA15213.E-mail:[email protected]
267
268 PRICEETAL.
(Angold&Costello,2006;Crone&Dahl,2012;Hyde,Mezulis,& including anxious youth with specific (fear-related) anxiety diag-
Abramson, 2008), particularly for females (Green, McGinnity, noses (Waters, Bradley, & Mogg, 2014) and adults and children
Meltzer, Ford, & Goodman, 2005). Although such peripubertal with unfavorable acute outcomes to certain forms of cognitive
changesarenormative,specificindividualsrespondtothemwith behavior therapy (CBT; Legerstee et al., 2010; Price, Tone, &
cascadingdetrimentaleffects.Identifyingspecificyouthathighest Anderson,2011;Waters,Mogg,&Bradley,2012).
risk,andideally,interveningbeforeadversedevelopmentaltrajec- Thedegreetowhichaberrantattentionalpatternsareremediated
tories set in, is an unrealized health care goal with substantial by conventional treatments remains unclear. Psychotherapy, and
publichealthramifications(Weissmanetal.,1999). CBTinparticular,isconsideredafirst-linetreatmentforpediatric
Pediatricanxietyisakeyriskfactorforsubsequentdevelopment anxiety,producingsubstantialreductionsinanxietyforthemajor-
of depression, with the majority of depressed youth having a ityofpatients(Silverman,Pina,&Viswesvaran,2008).However,
historyofanxiety(Kessler,Avenevoli,&Merikangas,2001;Pine, asubstantialminorityofpatients(e.g.,40%;Walkupetal.,2008)
Cohen,Gurley,Brook,&Ma,1998).However,onlyaminorityof donotrespond,andofthosewhodo,somefailtomaintaingains,
anxiousyouthgoontodevelopdepression.Identifyingbiobehav- suggesting the risk of progression from anxiety to depression
publishers.natedbroadly. ipapoborreipalcuilutlymrasttoaioorrksndeoiersssfitgdhoneefprpemrrfeooessrcsepihoeacncnr,tiiitsvaitcneiacdlditeenopftferpiercrvseiseevinneottnnliyotirnoidssnektlehifwvafeotirtrhttatsihrn,gepetmrhtoismmtohoosidtgipinhfegi-caribtifhsilkcee rsmoeknmailttliahsoienntospoafhrteirigdeishnuktc)’iesnasvcthiowgeniesslleaclniooycvuoeesu-rrtetahlwb.aetaAehrdleatnvhceiooosugrsganlohitfaiCvvvoeBiigTdbialiaanfnsocecrese,ai(antenxl.adgier.g,tayevolovtyeiedarreacelnhsicteeiess-
sallieddissemi pbaritAdieglnteetsrferwodmhaotatnenxneiteeidotyntahtolemdpea.pttreersnssiocno.uAldbercroannsttiptauttteeronnseofmatetcehnatinoinsttioc poaftatettrennst.ioSnuaclhacltoenrsactiioonusdbeeschraivbieodrsinmtahyebaettednisttiionncatlfbroiamsltihteerfaoturmres,
ite whichoccurrelativelyautomaticallyonatimecourseofmillisec-
ofob negativestimuliarepositedtoplayakeyroleinbothanxietyand onds to seconds (Buetti, Juan, Rinck, & Kerzel, 2012; Najmi,
oneott depression across the life span (de Raedt & Koster, 2010; Ma- Kuckertz,&Amir,2010).Althoughthereissomelimitedevidence
orisn cLeod,Mathews,&Tata,1986;Gerber,Peterson,Pine,Guyer,& that CBT for anxiety may reduce vigilance patterns (e.g., Lavy,
ationand sLteimibuelniluisft,th2o0u0g8h).tAtolthporoumghotperenfeegreantitviaelaatftfeencttiiovnetsotwataersdannedgamtiavle- vandenHout,&Arntz,1993;Mohlman,Price,&Vietri,2013;cf.
cier Waters,Wharton,Zimmer-Gembeck,&Craske,2008),suchfind-
ssous adaptive cognitions, excessive avoidance of threat represents the ings at the group level imply that individuals who begin at the
Aal oppositeextremeonanattentionalcontinuum,andmaybeequally
ologicalindividu danetdrimcoennctoalmiintatnhtathaitbpitrueactliuodnes(Madoagpgt,ivBereandgleayg,emMeinletsw, i&thDthirxeoants, omavpaopyiodseaiinttehted(raiprveeocritsdiioasntnti)nfotelhlnoidswpionafgttetthrrnee,atovmrigeminlaat.yncAmev–ooavivdeoaeindvtaenancttfeeunrcttihooennrtiincnuouuthmlde
he 2004). Although theoretical accounts have focused primarily on
ycth potentially interfere with maximal engagement in key therapy
Psof vigilance as an indicator of hyper-engagement with disorder- strategies thought to promote enduring reorganization of threat
ne relevant information (Mathews & MacLeod, 1994), avoidance
caus representationsinmemory(e.g.,exposureandhabituation;Foa&
eAmeriersonal batenexhxtaisev(tiyeo.,rgm.i,sasncahlisfoeoostlhiinrgeghfulayssaclp)l,iensrisocicasitlaelylnwtreaitlvheovdiardanawtnaicnle,baoonftdht/hodrreebaprtroeenasdisniobgnechaoannvd-- Kthorozuakg,h1a98v6a)r.ieItnythoaftaclatesren,aaticvuete(ib.ee.n,enfiotsnamttiegnhtitosntaillllybemoebdtiaaitneedd)
ythhep ioraldeactivation(Dimidjian,Barrera,Martell,Muñoz,&Lewin- pathways (including both specific and nonspecific factors), but a
bt dormantriskoflong-termrelapseand/orprogressiontonewsymp-
yrightedolelyfor srineosghu,nlh,tai2bn0it1mu1ai)st.isoeAnd,vooapnidpdaontrhcteuenadictuiqerusiinsfgiotirtohtnheroecfaoatuderasnpegtaiovgfee,mdpeervnoetblolaepnmmd-eponrroitecmnetsaesyd- toofm-thse(-ea.rgt.,cadreep.rPesrosigorne)sscioounldtopdoetepnretisasliloyne,nindupraertiincuslpairt,emofigshttatbee-
iscopndeds einmgoetmioontiroengurelagtuiolantisotnradteegfiiceist.sCcooumldpocuonndsteidtuoteveornetimdeev,etlhoepmreesnutlat-l ltiakueglhyt sakmilolnsgeffceecrttiavine fyoorutthhe imfananagxeiemtye-nftocoufseadnxipestyychitostehlfe,rabpuyt
entnte mechanismwherebyanxiousyouthbecomedepressedadolescents. failedtoremediateacoreattentionalpatternconferringriskforthe
documcleisi extErexmpeersi—mevnitgaillaenvciedeanncdeasvuopipdoanrtcset—hearneoltiinoknetdhawtibthotshymatptetnotmiosnoafl eamdoelregsecnecneceo.f depression during the key developmental stage of
hisarti anxiety and depression in youth. Vigilant patterns are the more Inthecurrentstudy,allparticipantsreceivedstandardizedpsy-
This widely documented characteristic among anxious youth samples chotherapy (CBT or client-centered therapy; CCT) in the context
T
(Shechner et al., 2012) and are particularly evident when early of a larger anxiety treatment trial and, on the whole, exhibited
attentionalprocessesareassessed,suchasduringinitialorienting substantialacutedecreasesinanxietyduringbothtreatments(clin-
tothreat(Shechneretal.,2013)andfollowingbrief(e.g.,500ms) ical trial results are presented separately; Silk et al., 2015). If
stimulus presentations (Bar-Haim, Lamy, Pergamin, Bakermans- attentional features indeed predict prospective symptoms, even
Kranenburg,&vanIJzendoorn,2007).Vigilancetowardnegative among individuals known to have received high-quality psycho-
stimuli has also been found in depressed youth and youth at risk therapy, and over and above any acute treatment benefit, this
for depression, particularly when using reaction time (RT) mea- would strongly imply that existing first-line behavioral interven-
suressensitivetoslightlylaterstagesofstimulusprocessing(e.g., tions are insufficient to ameliorate the specific form of risk con-
Joormann, Talbot, & Gotlib, 2007; Salum et al., 2013). By con- tainedincertainattentionalpatterns.Givenmountingevidencethat
trast, avoidant attentional patterns have been found in depressed attentionalpatternsthemselvesaremalleableusingautomatedap-
childrenwhenmeasuringthepersistentdirectionofeyegazeover proaches (MacLeod & Clarke, 2015), findings could simultane-
a more sustained presentation period (Harrison & Gibb, 2014). ouslysuggestviabletargetsforalternativeintervention/prevention
Avoidant patterns also characterize subsets of anxious samples, efforts.
FROMANXIOUSYOUTHTODEPRESSEDADOLESCENTS 269
To promote the feasibility of clinical translation, we focused incorporation of subclinical forms of depression, which are both
currentpredictioneffortsonmeasuresobtainedusingarelatively impairing and prognostic of subsequent depressive disorders
inexpensive laboratory set-up (computer, eye-tracker). We as- (Compas, Ey, & Grant, 1993). We hypothesized that attentional
sessedvisualattentionalpatternsineyegazeduringfearful–neutral markers (i.e., eye gaze and pupilometry, indexing perithreat and
face pair presentations, focusing specifically on overall bias in postthreatattention,respectively)wouldconferprospectiveriskof
dwelltime(themostconsistentmarkerofdepressionanddepres- depression during the transition to adolescence, in spite of state-
sion risk) and bias in initial fixation (an early attentional marker of-the-arttreatmentforanxietyduringyouth.Thiswouldsuggest
linked to anxiety; for review, see Armstrong & Olatunji, 2012). akeytransdiagnosticmechanismthatisnotremediatedbyexisting
Eye-trackingmeasureswereselectedtoindexattentionalpatterns first-linetreatments.
becausetheyprovidedetailedinformationaboutthetimecourseof
attention,includingindicesofbothrelativelyearly/automatic(i.e., Method
initial fixation) and relatively late/controlled (i.e., dwell time)
componentsofattention,andweremorereliablethanRTindices
Participants
y. obtained during this version of the task (Price et al., 2015).
shers.broadl Fdiesaorr-dreelraste(dCisstliemru&li,Kwohstiecrh, 2a0re10p;aGrtioctulilbarelyt arle.l,e2v0an0t4)t,owaenrexiesety- StaStiixsttiyc-aslevMenanyuoaulthof(aMgeesnt9al–1D3i;so2r9dfeermsa(4let)hweidt.h;DAimagenriocsatnicPasnyd-
publinated lected to best match concurrent symptoms and treatment targets chiatric Association, 1994) diagnoses of generalized anxiety dis-
dmi withinthesampleatbaseline. order, separation anxiety disorder, and/or social phobia were re-
salliedisse visAualtlhaotutegnhtieoynea-ltrmacekchinagniisnmdsicienstphreopvriedseenacediorefctthraesaste,spsmupeinlotmof- ctrriuailtewdillfobreaprleasregnetredpssyecphaortahteelryap(ySiltkriaelt.aRl.e,s2u0l1ts5)o;ffothrethterepartemseenntt
ite
ofob etry was used to provide complementary information on covert report, we focused on prediction of depressive symptoms that
oneott neural-attentionalprocessesoccurringinthewakeofthreatstimuli, emerge in spite of treatment. Sixty-seven youth had usable data
orsn duringasustainedpostthreatperiod.Pupildilationisaperipheral from(a)baseline(pretreatment)attentionalmeasuresand(b)clin-
i
ationand mcoagrnkietrivoefanneduraaflfeecntgivageepmroencetstshiantgplrooavdid.eWseashuamvempartievveioiunsdleyxroef- iacnaxliveatyriasybmlesptionmclusdaisnsgesbsaesdeliimnemdeedpiraetesslyioanfatenrdtahnexaiectuytesytrmeapttmomenst,
cier
sous ported sustained pupil alterations in the aftermath of fearful– phase, and depression and anxiety symptoms assessed approxi-
Asal neutral face pairs among anxious youth that persisted for (cid:2) 8 s mately 2 years following the conclusion of the acute treatment
ologicalindividu asifgtenrifythinregatatstetinmtiuolniawl aelrteerraetmioonvsetdha(tPernicdeureetbaely.,on2d01t3h)e,pproessseinbclye pthheassee,(5C3ByToourthCCalTso;sheaedTadbelpere1ssainvdebseylmowptfoomrsfuartshseerssdeedtaailcsu).teOlyf
he of threat and therefore cannot be measured via conventional be- posttreatment.Informedconsent/assentandstudyprocedureswere
ch
yt
Psof havioral (e.g., eye gaze) patterns. Sustained pupil alterations (in- approved by the University of Pittsburgh Institutional Review
ne creasesordecreases)intheaftermathofnegativestimulihavealso Board.
as
cu
erial beenobservedinanxiousadults(Oathes,Siegle,&Ray,2011)and Clinical assessments, treatment, and sample composition.
Amson depressed adults and youth (Siegle, Granholm, Ingram, & Matt, Data come from a large treatment outcome study of pediatric
eer 2001;Siegle,Steinhauer,Carter,Ramel,&Thase,2003;Silketal., anxiety (clinicaltrials.gov NCT00774150; Silk et al., 2015). In
hp
ythe 2007).Likeconventionalattentionalbiasmarkers,pupillarymark-
bt
yrightedolelyfor ewwriistthhcannneeugrtaertfailvleeicntifnobfroomtrhmatvaioitginoi)lnap)naattnt(edir.nea.sv,,opwirdietafhnetrdee(nptrtriieamfleenrneetnautlriaaellffeeenncggtsaaggpeeommsieetenndtt TDaebslceri1ptiveCharacteristicsoftheSample
ps
entiscontended isnneengetaeatdcivhenceaagstateet.invIteinocnsrtaeilamsouerdliiennmetaautyriaolrneepn(rege.asgge.,nemtrueamntpinewarstiietohvne;prraSetiviveiegoluefsolyermtparole.f-, Characteristic An(xnio(cid:3)us6y7o)uth
mi
docucleis 2st0im03u)l,iwmhaeyreraesprreelsaetnivtepleyrsinisctreenatsaetdteemngpatsgeamt aevnotifdoalnlocwei(nOgantheeustraelt AFegmeale,n(%) 113.16((15.34.)7%)
Thissarti al., 2011). Pupil dilation persisting in the aftermath of negative CBaauseclaisnieand,iangn(%os)esa,n(%) 61(91.0%)
Thi stimuli has been shown to prospectively predict acute treatment Separationanxietydisorder 13(19.4%)
outcomes in depression with high accuracy (Siegle et al., 2014; Socialphobia 17(25.4%)
Siegle, Steinhauer, Friedman, Thompson, & Thase, 2011), and Generalizedanxietydisorder 49(73.1%)
Specificphobia 11(16.4%)
mayalsohavestrongreliability(Siegleetal.,2014),makingitan
Majordepressivedisorder 1(1.5%)
attractive candidate for predicting outcomes at the level of indi-
BaselineSCARED 37.8(11.01)
vidualpatients. BaselineMFQ 20.4(11.32)
In summary, efforts to identify biomarkers of prospective de- 2-yearSCARED 17.51(11.57)
pression risk among youth have so far been limited. Here we 2-yearMFQ 11.0(10.1)
describe findings from one of the first studies to prospectively Note. Data presented as mean (standard deviations) unless otherwise
follow anxious youth (without primary depression at baseline) noted. SCARED (cid:3) Screen for Child Anxiety Related Emotional Disor-
overakey2-yeardevelopmentalwindowduringthetransitionto ders—child report; MFQ (cid:3) Mood and Feelings Questionnaire—child
report.
adolescence.Depressionwasassessedonacontinuum,consistent
aDiagnosticgroupsarepartiallyoverlappingduetoinclusionofcomorbid
withadimensionalapproachtouncoveringdevelopmentalmech- patients. Primary/principle diagnoses were not designated, meaning that
anisms of psychological distress (Nigg, 2015) and allowing for percentagesforthe3diagnosticinclusiongroupswillnotsumto100.
270 PRICEETAL.
brief, following a brief phone screen, an intake assessment oc- remainder of the trial irrespective of when a response was made
curredduringwhichastructureddiagnosticinterviewwasadmin- (10.6sforshortstimulustrials,8.8sforlongstimulustrials;each
isteredtothechildandhisorherparenttoconfirmpresenceofan trial (cid:3) 11.3 s total), allowing for continuous pupilometry assess-
anxiety disorder. Diagnoses were made by trained interviewers mentofcovertattentionalprocessesoccurringinthewakeofthreat
usingtheScheduleforAffectiveDisordersandSchizophreniafor (without interference from changes in screen luminescence). For
School-AgeChildren-PresentandLifetimeVersion(K-SADS-PL; consistencywithinallanalyses,datawererestrictedtothe32trials
Kaufmanetal.,1997).Parentsandyouthwereinterviewedsepa- per participant with long (2,000 ms) fearful–neutral face pair
rately,withinterviewersintegratingdatafrombothinformantsto presentations, as they provided sufficient time for meaningful
arriveatfinaldiagnoses.Diagnoseswerereviewedandsupervised eye-tracking analyses (whereas 200-ms presentations do not reli-
byachildpsychiatrist(NealD.Ryan).Participantswereexcluded ablyallowforcompletionofasingleeyemovement;Henderson&
iftheydemonstratedanIQbelow70asassessedbytheWechsler Hollingworth,1998).
Abbreviated Scale of Intelligence (WASI; Wechsler, 1999), re-
quired current ongoing treatment with psychoactive medications
Attentional Predictor Variables
y. includinganxiolyticsandantidepressants,wereacutelysuicidalor
shers.broadl aretqruiisrkemfoenrtsh,aromr htoadseplfrevoirouostlhyersc,omfapilleedtedtoamceoeutrsMeRoIf sCafBeTty. MAE)yea-ftfrixaecdkitnoga. taAblnetIoSpC,AwNasRusKe-d7t8o6,tra(IcSkCeAyeNmIonvce.,mWenotsbuarnnd,
publinated Participants were excluded from the study if they had current, pupillary motility continuously at 60 Hz. Eye fixations were de-
dmi primary major depressive disorder at baseline. Comorbid depres- finedaseyepositionsstablewithin1°ofvisualangleforatleast
salliedisse swivereediaslolordweerds s(enco(cid:3)nda1ryintocaunrxreienttyainnatleyrsmess;onfofurnecptoiortneadl irmespualctst 1re0p0remsesnatnindgwtehreefuoslelodwtoincgalgcauzlaetep2atbteiransss:c(oar)esp(edrcifefnetraegneceosfcotrrieasls)
ite
ofob affected by excluding this individual). Additional diagnostic ex- with initial fixations falling within regions of interest defined by
oneott clusionary criteria included current diagnosis of obsessive– thefearfulversusneutralfacelocations(an“early”indexofinitial
orsn compulsivedisorder,posttraumaticstressdisorder,conductdisor- attentionalcapture)and(b)percentageofdwelltimespentfixating
i
ationand ddeisro,rsduebrstcaonmcebainbeudsetyopredeoprenpdreednocme,iantatenntltyiohny-dpeefriaccitt/ihvye-piemrapcutlisviivtye opnreffeeraernfcuel tvherrosuugshnoeuutttrhael ffaacceespr(easnenitnadtieoxn)o.f overall attentional
cier
sous type, or lifetime diagnosis of autism or Asperger syndrome (as Botheye-trackingindicesreflectacontinuumfromavoidanceof
s
Aal assessed by the Child Asperger Syndrome Test; Allison et al., threat (i.e., gaze preference for neutral information) to vigilance
ologicalindividu 2sc0h0i7z)o,afbfiepcotliavreddiissoorrddeerr,. psychotic depression, schizophrenia, or (thgaatzelaprgreefresrceonrceesfionrdtihcraeteatgirnefaotremravtiigoinla)n,caendanwdesremcaalllecrul(anteegdastiuvceh)
he Patients were randomized to receive 16 sessions (14 with the scoresindicateavoidanceofthreat.Trialswithincorrectresponses,
ch
Psyoft child, plus 2 parent sessions) of CBT or CCT in a 2:1 ratio. comprisedof(cid:2)50%blinks,orwithnodetectablefixationsprior
ne Master’s-level and doctoral-level therapists administered both tomanualresponsewereexcludedpriortoanalysis(16%oftrials).
as
ericalu treatments (therapists and treatment were fully crossed). In brief, Participants (n (cid:3) 3) were excluded from the reported sample if
Amson CBT was delivered using the Coping Cat therapist manual (Ken- they had (cid:4) 10 usable trials. Excluded participants did not differ
eer dall & Hedtke, 2006a) and child workbook (Kendall & Hedtke, fromincludedparticipantsonanyclinicalordemographicvariable
hp
ythe 2006b). The first eight sessions focused on anxiety-management inTable1(ps(cid:2).1).
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yrightedolelyfor scbkhliiinllldgse;trh,thrMoeuasgnehncaoarnidnhoie8,r&asrecSshstyeioenor,sf2ei0nx0vp4oo)lsvuiesrdeattmhaesakntsuh.aeClriazCpeTidstn(Cognuodihdierinne,cgtDitvheee-, oduesrPcurliapbbiel’ldsar(syPtarmincdoeatreidltitaypl.r.,oc2Pe0du1up3ri)le.sdPiautompielrletaemrryovvraeeluspeboslinwnskeessr,ewaceslereapnrbeeadvsieoulusiinsnleyg-
ps
coed supportivepsychotherapybasedonhumanisticprinciples.Accep- corrected within each trial by subtracting mean pupil diameter
isnd tance, reflection, and nondirective problem solving are key tech- during the first 10 samples (167 ms) from the remainder of the
entnte niques.Theinterventionwasdevelopedtobeanalogoustotypical trial.Baseline-correctedpupildiametervalueswerethenaveraged
mi
docucleis sreucpepiovretiivnethpesyccohmomthuenraitpyy.Ftuhratthearnxdieotauislscohfiltdhreenstuadnydparodtoolceoscleanntds aincgrotsospaollstttrhiarelsatdpurroinbgeparteesmenptoartaiolnw,itnhdaotwis,offroimnteprreosbtecoornrseestpuonntdi-l
hisarti treatmentconditionsareprovidedelsewhere(Silketal.,2015). the conclusion of the trial (an 8.8-s window; incongruent and
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hi congruent trials averaged separately). Resulting means were
T
outlier-correctedpriortoanalysisusingaWinsorizingapproachin
Dot-Probe Task
whichvaluesoutside1.5interquartilerangesfromthe25thor75th
Participantscompletedthedot-probetaskwithconcurrenteye- percentilesofthedistributionwererescaledtothelastvalidvalue
tracking and pupilometry assessment, as previously described withinthatrange.
(Priceetal.,2013).Afteraninitialfixationcrossinthemiddleof Forconsistencywitheye-trackingindices,whichrepresentbias
the screen (500 ms), a fearful and a neutral face pair from the toward/away from threat in a single measure, pupil bias scores
NimStim battery (Tottenham et al., 2009) were presented simul- werequantifiedonthebasisofthedot-probeattentionalmanipu-
taneously on the top and bottom of the screen for either a short lation, which orients attention toward (congruent trials) or away
(200 ms) or long (2,000 ms) interval, followed by a probe (dot) from(incongruenttrials)thepreviousthreatlocation.Pupilbias
replacing one of the faces (“congruent” trials (cid:3) fearful face wascalculatedas:averagepupildiameter(expressedaschange
location;“incongruent”trials(cid:3)neutralfacelocation).Participants from baseline), averaged across the probe period, for congru-
respondedasquicklyaspossiblewithakeyboardpresstoindicate ent—incongruent trials. Akin to the eye-tracking bias scores,
the location of the probe. The dot remained on-screen for the largervaluesindicaterelativelygreaterneuralengagement(pu-
FROMANXIOUSYOUTHTODEPRESSEDADOLESCENTS 271
pil dilation) with the location of threat (i.e., postthreat vigi- Covariates
lance),andsmaller(negative)valuesindicaterelativelygreater
Baseline MFQ and SCARED scores, acute posttreatment
neural engagement with the neutral location (postthreat avoid-
SCARED scores (a primary marker of therapy response), and
ance).
therapycondition(CBTorCCT)werecontrolledinallregression
For post hoc pupilometry time-series analyses, a test statistic
analyses.Becausetheacutetreatmentphasetargetedanxietyspe-
(specifically, correlation with 2-year depression; or independent
cifically and primary depression constituted a study exclusion,
samples t test in the extreme-groups comparison analysis) was
acuteposttreatmentMFQscoreswereinconsistentlyobtainedand
calculatedateverytimepointwithinthemeanpupilwaveform.To
hold Type I error at p (cid:4) .05 across all timepoints, Guthrie and were available from only a subset (n (cid:3) 53) of participants. Re-
gression analyses were repeated controlling for posttreatment
Buchwald’s(1991)MonteCarlosimulationtechniquewasused
MFQwithinthissubsample(seetheonlinesupplementalmaterial).
to identify the duration of the temporal window over which a
Inexploratoryanalyses,pretreatmentage,gender,andtheAge(cid:5)
series of contiguous point-by-point t tests or correlation coef-
Gender interaction (a potential proxy for pubertal development,
ficients could be considered significant given the observed
y. temporal autocorrelation of the waveform, as described previ- given that girls enter puberty earlier than boys) were explored as
shers.broadl &ousClyar(tSeire,g2le00e3t;alS.,ie2g0l0e3,;SStieeignlhea,uSetre,in&haTuhera,sSe,te2n0g0e4r,).KAonmeciknyi-, additionaldevelopmentalcovariates.
publinated mumdurationof2.97s(178samples)wasidentifiedusingthis Analytic Strategy
dmi technique.
salliedisse intAernpraedtidnigtiopnuaplilpofisntdhinogcsantharloyusigshonfepuurpalil“dsaotuarcwealsoucaselidzattoioanid”iinn relBatiivoanrsihatiepscobrertewlaeteionnsatwteenrteiounsaeldpforerdpircetloirms,incaorvyairnitaetrerso,gaantidondoe-f
ite pendent variables. For primary prediction analyses, hierarchical
oneofottob adastuabcsoeltleocftesdubdjuercitnsg(ann(cid:3)ide4n3t)icwalitthasuksa(sbeleetfhuencotniolinnaelsMupRpIle(mfMenRtaI)l laitne2a-ryereagrsrepssoisotntrewaatmsuenset.dFtooridceonmtipfyarpisroend,icStoCrAsoRfEMDFsQcosrceosreast
orisn material). Although prediction analyses were intentionally con- 2-years were used as a secondary endpoint. Unless otherwise
ationand sotrraationreydsteot-mupe,afsMurResIodbattaainwaebrleeuwseitdhtaorperloavtiivdeelypointeenxtpiaelnlysivdeisalamb-- noted, predictors were entered as follows—Step 1: baseline
cier depression (MFQ) and anxiety (SCARED) scores, posttreat-
ssous biguatinginformationregardingtheinterpretationofprimarypupil ment anxiety (SCARED), and therapy condition; Step 2: eye-
Aal findings.
aldu tracking bias measures (dwell time bias and initial fixation
ologicindivi Dependent Variables bias); Step 3: pupil bias.
he
ch
yt The primary outcome was depressive symptoms 2-years post- Results
Psof
ne treatment, assessed on a continuum via the Mood and Feelings
as
ericalu Questionnaire—Child report (MFQ; Kent, Vostanis, & Feehan, Bivariate Relationships
mn 1997).Toassessspecificityforprogressiontodepression,anxiety
eAerso symptoms at 2-years posttreatment were also assessed via the Thecorrelationmatrixforpredictorvariables,covariates,and
hp
ythe child-report Screen for Child Anxiety Related Emotional Disor- dependent variables is presented in Table 2. Higher depressive
bt ders(SCARED;Birmaheretal.,1997). symptoms at 2 years (the primary outcome) were associated
yrightedolelyfor
ps
coed Table2
isnd CorrelationMatrix
entnte
documcleisi Attentionalfeatures Covariates Dveaprieanbdleenst
hisarti Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Ts
Thi 1.(cid:6)Pupildiameter(congruenttrials) — .354(cid:2)(cid:2) .618(cid:2)(cid:2) (cid:7).068 .158 .073 (cid:7).203 (cid:7).201 (cid:7).074 .099 .063 .062 (cid:7).036 (cid:7).092
2.(cid:6)Pupildiameter(incongruenttrials) — (cid:7).517(cid:2)(cid:2) (cid:7).209 .238 .072 (cid:7).073 (cid:7).055 (cid:7).046 .065 .249 .182 .338(cid:2)(cid:2) .085
3.Pupilbias(probeperiod) — .113 (cid:7).055 .006 (cid:7).125 (cid:7).138 (cid:7).029 .036 (cid:7).152 (cid:7).096 (cid:7).317(cid:2)(cid:2) (cid:7).156
4.Dwelltimebias — .183 .034 (cid:7).030 (cid:7).010 (cid:7).161 (cid:7).160 (cid:7).045 (cid:7).104 (cid:7).341(cid:2)(cid:2) (cid:7).134
5.Initialfixationbias — .123 (cid:7).037 (cid:7).005 .047 .061 (cid:7).076 (cid:7).019 (cid:7).102 (cid:7).121
6.Baselineage — (cid:7).153 (cid:7).022 .039 .111 .160 .152 .164 .065
7.Gender — .984(cid:2)(cid:2) (cid:7).115 .157 .196 .262(cid:2) .273(cid:2) .385(cid:2)(cid:2)
8.BaselineAge(cid:5)Gender — (cid:7).115 .162 .208 .292(cid:2) .293(cid:2) .402(cid:2)(cid:2)
9.BaselineMFQ — .474(cid:2)(cid:2) .357(cid:2)(cid:2) .210 .069 .051
10.BaselineSCARED — .184 .459(cid:2)(cid:2) .265(cid:2) .364(cid:2)(cid:2)
11.PosttreatmentMFQ — .558(cid:2)(cid:2) .331(cid:2) .320(cid:2)
12.PosttreatmentSCARED — .419(cid:2)(cid:2) .603(cid:2)(cid:2)
13.2-yearMFQ — .658(cid:2)(cid:2)
14.2-yearSCARED —
Note. MFQ(cid:3)MoodandFeelingsQuestionnaire;SCARED(cid:3)ScreenforChildAnxietyRelatedEmotionalDisorders.
(cid:2)p(cid:4).05level(2-tailed). (cid:2)(cid:2)p(cid:4).01level(2-tailed).
272 PRICEETAL.
with two indices of avoidant attention (see Figure 1): more Hierarchical Regressions Predicting 2-Year Outcomes
avoidant eye gaze patterns across the trial (dwell time bias:
r (cid:3) (cid:7).341, p (cid:3) .005) and lesser differential pupil diameter In primary prediction analyses, after controlling for baseline
(pupil bias) for congruent compared to incongruent trials depressionandanxiety,treatmentgroup,andposttreatmentanxiety
(r(cid:3)(cid:7).317;p(cid:3).01),whichwasdrivenbyarelationshipwith (Step 1: (cid:6)R2 (cid:3) .19, (cid:6)F (cid:3) 3.7, p (cid:3) .01), eye-tracking bias
4,62
increased pupil diameter during incongruent trials (r (cid:3) .338; measures (Step 2) explained significant additional variance in
p (cid:3) .005). 2-yearMFQscores((cid:6)R2(cid:3).09,(cid:6)F (cid:3)3.9,p(cid:3).03).Likewise,
2,60
To explore the timing of the observed pupil correlation pupilbiasexplainedsignificantvariancein2-yearMFQscoresat
during incongruent trials, a post hoc time-series analysis was Step2aftercontrollingforclinicalcovariatesatStep1((cid:6)R2(cid:3).07,
conducted.Significantcorrelationsbetweenpupildiameterand (cid:6)F (cid:3) 4.5, p (cid:3) .01). In a final hierarchical model, pupil bias
7,59
2-year depression began at the point of probe onset and con- wasaddedatStep3(aftercontrollingeye-trackingbiasindicesat
tinued almost continuously throughout the remaining 8.8 s of Step2)andexplainedfurthersignificantvariancein2-yearMFQ
y. the trial, with the peak correlation coefficient (r (cid:3) .35) occur- scores,abovebothclinicalandeye-trackingmeasures((cid:6)R2(cid:3).07,
shers.broadl rriensgpo4n.1sestaimfteeropfro8b4e0omnsse)t.(Si.iem.,il(cid:2)arl3y,swafhteernthcoemavpearrainggemthaentuoapl (cid:6)(aFdj1u,5s9te(cid:3)d 5R.29,(cid:3)p(cid:3).27.0;2F).7,A59tS(cid:3)te4p.53,,3p5%(cid:4)o.0f0v1a)r,iaanncdegwraesateexrp2la-yineeadr
blied and bottom quartile of 2-year MFQ scorers, significant pupil MFQ scores were predicted by more avoidant eye-tracking bias
dpuminat differences commenced shortly after probe onset and were ((cid:8) (cid:3) (cid:7).26, 95% CI [(cid:7).48, (cid:7).04], p (cid:3) .02) and more avoidant
salliedisse sthuesttariinaeld(Fniegaurlryec1o).ntinuouslythroughouttheremaining8.8sof pfourpailllbioatshe((cid:8)rv(cid:3)ari(cid:7)ab.2le6s,.95%CI[(cid:7).48,(cid:7).05],p(cid:3).02),controlling
ite
ofob
et
onot
n
ors
i
ationand
cier
os
su
s
Aal
aldu
ologicindivi
he
ch
yt
Psof
ne
as
cu
erial
mn
Aso
eer
hp
ythe
bt
yrightedolelyfor
ps
coed
sd
in
entnte
mi
docucleis
hisarti
Ts
hi
T
Figure 1. Scatterplots for attentional variables predicting 2-year depression. Time-series plot depicts pupil
diameter (expressed as change from baseline) in top and bottom quartiles of the 2-year Mood and Feelings
Questionnaire(childreport;MFQ),withred(darkgray)shadingindicatingtimepointswithsignificantgroup
difference.Initialdipduringfacepresentationisdrivenbypupillarylightreflex.Seetheonlinearticleforthe
colorversionofthisfigure.
FROMANXIOUSYOUTHTODEPRESSEDADOLESCENTS 273
Allsignificantfindingsabovewereupheldwhenposttreatment The detrimental impact of avoidance patterns was consistent
depressionwascovariedinparticipantswithavailabledata(seethe acrossbothperithreat(eye-tracking)andpostthreat(pupilometry)
onlinesupplementalmaterialfordetails). indices, in spite of quite distinct forms of information obtained
Parallelregressionanalysesfor2-yearanxietyrevealednosig- withthesemethods.Duringincongruenttrials,whichencouragean
nificant effects for attentional predictors at any step (dwell time avoidant response by orienting attention away from the previous
bias, initial fixation bias, pupil bias; ps (cid:2) .2). As above, baseline location of threat, elevated pupil dilation in youth at highest
depression and anxiety, treatment group, and posttreatment anxiety depression risk was sustained across a (cid:2) 8-s poststimulus period
collectivelypredicted2-yearanxiety(Step1:(cid:6)R2(cid:3).39,(cid:6)F (cid:3) (Figure 1). In conjunction with explicitly avoidant eye gaze pat-
4,62
10.0,p(cid:4).001)butSteps2and3didnotimproveprediction(Step2: terns,thispatternsuggestspossiblepersistentcognitiveeffortsto
(cid:6)R2(cid:3).02,(cid:6)F (cid:3).81,p(cid:3).45;Step3:(cid:6)R2(cid:3).01,(cid:6)F (cid:3)1.41, sustainattention(e.g.,mentalfocus)inthe“safe”(i.e.,previously
2,60 1,592
p(cid:3).24),andnointeractioneffectsweresignificant(seetheonline neutral) relative to the “dangerous” (i.e., previously threatening)
supplementalmaterial). context, even when actual visual attentional avoidance of threat
Interaction effects among covariates, and between covariates wasnolongernecessaryor,indeed,possible(giventhatnothreat
y. and attentional features, were not significant predictors of 2-year remained on-screen). Avoidant pupillary responses (i.e., reduced
shers.broadl dveaplirdes(ssieoenthoer aonnxliineety,suspupglgeemsetinntgalcmovaateriraiatel)s.iOnfthpeartmicoudlaerl nwoetree, roeussploynsbeesentorneepgoarttievde irnelaatidvueltstowneituhtrahligtrhialsetlyfp-reesp)ohrtaevde wproervriy-
publinated relationships between attentional features and 2-year depression (Oathesetal.,2011)anddepressedyouth(Silketal.,2007).Just
dmi werenotmoderatedbypsychotherapytreatmentcondition(seethe as in the current dataset, the alterations began in the wake of
salliedisse onlinesupplementalmaterial). smtiomvuedli,fraonmd pveierwsisatenddfroerspsoenvseersalwseerceomndasdea.ftSeurcshtimpauttleirwnserceourled-
ite
ofob Developmental Factors indicate preferential recruitment of elaborative processing and/or
oroneisnott genEdxeprl,oarantdorAygreeg(cid:5)resGsieonndaenrailnytseersacetxioanmsinsiungggethseteidnfolubesenrcveeodfraeglae-, cnoeggnatiitviveeincfoonrtmroaltimone.cThaonpisrmomsoitnetchlieniwcaalkteraonfslnaetiuotnra,lwreeloaptitveedttoo
ationand tionshipswerenotbetterexplainedbythesedemographicfactors. rtaeisntreidctqpuriicmklayryanrdegirneesxspioennsaivneallyysiensatoremlaetiavseulryessimthpalteclaanbobreatoobry-
cier Consistentwiththeclinicaldevelopmentalliterature,femalegen-
ssous derandtheAge(cid:5)Genderinteraction(i.e.,oldergirls,relativeto set-up(and,increasingly,usinghandheldand/ormobiledevices).
Aal However,inasupplementaryanalysisconductedamongasubset
ologicalindividu ysHyoomuwnpegtvoeermrg,aitarolllstohgaoynudg(dhbeopaygreses,asigtoeannndayenrdagaaenn)dxwieAetygre)eaa(cid:5)ts2so-Gyceeiaantrdesed(rsweineittheTraagbcrlteeiao1tne)sr. onfeuproarimticaigpianngts(sweehothepeornfolirnmeesduptphleemsaemntealtmasaktedriuarli)n,gpufpuinlcvtaioluneasl
he during incongruent trials tracked with larger responses in a right
ycth collectivelyexplained12%ofvariancein2-yeardepression(Step
Psof 1: (cid:6)R2 (cid:3) .12, (cid:6)F (cid:3) 2.81, p (cid:3) .05), these indices were no posterior parietal region implicated in sustaining visual attention
ne 3,63 (Malhotra, Coulthard, & Husain, 2009). This statistical relation-
caus longer significant once clinical and attentional variables were
eAmeriersonal e((cid:8)nt(cid:3)ere(cid:7)d.2(a7s,9a5b%ovCe;Ip[(cid:7)s.(cid:2)49,.1(cid:7)),.0a5n]d,pb(cid:3)oth.0a2v)oainddanatvodiwdaenlltptiumpeilbbiiaass sahhneilppatiatnecgnrottisoosnraiunlldeciovonidutrutoalallsmteferuncrhathtaienvrieslmienxkppselartthnienateionobtnssteor(vseeu.dgs.t,paiuanpreoidlupsaaatltt,etenertmniootno-,
byththep (th(cid:8)e(cid:3)fin(cid:7)al.2m4,o9d5e%l.ACgIe[(cid:7)an.4d6g,e(cid:7)nd.0e3r]d,ipd(cid:3)no.t03m)ordeemraatieneadnypraetdtiecnttiivoenianl tionalresponding).
yrightedolelyfor fseuaptpulreemteontparlemdiactter2ia-yl)e.ar depression or anxiety (see the online itnheGocuiuvtcmeonumtlhaeat,ityvdoewubtehulrladtteimhniegohfaenbsdethppaurvopisioplrebacliatiasvveeoxiddpealpanricneesesddioudnriisnrtiigsnkcthtervxeaharitibapintrecede-
ps
coed Discussion sentation,plussustainedavoidanceattemptsinthewakeofthreat.
isnd These two avoidant tendencies, in aggregate, could serve to pro-
entnte Morethan2yearsafteralaboratoryassessmentofattentionto hibitactiveengagementwiththreats,whiledecreasingavailability
mi
docucleis tdhirceteadt abmyoanvgoiadnaxnitougsazyeouptaht,teyronus,thovdeerpraenssdioanbosvcoerevsarwiaenrceeperxe-- ofofrmcosgonfiteivmeotrieosnourergceuslatfioornlienarthneinwgaaknedofapapthlyrienagtenminogreenacdoaupntitveer
hisarti plained by baseline clinical and demographic measures, and in (e.g., problem solving, consideration of actual rather than feared
Ts
hi spite of treatment-related effects (therapy condition, acute post- outcomes).Whencombinedwithincreasingstresssensitivityand
T
treatmentsymptoms).Depressionseveritywasfurtherpredictedby normative psychosocial changes during the peripubertal period,
a sustained, avoidant pattern of pupil dilation in the aftermath of avoidant attention could propagate more widespread withdrawal
threat, suggesting that persistent cognitive efforts at postthreat fromanincreasingly“threatening”(e.g.,interpersonally)environ-
avoidancefurthercompoundedthisrisk.Findingswerespecificfor ment, thereby setting the stage for depression to emerge in ado-
depression,whileanxietyat2yearswasrelatedtoclinicalbutnot lescence.
attentionalmeasures.Althoughthetotalvarianceexplainedinthe The existing literature in both anxiety and depression suggests
final model was modest (35%; 20% for attentional/pupilometry thattimecourseisakeyfactorinattentionalbiaseffects(deRaedt
measures alone), it is nevertheless notable that measures taken & Koster, 2010; Mogg et al., 2004). Our methodology enables
during a simple laboratory task were predictive of prospective separation of distinct components of visual attention (initial fixa-
depressive scores in spite of an intervening 2-year period of life tion, dwell time bias throughout the “intermediate” 2-s stimulus
events and developmental/pubertal progress. This long-term pat- presentation, and sustained postthreat processing). Findings sug-
tern suggests the attentional measures captured a key mechanism gestthatdepressionwaspredictedbyapervasivepatternofavoid-
intheprogressionfrompediatricanxietytoadolescentdepression. ance at intermediate and late stages of processing, while initial
274 PRICEETAL.
orienting at the earliest stages did not prospectively predict de- tion, our study used fearful faces as a threat cue because they
pression or anxiety. Concurrent anxiety has been most reliably reliably activate fear-processing regions of the brain (Whalen et
linked to early attentional features (e.g., response times to brief al., 2001) and have transdiagnostic relevance to fear perception
500-ms stimuli, initial fixations in eye gaze; Bantin, Stevens, through the implication that a generic, unspecified threat is pres-
Gerlach, & Hermann, 2015; Bar-Haim et al., 2007; Gamble & ent.Thisdesigndecisionstandsincontrasttomanystudiesusing
Rapee, 2010; Price, Siegle, & Mohlman, 2012), with a smaller angryordisgustedfacestoconnoteasocialformofthreatdirected
literature suggesting a switch to avoidance of threat occurring at attheparticipant;however,thereisevidencethatfearfulandangry
later processing stages (Mogg et al., 2004). Depression has been faces elicit comparable eye-tracking bias patterns during the dot-
linkedprimarilytolaterstagesofattention(e.g.,responsetimesto probe(Mogg,Garner,&Bradley,2007).Inthefuture,inclusionof
stimuli presented for 1,000-ms or longer, dwell time bias, disen- multiple stimulus types would help to disambiguate the relative
gagement difficulty; Kellough, Beevers, Ellis, & Wells, 2008; relevanceofvariousthreateninganddysphoriccuesinthetransi-
Leyman, De Raedt, Schacht, & Koster, 2007), although a recent tionfromanxietytodepression.
meta-analysis found that both early and late attentional compo- In summary, although our findings diverge in some respects
publishers.natedbroadly. nNcaodeennuvtslestisrdm,teharaeneylddebsmsteh,aeedyqimfuafailoclslsouytltcaryheffaldeiraicasbtceeltnedegr(apiPzgaeeitntcgekgrrhnofaurmoapmms,MoonnfecggcHhacutiuilgvdrherre,esnn&ttilamyOnudtdtloiea,pids2rue0olst1fsst0eea)ndt. fwslirptoeeemrrceatitaovutberteeta,sniywtnimoehdnipcathuolsmipisnadtgatoseamsrennissnsianmdtdeeeisdnvctirb.diybuTeachdlreodpssiersfe-fvsdeeierocesutniigsconlenysafilean,apgtdprueorropuearspec-shelsexivatoenennld,dctpohtrmehoye--
sallieddissemi etionlewgv,aairtsdedtnheerigrseakftoiovrfeedsaetipkmreeuyslsid,ieoppnarre(tGsicsouiotllanirblmy&adruJkoreiorn.rgmlaanten,st2a0g1e0s)o.fVpigroilcaenscse- panarciesoancsro.sFsinthdeinmgsajsourgitgyeostfath2a-tsittiimseacpoeurrssies,tecnotuppalettderwnitohffauvrothide-r
ite sustainedavoidanceinthewakeofthreat,thatconfersthehighest
ofob However, using methods more akin to the present study, cur- prospective risk. Although first-line psychotherapies could effec-
oneott rently depressed children have shown avoidant eye gaze patterns tively ameliorate and/or compensate for some of the attentional
orisn (specifically, avoidance of sad faces) persisting continuously for aberrations observed in cross-sectional studies, sustained avoid-
ationand puapttteorn20inseoyfefagcaezveihewasinbgee(nHaprorsisitoend&toGbiebbd,ev2e0l1o4p)m.Tenhtiaslalyvomideadni-t anceofthreatmayhaveaspecific,insidiouseffectovertime(e.g.,
cier lost opportunities for habituation and adaptive problem solving,
ssous ated. Specifically, although avoidance of sad faces may be a compoundedoverthecourseofdevelopment),leavingyouthvul-
Aal normative feature of infancy (Montague & Walker-Andrews,
ologicalindividu I2z0a0r1d),,1p9r8o8v)id,idnegpreefsfesecdtivcehimldoroednrmegauylactoionntinautethtiosaagpepl(yTtehrimsisntera&t- nefeirPtasrb.elveiotousdespturdesiessionofevaecnutwehpesnycthheoythsehraopwyaocuuttceotmreeatmhaevnet bsuegn--
he egywithoutthesamebenefit(possiblyduetoincreasingcapacity
ycth gested that anxious individuals showing avoidant attentional pat-
Psof forabstractcognition),whereasdepressedadultsmaynolongerbe ternsarenotaswell-suitedforcertainformsofpsychotherapyas
ne abletoresistattendingtowardnegativeinformationatall(result-
caus youth at the vigilant end of the spectrum (Legerstee et al., 2010;
eAmeriersonal icsnhugirpreinbnetvtsiwtgueidleaynn,taapvgaoetitd(eaarnnndcs)eg.eaWnnddiethrp)irnodsitdhpeencoctiotvnbesettdrtaeeirpnreeexdspsailoaginen.rtTahnhegereeslaoamftiopthnlee- Pporiscseibelet ailn.,te2r0p1re1t;atWioanteorsfettheal.c,u2r0re1n2t).fCinodninsigsstenist wthiatht tahvios,idoannet
ythhep was specifically selected to capture the high-risk peripubertal youthdidpoorlyinpsychotherapyandwerethereforelessbuffered
bt against subsequent depression. However, several pieces of evi-
yrightedolelyfor whchaivannedgoewusnwdacehrreogrsoesndetehperreefsloastliilovonewloy-futpehnopememroieogrdeg.neosA,umsberoa(tnahdioneugrgthdheavtseyulobouspttmahnemtniataaly)l dspeenccieficarfgouredaegpareinssstiotnhi(swihnetererparsetthateiotnre.aTtmheenctsurtraerngteteefdfeacntsxiweteyr)e,
iscopndeds pfaecrtsopresctdivoeinmdaeyedbemoredqeurairteedthteo nreavtuerael owfheatthteenrtidoenvaelloripsmksenftoarl saungdgewsetirnegnthoetlaopnpgaerre-tnetrmimtrmanedsiitaitoenlytoaafdteorletsrceeantmceen(atnd(Tcaobnlecom1)-,
entnte depression. Nevertheless, developmental changes over time were itant increased depression risk) were key. Furthermore, whereas
documcleisi acniesimmpaonritfaenstteedleimnednetporefstshievecusyrrmenpttofminsdionnglsy,aafstearvothideapnatstseangdeeno-f bdoecthretarseeastminentprciomnadriytioannsxiinetytheouctucroremnetstr(iaSlilpkroedtuacle.d, 2su0b1s5t)a,nttihael
hisarti timeandmaturationalprogress. impact of attentional features persisted after controlling for these
This Previous studies in currently depressed individuals suggest at- treatment-relatedeffects.Findingsthereforesuggestthattheatten-
T
tentional biases pertain specifically to sad/dysphoric stimuli, tional assessment captured a long-term form of risk that was
whereasthreat-relatedstimulielicitattentionalbiasesincurrently relatively impervious to the acute beneficial effects of the treat-
anxious individuals (Gotlib et al., 2004). Our study included as- ments. In other words, anxious youth exhibiting avoidant atten-
sessmentinacurrentlyanxiouscohortusingthreat-relatedstimuli tional features continued to be at risk for prospective depression,
(fearful faces). It is notable that attentional features were never- irrespectiveofhowwellthetreatmentamelioratedtheirsymptoms
theless predictive of depression, suggesting threat-related stimuli acutely.Clinically,thissuggeststhatalternativeand/oradjunctive
may have greater relevance to depression when placed within a treatments may be needed for this subset of anxious youth, even
developmental framework, just as anxiety itself is predictive of whenpsychotherapysucceedsinreducingsymptoms.Theseyouth
future depression in spite of separable foci of symptoms and may be at particular risk of falling through the cracks of clinical
cognition.However,thefailuretoincludedysphoricstimuliinthe care,astheymayshowinitialreductionsinsymptomsthatfailto
currentstudymeansthatwecannotspeaktothespecificityofour protectthemfromfurtherdevelopmentofdepressiononcedevel-
findingstofearfulfacesandmayhavemissedattentionalpatterns opmental risk factors (e.g., increased stress reactivity, psychoso-
with even greater relevance to depression development. In addi- cialstressors)arebroughttobear.
FROMANXIOUSYOUTHTODEPRESSEDADOLESCENTS 275
Ourfindingscouldhaveimplicationsfornoveltreatmentdevel- gest additional measures and/or refinements of current measures
opment, particularly in light of growing interest in mechanistic would be needed to facilitate clinical translation. In particular,
treatmentstargetingattentionalpatterns(e.g.,attentionalbiasmod- inclusion of dysphoric stimuli (rather than threat-related alone)
ification; ABM; MacLeod & Clarke, 2015). The vast majority of mayimproverelevancefordepression.Findingsmaynotgeneral-
ABMstudiesinanxiouspatientshavetrainedattentionawayfrom ize beyond the specific task design (e.g., 2-s fearful–neutral face
threat (toward neutral information), invoking an attentional goal pairs) and clinical population recruited here. Finally, the present
stateakintothepatternthatconferredriskinourstudy.Although findingsawaitreplicationinalargersamplewithawiderrangeof
severalstudiesshowedimmediateandshort-term(e.g.,at4-month anxietypresentationsanddepression-relatedoutcomesandamore
follow-up) benefits on anxiety measures (Amir et al., 2009; naturalistic,treatment-freefollow-upperiod.
Schmidt, Richey, Buckner, & Timpano, 2009), more recent find-
ings have been mixed (Linetzky, Pergamin-Hight, Pine, & Bar- Conclusions
Haim,2015),andnopublishedstudyhasexaminedclinicaleffects
Among anxious youth, laboratory assessments of attention—
(depressionoranxiety)atlonger-termfollow-up.Inthecontextof
y. pediatric anxiety, it may be important to consider the possible using measures feasible to obtain in a typical clinical setting—
shers.broadl dtheetriamtteennttaiolneaflfepcatstteorfntrianisntiilnlgedinbyanAaBvMoida(dnecseigpnaettdertno.rHeomweedviaetre, wyeearres.pPreedrsiicsttievnetoafvodiedparnecsesioofntshcroearet,sbaotthadduerlianygoafndmaofrteerththarnea2t
publinated relativelyearly/automaticaspectsofattention)maydiffersubstan- pthreesternatnastiitoionn, efmroemrgepdedaisatraicroabnuxsitetmyetcohaandioslmescceonntfedrerpinregssriisokn,foinr
dmi tivelyfromtheriskpatternobservedhere(i.e.,sustainedavoidance
salliedisse ianddeiytieogna,zaevaoniddapnutpaitltoemnteitornyapleprsaitstetirnngsamcraoyssbae(cid:9)de1t0r-imspeenrtiaoldo).nIlny shpibitietinogfastttaetne-tioofn-tahlea-avrotidbaenhcaevimoriaglhttrbeaetnmefeinttf.roAmnxiinocurseaysoeudthclienxi--
oroneofitisnottobe wrteehrsnuesnltthtohafetyaarsaipsrieesceoifnsicpthoaentittraennoetwioonunsamllya,tyrbabiunetinnfgaortpmwroohcreeendguterhnee.eyrAaolviczoceiuddra,npatostpetahnte-- cthdoaeislldapabitrlfteioencnrtgetl,iysotaanrnleldamnthhedidegpihaortleneyvseeaentvntodoaiuftdirvadinenegtperafaeftcostersronitosst,insoi,nnthaceiltcuslodeifnliefnd.gisStpipuoaocnnthet(nhWetafifateoliirssatsstmtcecoamosntupllyetdst,
ationand twiailtlhydrianwdefxrionmg aenmointinoantael,cwuiedses(pe.rge.a,dp,oatnendtipaellryvabsoivthepteonsditeivnecyantdo al.,1999).
cier
ssous negativecues),acrosslongerspansoftime.Evenso,ourfindings References
Aal couldimplicatetheneedforanalternativeformofABMtailored
ologicalindividu tuoaltsh,epianrdtiicvuildauralyl (feo.rg.l,attera/siunsintaginteodwatirmdethproeianttsin).avoidant individ- All&isoBnr,ayCn.,e,WCi.ll(i2am00s7,)J..T,ShecoCtth,iFld.,hoSotodttA,Csp.,erBgoelrtoSny,nPdr.,oBmaeroTne-sCto(CheAnS,TS).:,
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eAmericersonalu tmeomwanoaitrfidoesnttahalrtieoaanvt;soBidoaafrn-Hbcoeatihmatateentmxaiple.tt,sy,20as0no7dc)i,adbleupwtrieistshspdiaorranawm(abol)eu.hnatAviitnotercnaltliinoaincnaadll AmmCihar,ennuN,a.,lXoB.fe(ma2re0dn0,t9Ca)l..,dATisatotyerldnoetrir,osnC(.4trtTha.i,neidKn.l)gu.mWinpapsi,nhdHini.vg,itdoEunlia,alDss,CwJ:.,iAthBuutghrenonsr,e.rMali.,ze&d
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