Social attention in youth with social anxiety
To successfully navigate the social world we have to attend to complex and quickly shifting information such as facial expressions and emotional displays. Work in psychology and neuroscience has demonstrated that typically developing children are remarkably apt at doing this. However, many children with social anxiety have a difficult time directing their attention flexibly and adaptively to social events, typically manifested as avoidance of eye contact or hyper-vigilance towards potential social threat (e.g., someone looking angry). This atypical social attention has been suggested to lead to a range of problems. According to theoretical models, atypical social attention is one of the mechanisms underlying the development of social anxiety disorder (SAD), but it is also seen in other clinical conditions such as autism spectrum disorder (ASD) and generalized anxiety disorder (GAD). However, there is a lack of knowledge about these attentional mechanisms in children with SAD, the overlap between conditions, and if they can be affected by psychological treatment.
We aim to test the specificity of fundamental social attention mechanisms that have been linked to SAD and their relationship to the outcome of cognitive behavioral therapy (CBT) for children with SAD. Social attention will be measured with eye-tracking and children with SAD will be compared to other groups with clinical conditions related to atypical social attention (children with ASD or GAD) and non-anxious controls.
Final report
Final report regarding the grant P18:0068:1 ”Social attention in youth with social anxiety”
Project leader: Eva Serlachius
Participating researchers: Jens Högström and Johan Lundin Kleberg
Grand manager: Karolinska Institutet
Project aims and development
To successfully navigate in a social world we have to attend to complex and quickly shifting information such as facial expressions and emotional displays. Work in psychology and neuroscience has demonstrated that typically developing children are remarkably apt at doing this. However, many children with social anxiety have a difficulty directing their attention flexibly and adaptively to social events, typically manifested as avoidance of eye contact or hyper-vigilance towards potential social threat (e.g., someone looking angry). This atypical social attention has been suggested to lead to a range of problems. According to theoretical models, atypical social attention is one of the mechanisms underlying the development of social anxiety disorder (SAD), but it is also seen in other clinical conditions such as autism spectrum disorder (ASD) and generalized anxiety disorder (GAD). However, there is a lack of knowledge about these attentional mechanisms in children with SAD, the overlap between conditions, and if they can be affected by psychological treatment.
In the current project we aimed to test the specificity of fundamental social attention mechanisms that have been linked to SAD and their relationship to the outcome of cognitive behavioral therapy (CBT) for children with SAD. Social attention was measured with eye-tracking and children with SAD were compared to other groups with clinical conditions related to atypical social attention (children with ASD or GAD) and non-anxious controls.
The overall purpose of this research project was to delineate social attention in children and adolescents with SAD by measuring attention in socially anxious youth with a corneal reflection eye tracker. This approach enabled us to determine the time course of the various attention events that in previous studies have been indicated to occur in anxious individuals. To clarify the specificity of attention bias in SAD, we also measured social attention in youth with ASD that have symptom overlap with SAD, as well as in a control group with non-anxious children and adolescents. Pupillary responses were also measured as a means to map the specificity of atypical social attention in youth SAD. Furthermore, we intended to investigate if certain patterns of attention bias predict a better or worse response to CBT, and whether or not attention bias will be affected by such a treatment. This research has contributed to the understanding of attentional processes in SAD and the maintaining factors involved in the disorder.
Brief about the Implementation
A substantial part of the project took part during the COVID-19 pandemic and data collection was stopped during two extended periods in 2020 and 2021. This delayed the project and recruitment of participants in the ASD group is not yet completed and the generalized anxiety disorder (GAD) group could not be recruited at all. However, the recruitment goal for the SAD group has been attained and the goal for the non-anxious control group has been surpassed. We have, furthermore, added a study objective, to explore whether two additional aspects of social attention differ between individuals with social anxiety and the control groups: saccade speed and hyperscanning. Beyond these deviations, no significant departures from the initial plan have been made.
The three most important results from the project and conclusions to be drawn
1. Children and adolescents with SAD exhibit distinct facial recognition gaze patterns compared to non-anxious controls. The finding suggests that children with social anxiety scan a more limited part of the face, potentially in a more detail-oriented manner, relative to their counterparts without social anxiety. Furthermore, the analyses indicate that children with social anxiety may encounter challenges in shifting their attention across various facial regions. This is manifested as those with social anxiety tend to fixate their gaze on the eyes for prolonged periods, whereas children in the control group display a more flexible allocation of attention across different facial components. Such deviations in attentional patterns may contribute to the development and/or perpetuation of social anxiety.
2. Children and adolescents with SAD are slower to reorient from eyes than non-anxious controls, in line with the delayed disengagement hypothesis. The results, thus, point to delayed disengagement from eyes as a marker of social anxiety. Studies on adults with anxiety disorders have suggested that delayed disengagement from threat contributes to symptom maintenance. Difficulties with attentional disengagement from others eyes could potentially lead to an increase in arousal, that in turn exacerbates negative feelings associated with eye contact and social interaction. It is also possible that prolonged monitoring of other's eyes could cause youth with SAD to miss out on other aspects the social environment and thereby lead to social interaction difficulties. This could contribute to the experience of eye contact as aversive, and may be a maintaining factor of childhood SAD.
3. Atypical visual attention to faces is related to longitudinal change in social anxiety symptoms after either cognitive behavioral therapy (CBT) or a non-specific support intervention. Our results (in preparation) show that, youth with SAD who distribute their attention more widely within a face when asked to understand the emotional expression of the bearer are more likely to have improved three months after the end of the intervention. This suggests that a restricted pattern of attention may be a factor that maintains symptoms of social anxiety. The studied children’s distribution of attention did not change over time, suggesting that, although the interventions were effective in reducing symptoms of social anxiety, they did not change visual attention.
Potentially new research questions
Preliminarily, it can be posited that the project will lead to a continued inquiry into whether training in flexible attentional shifts during facial recognition could potentially reduce social anxiety and interrupt its perpetuation, especially if integrated into a conventional cognitive-behavioral therapy (CBT) regimen. Given that numerous analyses remain and since the social phobia group has not yet been contrasted against the autism and GAD groups, it is likely that the project will give rise to several additional research questions, or that the aforementioned conclusion may be adjusted. The longitudinal aspect of the project, which involves eye-tracking participants with social phobia three months post-treatment (be it CBT or placebo intervention), is also anticipated to generate new research questions.
Dissemination of results and collaborations
Results from the project have been presented at four different international meetings:
1. Nordic Child and Adolescent Psychiatry (NordCap) Research Meeting, 2020. digital
2. European Conference of Eye Movements (ECEM), 2019, Alicante, Spain
3. Deutsche Gesellschaft fur Kinder und Jugendpsychiatrie (DGKJP), 2019, Mannheim, Germany.
4. European Congress of Psychiatry (EPA), 2021 (Online).
In the spring of 2020, it was decided that the project team would contribute a chapter to an upcoming book on social anxiety (published by Studentlitteratur, see List of publications). This chapter focus on social attention and elements of the results and conclusions from the current project are described. The book targets clinical psychologists/therapists and psychiatrist, as well as medicine- and psychology students.
Through the project, collaborations have been established with dr. Jennifer Lau at King’s College, London, and dr. Andreas Frick at Uppsala University. Both dr. Lau and dr. Frick have co-authored articles produced within the framework of this project, providing expert insights on eye-tracking and social attention. Several of the experimental tasks employed have also been integrated into an ongoing research project concerning the rare genetic condition, Williams syndrome, conducted in collaboration with dr. Ann Nordgren and dr. Charlotte Willfors at the Karolinska Institutet. Williams syndrome is associated with distinct social attention patterns and an elevated risk of anxiety, making these findings pertinent to the research questions addressed in the current project.
Project leader: Eva Serlachius
Participating researchers: Jens Högström and Johan Lundin Kleberg
Grand manager: Karolinska Institutet
Project aims and development
To successfully navigate in a social world we have to attend to complex and quickly shifting information such as facial expressions and emotional displays. Work in psychology and neuroscience has demonstrated that typically developing children are remarkably apt at doing this. However, many children with social anxiety have a difficulty directing their attention flexibly and adaptively to social events, typically manifested as avoidance of eye contact or hyper-vigilance towards potential social threat (e.g., someone looking angry). This atypical social attention has been suggested to lead to a range of problems. According to theoretical models, atypical social attention is one of the mechanisms underlying the development of social anxiety disorder (SAD), but it is also seen in other clinical conditions such as autism spectrum disorder (ASD) and generalized anxiety disorder (GAD). However, there is a lack of knowledge about these attentional mechanisms in children with SAD, the overlap between conditions, and if they can be affected by psychological treatment.
In the current project we aimed to test the specificity of fundamental social attention mechanisms that have been linked to SAD and their relationship to the outcome of cognitive behavioral therapy (CBT) for children with SAD. Social attention was measured with eye-tracking and children with SAD were compared to other groups with clinical conditions related to atypical social attention (children with ASD or GAD) and non-anxious controls.
The overall purpose of this research project was to delineate social attention in children and adolescents with SAD by measuring attention in socially anxious youth with a corneal reflection eye tracker. This approach enabled us to determine the time course of the various attention events that in previous studies have been indicated to occur in anxious individuals. To clarify the specificity of attention bias in SAD, we also measured social attention in youth with ASD that have symptom overlap with SAD, as well as in a control group with non-anxious children and adolescents. Pupillary responses were also measured as a means to map the specificity of atypical social attention in youth SAD. Furthermore, we intended to investigate if certain patterns of attention bias predict a better or worse response to CBT, and whether or not attention bias will be affected by such a treatment. This research has contributed to the understanding of attentional processes in SAD and the maintaining factors involved in the disorder.
Brief about the Implementation
A substantial part of the project took part during the COVID-19 pandemic and data collection was stopped during two extended periods in 2020 and 2021. This delayed the project and recruitment of participants in the ASD group is not yet completed and the generalized anxiety disorder (GAD) group could not be recruited at all. However, the recruitment goal for the SAD group has been attained and the goal for the non-anxious control group has been surpassed. We have, furthermore, added a study objective, to explore whether two additional aspects of social attention differ between individuals with social anxiety and the control groups: saccade speed and hyperscanning. Beyond these deviations, no significant departures from the initial plan have been made.
The three most important results from the project and conclusions to be drawn
1. Children and adolescents with SAD exhibit distinct facial recognition gaze patterns compared to non-anxious controls. The finding suggests that children with social anxiety scan a more limited part of the face, potentially in a more detail-oriented manner, relative to their counterparts without social anxiety. Furthermore, the analyses indicate that children with social anxiety may encounter challenges in shifting their attention across various facial regions. This is manifested as those with social anxiety tend to fixate their gaze on the eyes for prolonged periods, whereas children in the control group display a more flexible allocation of attention across different facial components. Such deviations in attentional patterns may contribute to the development and/or perpetuation of social anxiety.
2. Children and adolescents with SAD are slower to reorient from eyes than non-anxious controls, in line with the delayed disengagement hypothesis. The results, thus, point to delayed disengagement from eyes as a marker of social anxiety. Studies on adults with anxiety disorders have suggested that delayed disengagement from threat contributes to symptom maintenance. Difficulties with attentional disengagement from others eyes could potentially lead to an increase in arousal, that in turn exacerbates negative feelings associated with eye contact and social interaction. It is also possible that prolonged monitoring of other's eyes could cause youth with SAD to miss out on other aspects the social environment and thereby lead to social interaction difficulties. This could contribute to the experience of eye contact as aversive, and may be a maintaining factor of childhood SAD.
3. Atypical visual attention to faces is related to longitudinal change in social anxiety symptoms after either cognitive behavioral therapy (CBT) or a non-specific support intervention. Our results (in preparation) show that, youth with SAD who distribute their attention more widely within a face when asked to understand the emotional expression of the bearer are more likely to have improved three months after the end of the intervention. This suggests that a restricted pattern of attention may be a factor that maintains symptoms of social anxiety. The studied children’s distribution of attention did not change over time, suggesting that, although the interventions were effective in reducing symptoms of social anxiety, they did not change visual attention.
Potentially new research questions
Preliminarily, it can be posited that the project will lead to a continued inquiry into whether training in flexible attentional shifts during facial recognition could potentially reduce social anxiety and interrupt its perpetuation, especially if integrated into a conventional cognitive-behavioral therapy (CBT) regimen. Given that numerous analyses remain and since the social phobia group has not yet been contrasted against the autism and GAD groups, it is likely that the project will give rise to several additional research questions, or that the aforementioned conclusion may be adjusted. The longitudinal aspect of the project, which involves eye-tracking participants with social phobia three months post-treatment (be it CBT or placebo intervention), is also anticipated to generate new research questions.
Dissemination of results and collaborations
Results from the project have been presented at four different international meetings:
1. Nordic Child and Adolescent Psychiatry (NordCap) Research Meeting, 2020. digital
2. European Conference of Eye Movements (ECEM), 2019, Alicante, Spain
3. Deutsche Gesellschaft fur Kinder und Jugendpsychiatrie (DGKJP), 2019, Mannheim, Germany.
4. European Congress of Psychiatry (EPA), 2021 (Online).
In the spring of 2020, it was decided that the project team would contribute a chapter to an upcoming book on social anxiety (published by Studentlitteratur, see List of publications). This chapter focus on social attention and elements of the results and conclusions from the current project are described. The book targets clinical psychologists/therapists and psychiatrist, as well as medicine- and psychology students.
Through the project, collaborations have been established with dr. Jennifer Lau at King’s College, London, and dr. Andreas Frick at Uppsala University. Both dr. Lau and dr. Frick have co-authored articles produced within the framework of this project, providing expert insights on eye-tracking and social attention. Several of the experimental tasks employed have also been integrated into an ongoing research project concerning the rare genetic condition, Williams syndrome, conducted in collaboration with dr. Ann Nordgren and dr. Charlotte Willfors at the Karolinska Institutet. Williams syndrome is associated with distinct social attention patterns and an elevated risk of anxiety, making these findings pertinent to the research questions addressed in the current project.