Patterns of attentional biases in children and emotional symptoms during the COVID-19 pandemic: a two-wave longitudinal study

The COVID-19 pandemic might lead to an increase in the rate of emotional symptoms among children [20]. Previous research demonstrated increased fear of COVID-19 and heightened anxiety symptoms and depression symptoms in children with a mean age of 14 years or 10 years during the COVID-19 pandemic [22, 34]. Based on the cognitive models, the tendency to attend to threatening or awarding information is one of the cognitive styles, contributing to emotional symptoms, including fear, anxiety symptoms, and depression symptoms [33]. Although research has demonstrated that low positive attentional bias and high negative attentional bias are risk factors underlying the emotional problems during the COVID-19 pandemic, there are insufficient studies that take a holistic approach and investigate individual differences in their patterns of attending to positive and negative information. Without a holistic perspective, it is unknown if a person who is high in both positive and negative attentional biases develops higher or lower emotional symptoms than a person who is low in both positive and negative attentional biases. With a holistic approach to investigating the overall patterns of attentional biases, the findings would help contribute to the current literature on whether negative attentional bias or positive attentional bias is more important in the development of emotional symptoms. If the profile of high positive and high negative attentional bias was related to low emotional symptoms than was the profile of low positive and low negative attentional biases, positive attentional bias might be more important than negative attentional bias in predicting emotional symptoms. This would provide important implications for the current cognitive models of emotional symptoms, which highlight negative attentional bias but ignore attention to positive information [19].

Longitudinal studies that examine how the profiles of attentional preferences affect emotional symptoms during the COVID-19 pandemic are particularly scarce. Considering the importance of attentional bias in children’s development of internalizing symptoms, more research is needed to investigate how children’s overall patterns of attentional biases might affect the development of fear, anxiety symptoms, and depression symptoms during the COVID-19 pandemic. These findings would add to the literature what were the overall patterns of negative and positive attentional biases in children during the COVID-19 pandemic, and how these patterns of negative and positive attentional biases were associated with emotional symptoms during the COVID-19 pandemic. Such findings might also add to our understanding of whether psychologists should consider both negative and positive attentional biases simultaneously when investigating the development of emotional symptoms in children, especially during the COVID-19 pandemic.

To address these research gaps, the present study aimed to reveal profiles of attentional biases and to examine how these profiles were associated with the development of fear of COVID-19, anxiety symptoms, and depression symptoms in children during the COVID-19 pandemic.

Attentional bias and internalizing symptoms

Attentional bias refers to the cognitive tendency to shift attention toward negative or positive stimuli. Based on the cognitive models, negative attentional bias is the vulnerability factor for the development of anxiety symptoms and depression symptoms in children [19, 33]. Research recruited 1291 children of 6–18 years with a mean age of 13.5 years, including non-selected youth, high-trait anxiety youth, and treatment-seeking anxiety patients, worldwide and assessed their negative attentional bias through behavioral tasks [1]. The study revealed a significant positive association between negative attentional bias and anxiety symptoms. The association between negative attentional bias measured by the dot-probe task and depression symptoms was also positive in 161 children of 9 to 17 years who were pure depressed, pure anxious, comorbid depressed and anxious, or healthy controls [10]. Another study that measured positive attentional bias in children of 7 to 17 years by the eye-tracking technique found that compared to non-anxious children (N = 49), anxious children (N = 43) had lower attention toward positive information [9]. For depression symptoms, a meta-analysis involving 16 studies found that depressed people over 18 years (366 depressed patients, and 563 health controls) had impaired positive attentional bias [28]. A longitudinal study showed that low positive attentional bias measured by spatial orienting tasks might cause increased depression symptoms for never-depressed adolescents (N = 531,81 developed depression during follow-up of 16 years [29]. The above studies measured attentional bias by behavioral tasks, such as the dot-probe task or the spatial orienting task. Although behavioral tasks are objective measures of attentional bias, these have limitations in their poor psychometric properties which include poor test–retest reliability or convergent validity [3, 30]. Therefore, other methods to assess attentional bias might be needed to increase our understanding of attentional bias. For negative attentional bias, a longitudinal study revealed that high negative attentional bias measured by the self-report inventory predicted the developmental trajectories of high anxiety symptoms in 72 Chinese children from grade 9 to 11 in high schools over three years [11]. The self-report inventory of attentional bias such as the Attention to Positive and Negative Information Scale had good reliabilities and validities [23]. However, the self-report measure of attentional bias was often criticized for its susceptibility to memory bias [25].

Attentional training that targeted negative attentional bias has shown efficacy in modifying self-esteem as an indicator of depression symptoms in 108 participants over 17 years old with mild or minimal depression symptoms (63 females, 45 males) [17]. Also, a study tested the efficacy of attentional bias modification in reducing negative attentional bias and social anxiety in 32 healthy adolescents aged 13–16 years from secondary schools in the Netherlands. Compared to adolescents who completed the placebo training, those who conducted attentional bias modification had reduced negative attentional bias and social anxiety symptoms [8]. This evidence further supported that high negative attentional bias might affect high anxiety symptoms and depression symptoms.

During the COVID-19 pandemic, children around the age of 14.23 years (N = 195) recruited from the Netherlands might experience strong fear of COVID-19 infection which was the result of communication of threatening COVID-19-related information with parents [22]. A meta-analysis has suggested that higher attention toward threats was related to higher fear-related symptoms in adult participants, including clinical, community, or student samples, in 40 studies [7]. Thus, attentional bias toward threats might also be related to higher fear of COVID-19. Moreover, a longitudinal study on 132 Italian adults who experienced lockdown due to the COVID-19 pandemic in Italy found that higher attention toward COVID-related threatening stimuli was associated with higher health anxiety symptoms [4]. Higher attention to COVID-19-related stimuli was associated with higher COVID-19 anxiety syndrome in 150 females and 148 males who were UK residents above 18 years [2]. Therefore, research on attentional bias during the COVID-19 pandemic might provide important implications for identifying children who are more likely to show stronger fear of COVID-19, anxiety symptoms, and depression symptoms during the COVID-19 pandemic.

Profiles of negative and positive attentional biases

Profiles of negative and positive attentional biases depicted overall patterns of attentional preferences to negative and positive stimuli. Although negative attentional bias might be the opposite of positive attentional bias in terms of the affective valence of preferred stimuli, people might have low negative attentional bias and low positive attentional bias simultaneously. The presence of high negative and high positive attentional biases might predict lower emotional symptoms than those with high negative and low positive attentional biases. For example, a study with an unselected community sample of 270 adults (the mean age of 22 years) from the undergraduate student population and community forum has shown that attentional bias toward threats was linked to high self-report anxiety symptoms only in individuals with a tendency to attend away from positive information [32]. Latent profile analysis is a person-centered statistical approach that is commonly used to reveal heterogeneous groups of people with common patterns of external or internal behavior [24]. A cross-sectional study assessed attentional biases by self-report inventories in 667 inpatients of 60–90 years from a hospital in China and revealed four distinct profiles of positive and negative attentional biases with latent profile analysis [13]. The four profiles consisted of “no positive and negative bias” which included 9.3% of participants, “minor positive bias & no negative bias” (48.0%), “major positive bias & minor negative bias” (25.6%), and “major positive bias & no negative bias” (17.1%). The “no positive and negative bias” and the “minor positive bias & no negative bias” groups had higher depression symptoms than the “major positive bias & no negative bias” group, suggesting that high positive attentional bias was a protective factor buffering depression symptoms. However, it is unclear if the results can be replicated in children during the COVID-19 pandemic. Moreover, the study is cross-sectional, which has limited ability to imply causality. Thus, more longitudinal research on children’s profiles of attentional biases is needed to understand how profiles of attentional bias affect fear of COVID-19, depression symptoms, and anxiety symptoms during the COVID-19 pandemic. Profiles of negative and positive attentional biases would provide clinical implications for identifying children who are at high risk of developing strong fear of COVID-19, anxiety symptoms, and depression symptoms based on their profiles of attentional biases during the COVID-19 pandemic. Also, the profiles would imply that clinicians should address profiles of negative and positive attentional biases when preventing children from development of emotional symptoms during the COVID-19 pandemic.

The current study

The current research recruited a sample of children from a primary school. The study aimed to 1) reveal distinct profiles of negative and positive attentional biases in children during the COVID-19 pandemic. Also, the study aimed to 2) reveal the relationship of profiles of attentional biases to fear of COVID-19, anxiety symptoms, and depression symptoms during the COVID-19 pandemic. The majority of existing studies have only investigated either negative attentional bias or positive attentional bias separately. No previous studies have used the latent profile analysis to investigate the effect of the overall patterns of attentional biases on children’s emotional symptoms during the COVID-19 pandemic. This study would be the first study that took a holistic approach to reveal profiles of attentional biases in children. Also, it would provide the first evidence from a longitudinal study for how profiles of attentional biases would affect fear of COVID-19, anxiety symptoms, and depression symptoms during the COVID-19 pandemic.

Based on the previous evidence, distinct profiles of attentional biases would be revealed which might include profiles of “low negative and positive attentional bias”, “low negative and high positive attentional bias”, “high negative and low positive attentional bias” and “high negative and positive attentional bias”. Compared to the “high negative and positive attentional bias” profile, the “low negative attentional bias and high positive attentional bias” profile would predict low fear, anxiety symptoms, and depression symptoms during the COVID-19 pandemic. While compared to the “low negative and positive attentional bias” profile, the “high negative attentional bias and low positive attentional bias” profile would be related to more fear, anxiety symptoms, and depression symptoms in children during the COVID-19 pandemic.

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