Gamified Attention Bias Modification Training to Augment Cognitive Behavioral Therapy for Youth Anxiety Disorders: A...

Augmenting cognitive behavioral therapy (CBT) with attention bias modification training (ABMT) may maximize therapeutic benefit for anxiety through targeting different underlying processes. Yet, corresponding neural mechanisms are unclear. This preregistered double-blind, randomized controlled trial assigned youth with anxiety disorders receiving CBT to active or sham gamified ABMT. Group differences in clinical efficacy, and associations between amygdala connectivity and treatment outcomes, were examined.

Pediatric patients (N = 121; 8-17 years of age) with anxiety disorders were randomized to active or sham gamified ABMT alongside 12 weeks of manualized CBT. Primary outcomes were clinician-rated Pediatric Anxiety Rating Scale (PARS) and Clinical Global Impression-Improvement (CGI-I) Scale scores. Amygdala seed-based connectivity during a functional magnetic resonance imaging (fMRI) dot-probe attention bias task was measured before and after treatment in patients, and across the same time interval in healthy controls.

Over treatment, PARS decreased significantly in both groups (F_2,214 = 82.84; p < .001, η_p² = 0.44). Contrary to hypotheses, active ABMT did not enhance symptom reductions (F_2,214 = 0.61; p=.54, η_p² < 0.01). There was no difference in the proportion of CGI-I treatment responders vs nonresponders between active and sham (χ² = 0.76, p = .38) treatments. Amygdala connectivity is reported, but should be interpreted with caution because of poor observed test-retest reliability in healthy controls (intraclass correlation coefficient [3,1] < 0.4). Lower posttreatment anxiety was associated with weaker left amygdala connectivity with several cortical regions on threat-congruent trials.

Hypotheses that youth receiving active gamified ABMT+CBT would show greater improvement were not supported. Findings highlight the need to explore alternative attention bias modification strategies for augmenting the clinical response to CBT for anxiety. Future research should continue to examine reliability of attention bias tasks adapted for fMRI.

Attention bias modification training (ABMT) may target different aspects of anxiety (ie, attentional bias to threat) than cognitive behavioral therapy (CBT), serving as a potential augmenting treatment for individuals with anxiety disorders. This double-blind randomized controlled trial examined treatment efficacy data from 121 youth (ages 8-17 years) with anxiety disorders assigned to either active or sham ABMT alongside manualized CBT. Results showed that while symptoms improved in both groups, ABMT did not enhance symptom reduction. These unexpected findings highlight the need to explore alternate strategies to help improve therapy outcomes for kids with anxiety.

A Clinical Trial of a Gamified Attention Bias Modification Training in Anxious Youth; https://clinicaltrials.gov/study/NCT03283930.

The Nature of the Effect; https://osf.io/fxc54github.