Bennett, E

Dhakal, S

Kumari, V

Lau, JYF

Niraula, S

Pandey, R

Sharma, NP

Vaswani, A

Behavioural and Cognitive Psychotherapy

Brunel University Research Archive

1 Acceptability of a brief training programme targeting attention and interpretation biases for threat in youth with a history of maltreatment This material has been published in revised form in Behavioural and Cognitive Psychotherapy [https://doi.org/10.1017/S1352465819000663]. This version is free to view and download for private research and study only. Not for re-distribution  or re-use. © British Association for Behavioural and Cognitive Psychotherapies 2019. 2 Abstract  Background: Tendencies to attend to threatening cues in the environment and to interpret ambiguous situations with negative/hostile intent maintain and may even precipitate internalising and externalising problems in young people with a history of maltreatment. Challenging maladaptive information-processing styles using cognitive bias modification (CBM) training may reduce symptoms. Aims: To investigate the acceptability of CBM training in 9 young people attending alternate education provision units in the UK and 10 young people living in out-of-home care institutions in Nepal with a history of maltreatment. Methods: CBM training comprised 5 sessions of training over a 2-week period; each training session comprised one module targeting attention biases and one module targeting interpretation biases for threat. A feedback form administered after training measured acceptability. Pre and post-intervention measures of internalising and externalising symptoms were also taken. Results: Most young people (89%) found the training helpful and 84% found the training materials realistic. There were reductions in many symptom domains, but with individual variation. Although limited by the lack of a control condition, we established generalizability of acceptability across participants from two cultural settings. Conclusions: Replication of these findings in larger feasibility randomised controlled trials with measures of attention and interpretation bias before and after intervention, are needed to assess the potential of CBM in reducing anxiety symptoms and its capacity to engage targeted mechanisms.   Keywords: Childhood adverse events, victimization, information-processing biases, cognitive bias modification training, prevention, feasibility   3 The physical, sexual and emotional abuse and neglect of children and adolescents is a significant global problem. To identify effective and accessible interventions to combat associated mental health problems as they arise in development, cognitive neuroscience research has advocated targeting ‘latent vulnerability factors’ mediating between adversity and symptomatic outcomes. Tendencies to selectively attend towards threat and to draw threatening, hostile interpretations of ambiguous situations are biases at two stages of information-processing known to characterise victims of childhood maltreatment in youth (Dodge, Pettit, Bates, & Valente, 1995; Shackman, Shackman, & Pollak, 2007). Although these information-processing biases are adaptive in dangerous, unpredictable conditions, such as growing up in adverse family environments, beyond these environments, they could contribute to persistent behavioural, emotional and social maladjustment, including clinical symptoms of internalising and externalising problems. Indeed, among physically-abused adolescents, attention biases for angry faces correlate with anxiety symptoms (Briggs-Gowan, et al., 2015) while in young people exposed to violence, interpretation biases correlate with aggressive tendencies (Shahinfar, et al., 2000). Given the associations between biased information-processing and emotional and behavioural problems among young people who have experienced maltreatment, targeting these biases in interventions could be a beneficial preventative strategy. Over the last decade, Cognitive Bias Modification (CBM) training programmes that aim to train more adaptive styles of attention-orienting and control towards benign/positive information (CBM-A) and styles of interpreting ambiguous cues in a non-threatening manner (CBM-I) have been implemented in adults with a range of psychiatric conditions, and extended for use in children and young people, largely with anxiety and depression, but also aggression. No study has investigated the viability of CBM-A and CBM-I in adolescent victims of maltreatment. To address this gap, here we presented pilot data on acceptability of a novel multi-session computerized training tool that targets attention and interpretation biases in young people with a history of victimization. A secondary aim was to describe overall changes in emotional, behavioural and social problems across participants. To enhance the generalizability of our findings across global contexts, parallel data collection initiatives occurred in the UK and Nepal with young people who had experienced maltreatment.  Methods  4  Sample: Nine young people (14-17 years) from the UK and 10 young people (13-16 years) from Nepal participated. UK participants (participants 1-9) were from two schools that provided alternative educational provision for young people unable to attend mainstream schools. The Nepalese participants (participants 11-20) were from 3 care homes, which provided residential facilities for rescued child labourers, street children, orphans, and those who had been separated from their family intentionally or unintentionally. To assess victimization history, employees working in alternate education provision units were asked to complete a 15-item measure, drawn from the Juvenile Victimization Questionnaire (JVQ) (Finkelhor, Hamby, Ormrod, & Turner, 2005) screening questions for UK participants. Information reported in participant case files was used to facilitate completion of this measure. For Nepalese participants, as this was part of a larger study of maltreatment in rescued child labourers, modules from the self-report version of the JVQ assessed victimization history (Dhakal et al., in press). Data across sites were used to generate analogous variables on the likelihood that the participant had experienced physical abuse, verbal (emotional) abuse, neglect (including guardian substance abuse, unsafe home environment), sexual exploitation, witnessed domestic violence, and exposure to conventional crime.  Procedure, training and measures: Ethical approval for data collection from the UK was sought from the Research Ethics Committee at King’s College London, and internally approved by safeguarding leads within the management structure of the educational unit. Permission for data collection in Nepal was granted by the Research Division Office of the Rector Tribhuwan University, and by the Central Child Welfare Board (CCWB) under the Ministry of Women, Children and Social Welfare. Ethical approval was sought from and given by the Nepal Health Research Council. Across both sites, informed consent was first sought from all parents and legal guardians, and from young people themselves. As most standardised measures were not available in Nepalese, we followed a rigorous process of translation and back-translation, with appropriate cultural adaptation. Permission was sought from the publishers/authors, and where appropriate, some were involved in this process.   All participants were assessed across 7 days within a 2-week period that included pre-intervention, training and post-intervention assessments. Participants were tested on different days, and therefore had their own study schedules. On Day 1, participants completed two subtests (Matrix  5 Reasoning and Block Design) of the Wechsler Abbreviated Scale of Intelligence – Second Edition (WASI-II) to create a composite Perceptual Reasoning Index (PRI) of non-verbal reasoning ability; the Youth Inventory-4R to assess potential emotional and behavioural symptoms in adolescents, according to DSM-IV classification; the Strengths and Difficulties Questionnaire (SDQ) to assess ‘total difficulties’; and the General Anxiety and Social Anxiety subscales of the Screen for Child Anxiety Related Disorders (SCARED)–Child Version Short Form to assess training-relevant anxiety subtypes. Training for all participants was scheduled across Days 2-6, with each 20-minute session including one module of CBM-I training and one module of CBM-A training (Lisk et al., 2018). Each daily session comprised a visual search attention training task and the ambiguous scenarios interpretation task used in earlier studies. In the attention training task, participants were instructed to repeatedly identify the only positive (smiling) face in a 4x4 matrix consisting of 15 other negative faces (5 fearful, 5 sad, and 5 angry). On each trial of the interpretation training task, participants read a text-based ambiguous situation that end with a word fragment. Correct completion disambiguates the scenario in a positive/benign direction. This is then reinforced by the correct completion of a comprehension question. Training scenarios were co-produced with social work and educational professionals working with young people with histories of adversity. Although the intended number of training sessions was 5 days, two UK participants completed only two sessions due to unexpected changes in their academic timetable. After completion of training, on Day 7 all participants completed the SDQ and the two SCARED subscales, and a self-report feedback questionnaire (Table 1). As well as items that were rated on continuous scales, there were open-ended questions for young people to feedback on aspects they found helpful, unhelpful, liked, disliked and general improvements.  Results  Sample description: All UK participants were male, while Nepalese participants were largely female (90%). Scores of the perceptual reasoning index probing nonverbal reasoning and problem solving ranged from 63 to 111 (percentile rank 1 to 77) for UK participants, while for Nepalese participants, the range was from 68-102 (percentile rank 2 to 55). Five and 2 participants from the UK and Nepal respectively met no diagnostic screening cut-offs on the YI-4R. However, as this was a pilot study, no diagnoses were used to exclude participation. Using 15 items from the JVQ, 6 of the 9  6 young people from the UK were rated as likely to have experienced some form of physical abuse; 8 to have experienced verbal (emotional) abuse; 6, neglectful experiences; and none, for sexual abuse although there were 3 cases where the information provided in case files was uncertain. About one third of the young people were thought exposed to domestic violence, and around half, more general violence with or without a weapon. For Nepal participants, all 10 young people had experienced physical abuse in their life, 7, verbal (emotional) abuse, 8 neglect, 4 sexual abuse, 7, witnessed domestic violence; and 9 witnessed general violence (according to the self-reported JVQ).    Acceptability: Responses to the first 11 questions of the training questionnaire are presented in Table 1 for participants from each site. Most UK and Nepal participants completed the intended number of training sessions, and most found the training to be at least “generally helpful”, with half rating it as ‘definitely’ helpful. When asked which specific areas the training was helpful at targeting, over half rated the training as useful for challenging worries, stress, and low mood. However, ratings of usefulness were lower in UK participants than Nepalese participants. Most UK participants did not believe they would be motivated to complete the training on their own, whereas over half of Nepalese participants endorsed either the ‘I think so’ or ‘definitely’ option when asked the same question.  Pre to post-intervention measures: To describe changes in emotional and behavioural problems from pre-to-post intervention, the direction and magnitude of any differences in these measures are presented. Overall, participants 1-6 (UK) who completed 5 sessions of training showed a decrease in total difficulties SDQ scores with a small-to-moderate effect size (cohen’s d=0.28). For participants 7-9 who only completed 2 sessions of training, an overall increase of problem behaviours was observed but with a small effect size (cohen’s d=0.19). For Nepalese participants, overall, there was a decreased total difficulties SDQ scores with a small effect size (cohen’s d=0.22). For general anxiety SCARED scores, overall, participants 1-6 (UK) who completed 5 sessions of training showed a decrease in scores with a small effect size (cohen’s d=0.12). For participants 7-9 (UK) who only completed 2 sessions of training, an overall increase was observed with a small effect size (cohen’s d=-0.22). Looking at all Nepalese participants, completing training led to a slight decrease in symptoms with a small effect size (cohen’s d=0.09). For social anxiety SCARED scores, overall, participants 1-6 (UK) who completed 5 sessions of training showed a decrease in scores with a large  7 effect size (cohen’s d=0.81). For participants 7-9 who only completed 2 sessions of training, no difference was observed. For Nepalese participants, completing training led to increased symptoms with a small effect size (cohen’s d=0.24). Discussion  Cognitive training programs that modify attention patterns and interpretational style thought to mediate between maltreatment and later emotional and behavioural problems could have preventative potential for those exposed to victimization. Our data speak primarily to the acceptability of CBM-A and CBM-I training protocols and procedures in young people with a likely history of victimization across two alternate education units in the UK and three care-homes in Nepal. While most participants found the training helpful, ratings were numerically lower in UK than Nepalese participants. Yet, UK participants who received 5 training sessions showed more consistent improvements in emotional and behavioural symptoms, with especially large effects for social anxiety, possibly because these training techniques were adapted from procedures first used in young people with social anxiety (Lisk et al., 2018). Improvements of emotional and behavioural symptoms in Nepalese participants however were less clear: a small reduction in total difficulties at post-intervention was found but social anxiety increased. Different results across samples could indicate cultural differences or differences in gender composition across the samples. Alternatively, even within culture, heterogeneity in maltreatment history and current psychiatric disturbances could confound clear patterns of training-related change. In sum, our data provide mixed results on the efficacy of CBM but show acceptability by maltreated samples across cultures. They thus support the potential of applying CBM to a larger global sample of victimised young people using a feasibility randomised controlled trial with other aspects of feasibility as outcomes, and anxiety and other problem behaviours as measures of change.    8 References  Briggs-Gowan, M. J., Pollak, S. D., Grasso, D., Voss, J., Mian, N. D., Zobel, E., et al. (2015). Attention bias and anxiety in young children exposed to family violence. Journal of Child Psychology and Psychiatry, 56(11), 1194-1201.  Dodge, K. A., Pettit, G. S., Bates, J. E., & Valente, E. (1995). Social information-processing patterns partially mediate the effect of early physical abuse on later conduct problems. Journal of Abnormal Psychology, 104(4), 632-643.  Finkelhor, D., Hamby, S. L., Ormrod, R., & Turner, H. (2005). The Juvenile Victimization Questionnaire: reliability, validity, and national norms. Child Abuse and Neglect, 29(4), 383-412. doi: 10.1016/j.chiabu.2004.11.001 Lisk, S., Pile, V., Haller, S., Kumari, V. & Lau, J.Y. (2018). Multisession Cognitive Bias Modification targeting multiple biases in adolescents with elevated social anxiety. Cognitive Therapy and Research, 42(5), 581–597. doi: 10.1007/s10608-018-9912-y Shackman, J. E., Shackman, A. J., & Pollak, S. D. (2007). Physical abuse amplifies attention to threat and increases anxiety in children. Emotion, 7(4), 838-852. doi: 10.1037/1528-3542.7.4.838 Shahinfar, A., Fox, N. A., & Leavitt, L. A. (2000). Preschool children's exposure to violence: relation of behavior problems to parent and child reports. American Journal of Orthopsychiatry, 70(1), 115-125.    9  

Acceptability of a brief training programme targeting attention and interpretation biases for threat in youth with a history of maltreatment

http://bura.brunel.ac.uk/bitstream/2438/23622/1/FullText.pdf

Acceptability of a brief training programme targeting attention and interpretation biases for threat in youth with a history of maltreatment

Abstract

Similar works

Full text

Available Versions

Brunel University Research Archive