Mental health difficulties, like anxiety and depression, are commonly experienced by young people. Since 2017, rates of mental health difficulties have increased from 11.6% to 17.4% for 6-16 year olds, and from 10.1% to 17.4% in 17-19 year olds (NHS Digital, 2021). As 75% of mental health difficulties are established by the age of 24 (Kessler et al., 2005), it is crucial that effective interventions are made accessible as early as possible.
To have the most effective interventions, an understanding of the underlying mechanisms that lead to symptom reduction is important. Such mechanisms can then be emphasised and targeted within treatment plans, and also used to develop novel interventions. One potential underlying mechanism of child anxiety and depression that is widely discussed in the literature is attention and interpretations. More specifically, shifting attention from negative to positive, and managing interpretations of uncertain situations to become more positive. Research suggests that maladaptive attention and interpretation patterns contribute and maintain mental health difficulties (Lau et al., 2017; Beck et al., 2014), and that challenging these can be beneficial in symptom reduction (Beck et al., 2011).
Jennifer Lau and colleagues (2021) investigated this in their review. Their aims were to:
- “Describe interventions that explicitly target each cognitive pattern and compare their effectiveness at reducing symptoms in those with clinical anxiety/depression”;
- “Describe pre-existing individual differences that moderate symptom reduction effects”;
- “Explore whether combined interventions targeting both processes yield greater therapeutic effects”;
- “Interview young people with lived experiences of anxiety/depression about how the effectiveness of these techniques could be enhanced”.
The authors conducted a systematic review and narrative synthesis (as the heterogeneity of the samples, design and intervention characteristics did not warrant a meta-analysis).
Four electronic databases were used to search for studies that involved reducing self-reported anxiety and/or depression in young people by altering attention or interpretation patterns. Two psychology students screened the full texts, with 10% of these reviewed by the primary author.
The inclusion criteria involved the studies having undergone peer review and originally published in English-language journals, and must have included human participants 14-25 years old.
To meet the research aims, effect sizes of any symptoms changes post-intervention and in comparison to control groups were calculated for each paper.
Ten young people who had experiences of anxiety or depression were involved in the study to provide qualitative views on the quantitative findings.
Eighty papers met the inclusion criteria for the study. Of these, 22 studies modified attention patterns, 52 related to interpretational patterns, and the remaining 6 targeted both of these strategies.
Attention pattern interventions
19 studies used Attention Bias Modification (AMB) training to shift negative attention patterns to positive stimuli across training trials. ABM was delivered between 1-13 sessions across the studies, and was predominantly delivered via computers.
10 ABM studies reported significantly greater reduction of attention biases when in the intervention group compared to the comparison group. Three other studies reported this finding but only when specific versions like spatial cueing and visual search were used. There were mixed results for the 11 studies using high-symptom participants. Apart from one study, the reduction in anxiety and depression symptoms following intervention were small and did not significantly differ from control conditions.
Two studies used attention flexibility training to control attention, both showing symptom reduction in the treatment group.
Interpretation pattern interventions
52 studies involved modifying interpretations. 23 included Cognitive Bias Modification of Interpretations (CBM-I) training, where training encourages participants to interpret ambiguous information as positive instead of negative. 78% of the studies found that CBM-I led to either decreased negative interpretations or increased positive interpretations following intervention in comparison to the control group. Six studies using participants with high symptom scores found a mixture of symptom reduction severity, with one study reporting large symptom reductions, three reporting medium reductions, and two reporting small reductions.
31 studies used Cognitive Restructuring (CR), where explicit instructions encourage participants to come up with alternative explanations and consider the evidence for and against each explanation. Seven studies reported expected changes in the intervention compared to the control condition.
Six studies targeted both attention and interpretation patterns. The studies all showed greater symptom reduction in the treatment condition than the comparison group.
10 young people (15-24 years old; 7 female; 6 White British) who had previous lived experience of anxiety and depression were asked about managing their unhelpful thinking styles in their day-to-day life.
All participants agreed that using CR and CBM-I techniques were useful in daily life. Some participants noted that a specific obstacle to using the interventions was being able to actually recognise their thinking patterns initially. Suggestions that were made to the current approaches included using both attention and interpretation patterns, or deliberately recalling positive past experiences or positive aspects of themselves.
The authors concluded that:
Helpful attention and interpretation patterns can potentially help young people better navigate daily-life emotional situations.
Young peoples’ feedback suggests combining complementary techniques within multi-pronged toolboxes to develop resilient thinking patterns in youth is empowering.
Strengths and limitations
The research design was a particular strength. The broad search strategy allowed for a large number of papers to be identified. The use of qualitative feedback meant that more depth and detail could be found from the use of attention and interpretation interventions, strengthening the researchers’ understanding of this complex area.
There are some limitations. As the inclusion criteria meant only English-language journals were used, the review is subject to publication bias. This is because studies with positive conclusions are typically published in English-language journals over and above studies with inconclusive findings (Bigby, 2014). This means that, along with the search strategy only including four databases, valid studies may have been excluded from the review.
Finally, as the paper has yet to undergo peer review, conclusions and applications to clinical practice cannot be made, as the authors acknowledge.
Implications for practice
This paper highlights the need for more research, as there was little empirical evidence establishing the specific intervention mechanisms. With further investigation, this could support clinicians to refine existing interventions for depression and anxiety to ensure the most effective underlying mechanisms are incorporated into treatment plans.
The qualitative findings imply the importance of co-design and co-evaluation with young people using therapeutic services. It suggests that service-user forums are necessary to help clinicians identify treatment barriers, and therefore should be encouraged to ensure the best outcomes for service-user and service by designing the most effective interventions.
Statement of interest
Lau, J., Watkins-Muleba, R., Lee, I., Pile, V., & Hirsch, C. (in Press, 2021). Promoting helpful attention and interpretation patterns to reduce anxiety and depression in young people: Weaving scientific data with young peoples’ lived experiences. Research Square.
Beck, A., & Dozois, D. (2011). Cognitive therapy: Current status and future directions. Annual Review of Medicine, 62, 397-409.
Beck, A., & Haigh, E. (2014). Advances in cognitive theory and therapy: The generic cognitive model. Annual Review of Clinical Psychology, 10, 1-24.
Bigby, M. (2014). Understanding and evaluating systematic reviews and meta-analyses. Indian Journal of Dermatology, 59, 134-139.
Kessler, R., Berglund, P., Demler, O., Jin, R.,. Merikangas, K., & Walters, E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity Survey replication. Archives of General Psychiatry, 62, 593-602.
Lau, J., & Waters, A. (2017). Annual Research Review: An expanded account of information-processing mechanisms in risk for child and adolescent anxiety and depression. Journal of Child Psychology & Psychiatry, 58, 387-407.
NHS Digital (2021). Rate of mental disorders among children remain stable in 2021 after previous rise, report shows.
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What a superb article Alice – well done! I can see the hallmarks of a truly great professional.