Major Grant Proposal: Attention Bias Training in Depressed Adolescents

Caitlin Eggleston

Project Summary: Commented [A1]: This summary is informative.

In this project I propose to study a sample of adolescents diagnosed with Major Reviewers see that this is an experimental research project,
and it addresses one of the key things that reviewers look
Depressive Disorder (MDD) to examine the effect of attention bias training (ABT) on negative for a working hypothesis.
attentional biases and the impact of this training on depressive symptoms. Individuals diagnosed
with MDD have been found to have an attentional bias away from positive emotional
information and towards negative emotional information. These biases are thought to contribute
to the onset and maintenance of MDD. ABT has been shown to successfully retrain attention in
individuals with anxiety and adults with MDD, but has not yet been applied to adolescents
diagnosed with MDD. Participants will be assigned to either a Real or Sham training condition,
and their levels of depressive symptomatology and attentional biases will be assessed before and
after they complete a week of ABT. I hypothesize that participants who receive the Real training
will show an attentional bias away from negative emotional information and towards positive
emotional information, which will also result in a decrease in their reported depressive
symptoms; no such bias or symptom change is hypothesized for participants in the Sham
condition.
Objective:
I propose to examine the effect of attention bias training (ABT) on negative attentional
biases in adolescents diagnosed with Major Depressive Disorder (MDD) and the impact of this
training on depressive symptoms. Previous research has demonstrated that adults diagnosed with
MDD are characterized by a bias in attention towards and memory for negative emotional
information. ABT has been shown to successfully retrain attention in individuals with anxiety
and in adults with depression, but the effectiveness and impact of ABT has not yet been
examined in depressed adolescents. Some researchers have shown further that ABT leads to an
improvement in depressive symptomatology in depressed adults, supporting the formulation that
attention biases contribute to the onset and maintenance of this disorder. The goal of my
proposed study is to replicate these findings in a sample in which the effects of ABT have not yet
been examined: adolescents diagnosed with MDD. In this study I will examine whether ABT Commented [A2]: Reviewers see that this project offers a
leads to a retraining of attentional biases and to a decrease in depressive symptomatology in new perspective on ABT studies.
depressed adolescents.
This project is a continuation of work that I completed last summer through the Commented [A3]: This provides relevant information on
PsychSummer program. In that project, pilot data indicated that in a small sample of subjects, the applicants preparation to undertake this research.
one week of ABT reduced negative attentional biases. The research I propose to conduct this
summer will be part of my proposed Honors thesis in which I will examine both the effects of
using the dot-probe task to train less negative and more positive attentional biases in depressed
adolescents and the impact of this training on level of depressive symptoms.
I hypothesize that, before ABT, depressed adolescents will show an attention bias
towards negative emotional stimuli and away from positive emotional stimuli; in contrast,
healthy controls will show the opposite pattern of attention biases. In addition, I predict that
depressed individuals who receive Real ABT dot-probe training (see below) will show a
reorientation of their attention away from negative emotional stimuli and towards positive
stimuli, whereas depressed adolescents in a Sham ABT control condition will not demonstrate
this training effect. Finally I predict that adolescents in the Real ABT condition will demonstrate
a significant decrease in their level of depressive symptomatology following training, whereas
adolescents in the Sham ABT condition will not show this beneficial effect.

Significance:
More than 30 million adults meet criteria for MDD during their lifetime; in addition, Commented [A4]: This paragraph contextualizes the work
more than 80% of adults with MDD will experience a recurrent episode of depression (Kessler & on MDD.
Wang, 2009), making this disorder one of the most common of all psychiatric illnesses. MDD
also affects 9% of children and adolescents in the United States (Avenevoli, et al., 2008); nearly
40% of these children and adolescents have a recurrent episode within three years (Kessler et al.,
2001). Not only are depressed adolescents with MDD likely to experience recurrent episodes, but
further, early-onset depression in adolescence is associated with longer and more severe
depressive episodes (Lewinsohn et al., 1994) compared with those who develop depression later
in life. Furthermore, adolescents who experience an episode of MDD show functional
impairment in academic and occupational performance, interpersonal functioning, physical well-
being, and quality of life (Lewinsohn et al., 2003). More research is clearly needed to explore
how to help adolescents with MDD improve their quality of life for both short- and long-term
benefits.
Commented [A5]: The following paragraphs connect ABT
Depression in adults has been found to be associated with a bias towards negative research with MDD research. A good range of references
emotional information and an inability to disengage attention from negative, mood-congruent, are included, and this shows the researchers depth of
engagement with the work in this field.

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stimuli. This negative information-processing bias has been found to be associated with greater
symptom severity (Wells & Beevers, 2010; Hallion & Ruscio, 2011; Gotlib et al, 2004).
Adolescents with MDD have also been found to show this selective bias towards negative
information. Hankin et al. (2010), for example, found that currently depressed adolescents show
an attentional bias towards images of sad faces, compared with age-matched controls who avoid
sad faces. Moreover, this negative attentional bias appears to contribute to the development and
maintenance of MDD, with stronger biases associated with increased symptom severity (Baert,
De Raedt, & Koster, 2010; Baert, De Raedt, Schacht, & Koster, 2010).
This negative attentional bias can be modified through ABT, which teaches individuals to
orient their attention away from a negative stimulus and/or towards a positive stimulus. One
form of ABT uses the dot-probe task, in which individuals are shown two stimuli side by side on
a computer screen, one emotionally valanced and the other neutral, followed by a dot probe that
replaces one of the two stimuli after they disappear. The individual must then respond as quickly
and as accurately as possible to indicate the location of the dot probe. Selective placement of the
dot can be used to train individuals to orient their attention towards more positively valenced
stimuli, even if their natural tendency is to attend to negatively valenced stimuli (Wells &
Beevers, 2010). A recent study using this dot-probe task training showed not only that currently
depressed undergraduate students can re-train their attentional biases, but further, that this
training leads to a decrease in the students depressive symptoms (Wells & Beevers, 2010).
Existing research with depressed and anxious adults has shown promise for the effects of
ABT on reducing the severity of both negative attention bias and depressive symptoms (Wells &
Beevers, 2010; Baert et al., 2010; Browning et al, 2010; Hallion & Ruscio, 2011). It is important
to note, however, that little comparable research has been conducted with adolescents. ABT has Commented [A6]: This focuses the reviewers attention
traditionally been used for anxiety; only recently have researchers begun to explore its to the contribution of this research. Notice that without the
rich discussion above, a statement about little research in
application to depression (Hallion & Ruscio, 2011; Baert et al., 2010). This project is designed to the field would not be convincing to reviewers.
examine the effectiveness of ABT in depressed adolescents, a population that has not been
studied, for both retraining negative attention biases and for decreasing depressive symptoms.
This project will contribute to the existing research on the effectiveness of ABT for depressed
individuals, with a focus on adolescents, who experience chronic and severe depression and have
a reduced quality of life. With this work, I hope to gain a better understanding of the relation
between attention biases and psychopathological symptoms to help shape future approaches to
intervention and treatment of major depression.

Methodology:
Participants: Twenty depressed male and female adolescents (ages 13-17) will be recruited
through the Pediatric Mood Disorders Clinic in the Department of Psychiatry and Behavioral
Sciences at Stanford University and from the local community. Twenty healthy control
adolescents will be recruited from the community. Exclusion criteria for depressed adolescents
will be 1) history of major neurological disorder or illness; and 2) comorbid Bipolar I Disorder,
Attention Deficit Hyperactive Disorder, or current alcohol/drug dependence. Exclusion criteria
for healthy controls include, in addition, any past or current psychiatric disorder. The healthy
controls will be used as a comparison group and will not complete ABT or participate in the
post-training session (see below).
Commented [A7]: Including information on how
participants will be recruited demonstrates the feasibility of
the project.
Commented [A8]: The methodology section is very
detailed here. Reviewers would encourage using the first
person in the description of methods. This will show clearly
where the applicant is collaborating with other, where the
work is building on others, and where the applicant is
working independently.

Participant Eligibility Visit: During their first visit, both depressed and control adolescents will Commented [A9]: The paragraphs that follow spell out
participate in a semi-structured interview, the Kiddie Schedule for Affective Disorders and the steps in preparing participants and how the experiments
will be run.

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Schizophrenia, (KSADS-PL; Kaufman et al., 1997) to confirm their eligibility and assess
exclusion criteria. Participants will also complete a packet of questionnaires at this session
including a self-report measure of depressive symptomatology, the Childrens Depression
Inventory (CDI; Kovacs, 1985).

Pre-Training Session: In this project, attentional biases will be assessed and modified using the
dot-probe task. During their second visit, all participants will complete the pre-training dot-probe
task. In this task, participants are presented with a pair of faces (emotional-neutral) for 1000ms
followed by a dot probe that appears in the location of one of the two faces. Participants make a
button-press responding to the location of the probe. Response times will be recorded in order to
determine attentional biases. Response times are faster when the dot-probe location is congruent
with the attended face than when the location and attended face are incongruent; thus, this
dependent variable allows us to infer to which face the participant is attending. Faces for the
current version of the task were selected from the MacArthur Network Face Stimuli Set
(http://www.macbrain.org/resources.htm). Based on findings that selective attentional biases in
depression occur at longer stimulus durations (Joormann et al., 2007), the face stimuli will be
presented for 1000ms. Because this pre-training assessment is intended to measure existing
attentional biases, the dot probe will appear equally behind the happy, sad, and neutral faces.

Training: Depressed adolescents will complete a total of six training sessions. They will be
randomly assigned to either the Real ABT condition, in which the dot always appears behind the
more positive face on each trial, or the Sham ABT condition, in which the dot appears at equal
rates behind the positive, negative, and neutral faces. The first training will take place in the
Mood and Anxiety Disorders Laboratory at Stanford to make sure that participants understand
the task and have the opportunity to ask any questions. Participants are then sent home with a
laptop and are asked to complete five additional trainings over the course of one week. Each
training will take approximately 15-20 minutes and the experimenter will be blind to the training
condition.

Post-Training Session: Participants will return to Stanford one week after their pre-training
session and will complete the dot-probe task again, with the probe appearing at equal rates
behind the negative, neutral, and positive faces, as was presented in the pre-training session. At
this time they will also complete a questionnaire packet that will include the CDI.

Applicants Role: I will shadow all participant interviews to learn how to conduct the KSADS-
PL, and will conduct the majority of the pre- and post-training sessions, in addition to
coordinating and scheduling all participants in this study. I will also be responsible for data
collection and analysis.

Data Collection and Analysis: An attentional bias score will be calculated from participant
response times during each condition by subtracting the congruent reaction times from the
incongruent reaction times (IncongruentRT-CongruentRT). This score will be used to assess
changes in attention bias at pre- and post-training. In addition, for both positive and negative
attention biases, a 2x2 analysis of variance (ANOVA) will be conducted to assess interactions
between training time and training group, and a 2x6 repeated measures ANOVA will be
conducted to examine interactions between training group and training session. I will also
Commented [A10]: Succinct details of data collection and
analysis help reviewers to see that the applicant has
thought through how to work with the data. It would be
good to also indicate here, for example, whether such
procedures are standardly used in the field.

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examine whether participants scores on the CDI change significantly from pre- to post-training,
and whether there are significant differences between groups. All analysis will be conducted by
the grant applicant with support from Ian H. Gotlib and Natalie Colich. Commented [A11]: This shows that the applicant has
support from, and will continue to work with her research
mentors.
Pilot Data: During summer of 2011, ten adolescents were run through the training (Real: n= 6,
Sham: n=4). All participants were currently depressed and showed a bias towards negative
stimuli and no bias for positive stimuli at their pre-training session. At post-training, adolescents
in the Real ABT group showed increased allocation of attention towards positive stimuli and
away from negative stimuli, whereas participants in the Sham ABT group showed no change
(See Figure 1). Indeed, for positive attentional bias, the interaction between training time
(pre/post) and training group (real/sham) was significant, F (1, 8) = 20.6, p = 0.002. These
findings suggest that training was successful at reorienting attention. The proposed project
examines this training procedure with a larger sample, as well as the effects of the training on
changes in depressive symptomatology.

Resources and Preparation:

Relevant Experience:
I have taken classes in basic statistics (Stats 60), clinical psychology (Psych 90), Commented [A12]: Course names together with course
abnormal psychology (Psych 95), and adolescent mental health (HumBio 142M). In addition, I numbers are very helpful.
have experience working with mental health issues as a Peer Counselor at the Bridge Peer
Counseling Center at Stanford.
I have experience working with Qualtrics, which will be used to obtain questionnaire
data, along with SPSS and Excel, which will be used for data analysis.
I have been a research assistant in the Mood and Anxiety Disorders Lab since January
2011 and I have been working on this particular project since February 2012. Last summer I
received a grant through the Stanford Psychology Departments PsychSummer program to
complete pilot research for this project.
I have completed CITI training for work with Human Subjects. Commented [A13]: This and the information below on
the status of the status of the IRB protocol is crucial for
reviewers to determine the feasibility of funding the project
Resources: I will be working closely with graduate student Natalie Colich on this project, and given the stated project timeline. (IRB protocol must be in
will also be advised by Ian H. Gotlib, PhD. My proposed project is part of a larger study being hand before UAR research funds can be awarded.)
run in the Mood and Anxiety Disorders Laboratory which includes additional behavioral tasks
given at the pre- and post-training sessions, as well as a scan session for participants who are
eligible to be scanned.

Human Subjects Approval: This study is part of a larger research project that is included in Dr.
Gotlibs current IRB protocol. Commented [A14]: Be sure to check with the faculty PI
whether your name has been added to the current IRB
protocol.
Tentative Timeline:
Recruitment of participants is currently underway and will continue through the summer. The
latter part of the summer will be devoted to data analysis. The proposed dates for summer work
on the project are June 18, 2012 August 24, 2012 (10 weeks), during which I will run as many
participants as possible and begin data analysis.

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Milestones:
- Completion of running all participants by the end of August
- Analyzing preliminary data to test my hypotheses
- Analyzing all data

Budget:
The requested budget for this project is $6000. Commented [A15]: Check latest UAR budget guidelines.
- Summer Housing: $2600
- Summer Meal Plan: $1600
- 10 Week Stipend: $1800

Pilot Data:
Figure 1. Attentional biases in the Real and Sham ABT groups pre- and post-training
60.000
Pre- and Post-Training Bias
50.000

Sham ABT
40.000
Attention Bias Score (ms)

30.000

20.000

10.000

.000

-10.000

-20.000 Positive Negative Positive Negative

-30.000

Pre-Training Post-Training

References:

Avenevoli, S., Knight, E., Kessler, R.C. & Merikangas, K.R. (2008). Epidemiology of
depression in children and adolescents. In J.R.Z. Abela & B.L. Hankin (Eds.), Handbook of
depression in children and adolescents (pp. 6-32). New York, New York: Guilford Press.

Baert, S., De Raedt, R., & Koster, E. (2010). Depression-related attentional bias: The influence
of symptom severity and symptom specificity. Cognition and Emotion, 24(6), 1044-1052.

Baert, S., De Raedt, R., Schacht, R., & Koster, E.H.W. (2010). Attentional bias training in
depression: therapeutic effects depend on depression severity. Journal of Behavior Therapy and
Experimental Psychiatry, 41, 265-274.

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Browning, M., Holmes, E.A., & Harmer, C.J. (2010). The modification of attentional bias to
emotional information: a review of the techniques, mechanisms, and relevance to emotional
disorders. Cognitive, Affective, & Behavioral Neuroscience,10(1), 8-20.

Gotlib, I. H., Kasch, K. L., Traill, S., Joormann, J., Arnow, B. A., & Johnson, S. L. (2004).
Coherence and specificity of information-processing biases in depression and social phobia.
Journal of Abnormal Psychology, 113(3), 386-398.

Hallion, L. S., & Ruscio, A. M. (2011). A meta-analysis of the effect of cognitive bias
modification on anxiety and depression. Psychological Bulletin, doi: 10.1037/a0024355

Hankin, B.L., Gibb, B.E., Abela, J.R.Z. & Flory, K. (2010). Selective attention to affective
stimuli and clinical depression among youths: the role of anxiety and specificity of emotion.
Journal of Abnormal Psychology, 119(3), 491-501.

Joormann, J., Talbot, L., & Gotlib, I.H. (2007). Biased processing of emotional information in
girls at risk for depression. Journal of Abnormal Psychology, 116(1), 135-143

Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., Williamson, D. & Ryan, N.
(1997). Schedule for affective disorders and schizophrenia for school-aged children present
and lifetime version: initial reliability and validity data. Journal of the American Academy of
Child and Adolescent Psychiatry, 36, 980-989.

Lewinsohn, P.M., Rohde, P., Seeley, J.R., Klein, D.N. & Gotlib, I.H. (2003). Psychosocial
functioning of young adults who have experienced and recovered from major depressive disorder
during adolescence. Journal of Abnormal Psychology, 112(3), 353-363.

Lewinsohn P.M., Roberts R.E., Seeley J.R., Rohde P, Gotlib I.H., Hops H. (1994) Adolescent
psychopathology: II. Psychosocial risk factors for depression. Journal of Abnormal Psychology,
103(2), 302-315

Kessler, R.C., Avenevoli, S. & Merikangas, K.R. (2001). Mood Disorders in Children and
Adolescents: An Epidemiologic Perspective. Biological Psychiatry, 49, 1002-1014

Kessler, R. & Wang, P. The Epidemiology of Depression. The Handbook of Depression.

New York: Guilford; 2009.

Kovacs, M. (1985). The Children's Depression Inventory (CDI). Psychopharmacology Bulletin,

21, 995998.

Wells, T. T., & Beevers, C. G. (2010). Biased attention and dysphoria: Manipulating selective
attention reduces subsequent depressive symptoms. Cognition and Emotion, 24(4), 719-728.