A multi-method, multi-rater approach to understanding avoidance in childhood anxiety and its impact on treatment outcomes

Abstract

These are the slides from a presentation given at Association of Depression and Anxiety of America on 04/05/2025.Background: Childhood anxiety is prevalent, affecting ~25% of youth. Children with anxiety often avoid situations, thoughts, or objects that they perceive as threatening. Although avoidance temporarily reduces anxiety by providing escape from perceived threat, it maintains symptoms over time. Avoidance encompasses behavioral, cognitive, and attentional mechanisms; thus, it may be best captured by a multi-method, multi-rater approach. The purpose of this study was to 1) explore if multi-method measures of behavioral, cognitive, and attentional avoidance load onto a single avoidance factor and 2) understand how that avoidance factor relates to treatment outcomes for clinically anxious youth. Methods: Participants were 133 youth (Mage=11.06, SD=1.53) diagnosed with an anxiety disorder (e.g., generalized, social, and/or separation) in a larger treatment outcome study comparing CBT and child-centered therapy. Behavioral and cognitive avoidance was measured via child-report on ecological momentary assessment (EMA): one item assessing distraction and one item assessing suppression. Behavioral avoidance was assessed via clinician-report on the Pediatric Anxiety Rating Scale (PARS). Attentional avoidance was measured by a child dot-probe eye-tracking task. Treatment outcomes were measured by SCARED-C/P scores. A principal component analysis (PCA) was conducted, with all avoidance measures expected to load onto a single factor. The avoidance factor was used as a predictor in regressions on SCARED-C/P scores at post-treatment, controlling for baseline scores and treatment condition. We hypothesized that avoidance would be related to better treatment outcomes. Results: In the PCA including all avoidance measures, the Kaiser-Meyer-Olkin value was below threshold (.498), indicating that these data were not suitable for factor analysis. Exploratory factor analyses (EFA) were then conducted to see if the two EMA items loaded onto a single factor of real-world avoidance and the two measures associated with in-lab evaluation (PARS and eye-tracking) loaded onto a single factor of lab-based avoidance. The EMA items both loaded onto a single factor, with an eigenvalue of 1.45 and communalities of 0.72, explaining 100% of the variation in items. For the PCA with eye-tracking and the PARS, Bartlett’s Test was not significant (p=.06); thus, the data were unsuitable for a PCA. Results of the multiple linear regression predicting SCARED-C scores from the real-world avoidance construct indicated that only therapy type (β=-4.3, p<.05) and baseline SCARED-C scores (β=.38, p<.05) were significant predictors. Multiple linear regression results predicting SCARED-P scores found that both the EMA avoidance factor (β=1.65, p=.003) and baseline SCARED-P scores (β=.58, p<.001) were significant predictors. Conclusions: It is possible that our avoidance measures each capture a unique mechanism underlying avoidance in childhood anxiety; the EMA items loaded onto a single factor, potentially due to shared method variance. EMA items predicted SCARED-P scores with worse avoidance at baseline predicting more anxiety post-treatment, suggesting that interventions may not have adequately ameliorated avoidance. The lack of shared variance among avoidance measures highlights the necessity of multi-method, multi-rater report to comprehensively understand avoidance as this may be an important target for interventions due to its impact on treatment outcomes for anxious youth