Attention Retraining Enhances CBT For Adolescent Anxiety

Attention-retraining therapy works in adolescents with anxiety disorders, the first randomized, controlled trial in this age group has found.

Previous studies of attention-retraining therapy all focused on adults. In this study of 42 adolescents with severe anxiety in a residential treatment program, standard treatment with 25 hours/week of cognitive-behavioral therapy (CBT) significantly improved symptom scores in a control group that got CBT plus a computerized placebo, but scores improved even more in patients randomized to CBT plus computerized attention-retraining therapy.

Bradley C. Riemann, Ph.D.
Scores improved on a broad measure of pediatric anxiety, the SCARED (Self-Report for Child Anxiety Related Emotional Disorder) checklist, from an average of 32 at admission to 21 at discharge in the CBT group and from 34 to 12 in the combination group, Bradley C. Riemann, Ph.D., and his associates reported at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Most patients in each group had a primary diagnosis of obsessive-compulsive disorder (OCD): 17 patients in the control group and 13 in the combination group. Scores improved on the CYBOCS-SR (Children’s Yale-Brown Obsessive Compulsive Scale–Self-Report) symptom checklist from 25 at admission to 12 at discharge in the CBT group and from 26 to 7 in the combination group, reported Dr. Riemann of Rogers Memorial Hospital, Oconomowoc, Wisc.

“What you see is enhancement effects,” he said.

In more clinical terms, the CBT group went from scores in the severe range to the mild range. “So, CBT works,” he said. In the combination group, patient scores went from the severe range to the “essentially subclinical” range.

This was a complex patient group with high levels of comorbidity and life disruption. Primary diagnoses included OCD, social anxiety disorder, generalized anxiety disorder, panic disorder, and anxiety disorder not otherwise specified. Comorbidities included major depression in a large proportion of patients, attention-deficit/hyperactivity disorder (ADHD), or eating disorders. Characteristics did not differ significantly between groups.

Patients averaged 15-16 years of age and stayed an average of 60-62 days in the residential program.

The attention-retraining group was asked to do the computerized therapy each weekday during “school” time, and patients ended up doing it about 3.5 days/week on average, he said.

The computer exercises presented a screen with a neutral face and a face showing disgust, followed by a screen with no faces but a “probe” where one of the faces had been (such as the letter E indicating that the patient should respond with a left-click of the mouse or the letter F indicating a right click for response). In the attention-retraining group, the probe always followed the neutral face. In the control group, the probe appeared 50% of the time behind each face.

“We weren’t targeting OCD, but keep in mind that there is an area of disgust that you see in OCD. Maybe this was hitting that target as well,” Dr. Riemann said.

The attention retraining also seemed to have generalized effects in small subgroups with comorbid ADHD. The six patients with ADHD in the control group showed less improvement in their anxiety than control patients without ADHD, suggesting that the ADHD was interfering with the CBT. But in the combination therapy group, gains were not attenuated in the four patients with comorbid ADHD. The numbers are too small to make too much of this but suggest that perhaps attention-retraining therapy “may be something that could be applied to that even more complicated population” with anxiety and ADHD, he said.

The attention retraining is based on previous research showing that anxious individuals consistently focus their attention where they perceive potential threats, including a meta-analysis of 172 studies (Psychol. Bull. 2007;133:1-24).

At least two studies of single sessions of computerized attention retraining and three studies of multiple treatment sessions in adults have shown significant reductions in anxiety after treatment. The adult multiple-session studies typically involved twice-weekly sessions for 4 weeks, less frequent than in the adolescent trial.

Dr. Riemann reported having no financial disclosures.

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Attention Retraining Worth Trying

I loved the attention retraining study. We’re going to start doing some of this. It’s fun to see that data. What’s cool to me is the effect size – it’s a huge difference. The other thing that’s cool is that this was done in kind of a high-end clinical center, suggesting that many of us who work in large clinical services can do research there, but we have to have a sophisticated form of clinical trial methodology in order to do that.

Dr. John T. Walkup

Dr. John T. Walkup is professor of psychiatry and director of child and adolescent psychiatry at Cornell University, New York. He gave these comments at the meeting. Dr. Walkup has received free drugs and placebos for research studies from Pfizer, Abbott Laboratories, and Eli Lilly and Co.

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