Perceived acceptability and appropriateness of a web-based program targeting risk for anxiety in young children and their parents.

OBJECTIVE: This mixed-methods study examined perceived acceptability and appropriateness of a novel digital mental health program targeting anxiety risk (i.e., perfectionism or error sensitivity) in 5-to-7-year-old children and their parents. METHODS: Parent-child dyads participated in a modular, web-based cognitive-behavioral program targeting negative overreactions to making mistakes. The program, "Making Mistakes", consisted of a 6-month series of short video clips, journaling activities, and weekly reminders, and modules were delivered to caregivers and children separately. 86 dyads completed self-report measures, 18 of whom participated in semi-structured interviews, following completion of the primary program module. A standard thematic analysis was used to elucidate themes from the parent and child interview content. RESULTS: Our quantitative and qualitative results were generally aligned. Children and parents viewed the novel digital mental health program as acceptable and appropriate, favoring the cognitive behavioral strategies such as modeling positive reactions to mistakes, responding positively to child mistakes, and emphasizing effort over outcome. Participants also provided helpful feedback related to program content, delivery, and engagement, as well as suggestions to enhance the program. CONCLUSIONS: Findings have implications for design and content features of parent-based and dyad-based programs, as well as digital mental health programs focused on reducing anxiety risk.

The associations among sleep-related difficulties, anxiety, and error-related brain activity in youth.

Given the high prevalence of anxiety disorders and their associated impairment, elucidating neural mechanisms related to these disorders has been increasingly prioritized. The error-related negativity (ERN) has been identified as a neural marker that indexes risk for anxiety across development. The ERN seems to confer risk for developing anxiety, especially in the context of stressful life events. The present study sought to examine sleep-related difficulties as another stressful factor that might impact the ERN. In a sample of 221 girls, aged 8 to 15 years old, we first examined the relationship between longer-term (i.e., over the past month) and shorter-term (i.e., over the past week) sleep difficulties and the ERN. We then investigated whether specific sleep difficulties uniquely predict the ERN. In exploratory analyses, we assessed whether sleep difficulties moderate the relationship between the ERN and anxiety. Results indicated that youth who report longer-term lower sleep duration, longer-term worse sleep, and shorter-term lower sleep duration on school days over the past week have a larger (i.e., more negative) ERN. Additionally, only shorter-term sleep duration on school days over the past week uniquely predicted the ERN. Finally, an elevated ERN predicted greater clinical anxiety in the context of longer-term sleep difficulties. Future studies should clarify the direction of these associations via longitudinal designs.

The free-viewing matrix task: A reliable measure of attention allocation in psychopathology.

Aberrant attention allocation has been implicated in the etiology and maintenance of a range of psychopathologies. However, three decades of research, relying primarily on manual response-time tasks, have been challenged on the grounds of poor reliability of its attention bias indices. Here, in a large, multisite, international study we provide reliability information for a new eye-tracking-based measure of attention allocation and its relation to psychopathology and age. Data from 1567 participants, across a wide range of psychiatric diagnoses and ages, were aggregated from nine sites around the world. Of these, 213 participants also provided retest data. Acceptable overall internal consistency and test-retest reliability were observed among adult participants (Cronbach's alpha = 0.86 and r(213) = 0.89, respectively), as well as across all examined psychopathologies. Youth demonstrated lower internal consistency scores (Cronbach's alpha = 0.65). Finally, the percent dwell time index derived from the task statistically differentiated between healthy participants and participants diagnosed with social anxiety disorder, major depression, and post-traumatic stress disorder. These results potentially address a long-standing reliability crisis in this research field. Aberrant attention allocation patterns in a variety of psychiatric disorders may be targeted with the hope of affecting symptoms. The attention allocation index derived from the matrix task offers reliable means to measure such cognitive target engagement in clinical contexts.

An Experimental Therapeutics Approach to the Development of a Novel Computerized Treatment Targeting Error-Related Brain Activity in Young Children.

In the current study, we utilize an experimental medicine approach to examine the extent to which a single-session, computerized intervention impacts a transdiagnostic neural marker of risk (i.e., the error-related negativity [ERN]) in 70 children between the ages of 6 and 9 years. The ERN is a deflection in the event-related potential occurring after an individual makes a mistake on a lab-based task and has been shown to be transdiagnostically associated with a variety of anxiety disorders (e.g., social anxiety, generalized anxiety), obsessive-compulsive disorder, and depressive disorders in over 60 studies to date. Building on these findings, work has been done to link an increased ERN to negative reactions to, and avoidance of, making mistakes (i.e., error sensitivity). In the current study, we capitalize on this previous work by examining the extent to which a single-session, computerized intervention may engage the target of "error sensitivity" (measured by the ERN, as well as self-report of error sensitivity). We examine the convergence of multiple measures of the construct of "error sensitivity" (i.e., child self-report, parent report on child, and child electroencephalogram [EEG]). We also examine relationships between these three measures of "error sensitivity" and child anxiety symptoms. Overall, results suggested that treatment condition predicted changes in self-reported error sensitivity but not changes in ERN. Based on the lack of previous work in this area, we view this study as a novel, preliminary, first step toward using an experimental medicine approach to examine our ability to engage the target of the ERN (i.e., error sensitivity) early in development.

Relational victimization prospectively predicts increases in error-related brain activity and social anxiety in children and adolescents across two years.

Recent research has focused on identifying neural markers associated with risk for anxiety, including the error-related negativity (ERN). An elevated ERN amplitude has been observed in anxious individuals from middle childhood onward and has been shown to predict risk for future increases in anxiety development. The ERN is sensitive to environmental influences during development, including interpersonal stressors. Of note, one particular type of interpersonal stressor, relational victimization, has been related to increases in anxiety in adolescents. We tested whether relational victimization predicts increases in the ERN and social anxiety symptoms across two years in a sample of 152 child and adolescent females (ages 8 - 15). Results indicated that children and adolescents' baseline ERN was positively related to the ERN two years later. Furthermore, greater relational victimization at baseline predicted greater increases in the ERN two years later, controlling for baseline ERN. Moreover, relational victimization at baseline predicted increases in social anxiety, and this relationship was mediated by increases in the ERN. These results suggest that relational victimization impacts the developmental trajectory of the neural response to errors and thereby impacts increases in social anxiety among children and adolescents.

The relation between executive functions, error-related brain activity, and ADHD symptoms in clinically evaluated school-aged children.

Two event-related potentials (ERPs) elicited following errors, the error-related negativity (ERN) and error positivity (Pe), have been proposed to reflect cognitive control, though the specific processes remain debated. Few studies have examined the ERN and Pe's relations with individual differences in cognitive control/executive functioning using well-validated tests administered separately from the inhibition tasks used to elicit the ERN/Pe. Additionally, neurocognitive tests of executive functions tend to strongly predict ADHD symptoms, but the extent to which task-based and EEG-based estimates of executive functioning/cognitive control account for the same variance in ADHD symptoms remains unclear. The current study addressed these limitations by examining relations between the ERN/Pe and three core executive functions (working memory, inhibitory control, set shifting) in a clinically-evaluated sample of 53 children ages 8-12 (Mage = 10.36, SD = 1.42; 77.4% White/Non-Hispanic; 16 girls) with and without ADHD. Results demonstrated that neither the ERN nor Pe were related to overall cognitive control/executive functioning, or to working memory or set shifting specifically (all 95%CIs include 0.0). In contrast, a larger Pe was associated with better-developed inhibitory control (ß=-.35, 95%CI excludes 0.0), but did not capture aspects of inhibitory control that are important for predicting ADHD symptoms. Neither the ERN nor Pe predicted ADHD symptoms (95%CIs include 0.0). Results were generally robust to control for age, sex, SES, ADHD symptom cluster, and anxiety, and emphasize the need for caution when interpreting the ERN/Pe as indices of broad-based cognitive control/executive functioning, as well as using the ERN/Pe to examine cognitive processes contributing to ADHD symptomatology.

Corporal Punishment Is Uniquely Associated With a Greater Neural Response to Errors and Blunted Neural Response to Rewards in Adolescence.

BACKGROUND: Although corporal punishment is a common form of punishment with known negative impacts on health and behavior, how such punishment affects neurocognitive systems is relatively unknown. METHODS: To address this issue, we examined how corporal punishment affected neural measures of error and reward processing in 149 adolescent boys and girls of ages 11 to 14 years (mean age [SD] = 11.02 [1.16]). Corporal punishment experienced over the lifetime was assessed using the Stress and Adversity Inventory. In addition, participants completed a flankers task and a reward task to measure the error-related negativity and reward positivity, respectively, as well as measures of anxiety and depressive symptoms. RESULTS: As hypothesized, participants who experienced lifetime corporal punishment reported more anxiety and depressive symptoms. Experiencing corporal punishment was also related to a larger error-related negativity and blunted reward positivity. Importantly, corporal punishment was independently related to a larger error-related negativity and a more blunted reward positivity beyond the impact of harsh parenting and lifetime stressors. CONCLUSIONS: Corporal punishment appears to potentiate neural response to errors and decrease neural response to rewards, which could increase risk for anxiety and depressive symptoms.

Error-related brain activity: A time-domain and time-frequency investigation in pediatric obsessive-compulsive disorder.

Increased error-related negativity (ERN), a measure of error monitoring, has been suggested as a biomarker of obsessive-compulsive disorder (OCD). Additional insight into error monitoring is possible using time-frequency decomposition of electroencephalographic (EEG) data, as it allows disentangling the brain's parallel processing of information. Greater error-related theta is thought to reflect an error detection signal, while delta activity may reflect more elaborative post-detection processes (i.e., strategic adjustments). Recent investigations show that decreased error-related alpha may index attentional engagement following errors; additionally, increases and decreases in error-related beta could reflect motor inhibition and motor preparation, respectively. However, time-frequency dynamics of error monitoring in OCD are largely unknown. The present study examined time-frequency theta, delta, alpha and beta power in early adolescents with OCD using a data-driven, cluster-based approach. The aim was to explore electrocortical measures of error monitoring in early adolescents with (n = 27, 15 females) and without OCD (n = 27, 14 females) during an arrowhead version of the flanker task while EEG activity was recorded. Results indicated that the OCD group was characterized by increased ERN and error-related theta, as well as reduced error-related beta power decrease (i.e., greater power) compared to participants without OCD. Greater error-related beta explained variance in OCD over and above the ERN and error-related theta. By examining separate time-frequency measures, the present study provides novel insights into the dynamics of error monitoring, suggesting that pediatric OCD may be characterized by enhanced error monitoring (i.e., greater theta power) and post-error inhibition (i.e., reduced beta power decrease).

The impact of punishment on error-related brain activity in children.

The error-related negativity (ERN) is sensitive to individual differences relating to anxiety and is modulated by manipulations that increase the threat-value of committing errors. In adults, the ERN magnitude is enhanced when errors are followed by punishment, especially among anxious individuals. Punitive parenting is related to an elevated ERN in children; however, the effects of task-based punishment on the ERN in children have yet to be understood. Furthermore, there is a need to assess developmental periods wherein the ERN might be especially prone to modulation by punishment. We examined the impact of punishment on the ERN in a sample of children and assessed whether the impact of punishment on the ERN was moderated by age and anxiety. Punishment potentiated the ERN in children, especially among higher trait-anxious individuals; the punishment potentiation of the ERN was also associated with older age. The interaction between child age and anxiety symptoms did not significantly predict the punishment potentiation of the ERN; however, both child age and anxiety symptoms uniquely predicted the punishment potentiation of the ∆ERN. Anxious children may be especially prone to punishment-related alterations in error monitoring, and the impact of punishment on the ERN may become more pronounced as children age.

Measuring and Enhancing Initial Parent Engagement in Parenting Education: Experiment and Psychometric Analysis.

BACKGROUND: Prevention efforts focused on parenting can prevent and reduce the rates of child internalizing and externalizing problems, and positive changes in parenting skills have been shown to mediate improvements in child behavioral problems. However, parent skills training programs remain underused, with estimates that under half of eligible parents complete treatment and even lower rates engage in preventive interventions. Moreover, there is no validated measure to assess initial engagement in parent education or skills training, which is an understudied stage of parent engagement. OBJECTIVE: We aimed to test a novel engagement strategy, exploring whether including information pertaining to the neuroscience of child development and parent skills training enhanced parental intent to enroll. In addition, a novel self-report measure, the 18-item Parenting Resources Acceptability Measure (PRAM), was developed and validated. METHODS: In a group of 166 parents of children aged 5 to 12 years, using an engagement strategy based on the Seductive Allure of Neuroscience Explanations, we conducted a web-based experiment to assess whether the inclusion of neuroscience information related to higher levels of engagement via self-report and behavioral measures. The PRAM was subjected to an exploratory factor analysis and examined against relevant validity measures and acceptability measurement criteria. RESULTS: Three PRAM factors emerged ("Acceptability of Parenting Resources," "Interest in Learning Parenting Strategies," and "Acceptability of Parenting Websites"), which explained 68.4% of the total variance. Internal consistency among the factors and the total score ranged from good to excellent. The PRAM was correlated with other relevant measures (Parental Locus of Control, Parenting Sense of Competence, Strengths and Difficulties Questionnaire, Parent Engagement in Evidence-Based Services, and behavioral outcomes) and demonstrated good criterion validity and responsiveness. Regarding the engagement manipulation, parents who did not receive the neuroscience explanation self-reported lower interest in learning new parenting skills after watching an informational video compared with parents who did receive a neuroscience explanation. However, there were no significant differences between conditions in behavioral measures of intent to enroll, including the number of mouse clicks, amount of time spent on a page of parenting resources, and requests to receive parenting resources. The effects did not persist at the 1-month follow-up, suggesting that the effects on engagement may be time-limited. CONCLUSIONS: The findings provide preliminary evidence for the utility of theory-driven strategies to enhance initial parental engagement in parent skills training, specifically parental interest in learning new parenting skills. In addition, the study findings demonstrate the good initial psychometric properties of the PRAM, a tool to assess parental intent to enroll, which is an early stage of engagement.

The relationship between stressful life events and the error-related negativity in children and adolescents.

The error-related negativity (ERN) has been cited as a neural marker that indexes risk for anxiety in children and across development. Environmental factors, such as punishment in the lab and parenting styles, have been shown to impact the ERN. However, little is known about how other environmental factors may shape this neural risk marker. The current study examines how the environmental factor of stressful life events may relate to the ERN in children and adolescents. In a sample of 176 females, ages 8-15 years, we examined associations between the frequency of recent stressful life events and the ERN. We also investigated whether interpersonal dependent life events or non-interpersonal life events uniquely relate to the ERN. Finally, we explored whether recent stressors differentially relate to the ERN based on age. Results suggest that youth who have experienced more frequent stressful life events have an increased (i.e., more negative) ERN. Moreover, more frequent interpersonal dependent stressors uniquely predicted the magnitude of the ERN. Lastly, results supported a moderation model wherein the relationship between the frequency of interpersonal dependent stressors and the ERN was moderated by age, such that the relationship between stressors and the ERN was significant only for younger children.

On the relationship between the error-related negativity and anxiety in children and adolescents: From a neural marker to a novel target for intervention.

The current review focuses on our work on the relationship between the error-related negativity (i.e., ERN) and anxiety in children and adolescents. The ERN is an event-related potential (ERP) that appears as a negative deflection in the ERP waveform when individuals make errors and has been found to be increased in anxious individuals. We, and others, have extended this work into developmental populations, finding that the ERN can be measured reliably in children and that the ERN is increased among clinically anxious youth. Furthermore, we have found that the ERN predicts risk for increases in anxiety across development, among healthy and clinically anxious children. We have done work to elucidate what psychological phenomena the increased ERN among anxious children may reflect by creating a self-report measure of error sensitivity (i.e., the Child Error Sensitivity Index) that relates to the ERN. Moreover, we review our work on parenting and the ERN, which suggests that harsh or critical parenting styles may potentiate the ERN in offspring. And, building on these findings, we discuss our recent work to develop novel, computerized intervention strategies to reduce the ERN and thereby risk for anxiety.

Overprotective Parenting Mediates the Relationship Between Early Childhood ADHD and Anxiety Symptoms: Evidence From a Cross-Sectional and Longitudinal Study.

Attention Deficit/Hyperactivity Disorder (ADHD) is often comorbid with anxiety disorders in children. Both ADHD and anxiety in childhood has been linked to overprotective parenting styles. In the current study we examine a model wherein early ADHD symptoms predict overprotective parenting, which in turn predicts anxiety symptoms later in childhood. In Study 1 we utilize cross-sectional data in 102 child/parent dyads between the ages of 5 and 7 years old and Study 2 extends these findings by examining this same mediation model longitudinally in 376 child/parent dyads who were assessed when children were 3, 6, and 9 years old. Results from both studies supported a mediation model wherein the relationship between child ADHD symptoms and child anxiety symptoms was mediated by parental overprotection. This is the first study, to our knowledge, to examine overprotective parenting as a mechanism underlying the heterotypic continuity or sequential comorbidity of ADHD to anxiety symptoms.

Error-related negativity predicts increases in anxiety in a sample of clinically anxious female children and adolescents over 2 years.

BACKGROUND: An increased neural response to making errors has emerged as a biomarker of anxiety. Error negativity (Ne) or errorrelated negativity (ERN) is an event-related potential generated when people commit errors; the Ne/ERN is greater among people with anxiety and predicts increases in anxiety. However, no previous study has examined whether the Ne/ERN can be used as a prognostic indicator among people with current anxiety. The present study addressed this gap by examining whether the Ne/ERN prospectively predicts increases in anxiety symptoms in clinically anxious children and adolescents. METHODS: The sample included 34 female participants between the ages of 8 and 14 years who met the criteria for a clinical anxiety disorder based on clinical interview. The Ne/ERN was measured using a flanker task. RESULTS: Increased Ne/ERN at baseline predicted increases in total anxiety symptoms 2 years later, even when accounting for baseline symptoms. The Ne/ERN predicted increases in the symptom domains of generalized anxiety, social anxiety and harm avoidance/perfectionism, but not panic, separation anxiety, school avoidance or physical symptoms. LIMITATIONS: The sample size was small, which may have inflated the false discovery rate. To mitigate this possibility, we used multiple self-report measures, and the results for the 2 measures (as well as their symptom domains) converged. CONCLUSION: These data suggest that the Ne/ERN can delineate specific risk trajectories, even among those who already meet the criteria for a clinical anxiety disorder. Considering the need for prognostic markers among people with clinical anxiety, the current findings are an important and novel extension of previous work.

COVID-related fear maintains controlling parenting behaviors during the pandemic.

The direct threat posed by the 2019 novel coronavirus (COVID-19), uncertainty surrounding best safety practices, and secondary consequences of the virus have led to widespread stress and declining mental health across communities and individuals. These stresses may impact parenting behaviors, potentially leading to negative consequences for children. Controlling parenting behaviors increase in the face of perceived environmental threat and are associated with adverse mental health outcomes for children; however, determinants of parenting behaviors have not been investigated during the COVID-19 pandemic. The current study prospectively evaluated parenting behaviors during the pandemic (N=87). Results indicated that all negative affect emotions investigated were positively associated with controlling parenting behaviors. However, only COVID-related fear predicted changes in controlling parenting behaviors across timepoints. Specifically, although controlling parenting behaviors decreased in the overall sample from time 1 to time 2, higher COVID-related fear scores at time 1 predicted maintenance of high levels of controlling parenting behaviors at time 2. Additionally, this effect was specific to controlling, as opposed to more adaptive, parenting behaviors. Future studies should investigate the association between parents' COVID-related fear, controlling parenting behaviors, and adverse mental health outcomes for children in the context of the COVID-19 pandemic.

Psychometric properties of threat-related attentional bias in young children using eye-tracking.

Anxiety is one of the most common forms of child psychopathology associated with persistent impairment across the lifespan. Therefore, investigating mechanisms that underlie anxiety in early childhood may improve prevention and intervention efforts. Researchers have linked selective attention toward threat (i.e., attentional bias to threat) with the development of anxiety. However, previous work on attentional bias has used less reliable, reaction time (RT)-based measures of attention. Additionally, few studies have used eye-tracking to measure attentional bias in young children. In the present study, we investigated the psychometric properties of an eye-tracking measure of attentional bias in a sample of young children between 6- and 9-years-old and explored if trait and clinical anxiety were related to attentional biases to threat. Results showed good psychometric properties for threat and neutral attentional biases, comparable to those found in adult eye-tracking studies. Temperamental and clinical anxiety did not significantly relate to threat/neutral dwell time and attentional biases. The significance of these null findings was discussed in relation to existing developmental theories of attentional biases. Future studies should explore if temperamental or clinical anxiety prospectively predict threat attentional bias and the onset of anxiety in older children using a longitudinal design.

Aberrant attentional bias to sad faces in depression and the role of stressful life events: Evidence from an eye-tracking paradigm.

Attentional biases are thought to be involved in the etiopathogenesis of depressive disorders. Recent studies indicate eye-tracking techniques could overcome methodological issues of traditional reaction time bias measures and be used to reliably quantify biases in attention. In the current study, 50 participants with a current depressive disorder and 31 never-depressed individuals performed a free-viewing eye-tracking paradigm with two counterbalanced blocks; one contained four-by-four arrays of happy and neutral faces, the other arrays of sad and neutral faces. Average dwell-times were analyzed, and internal consistency was examined. Dwell-time measures had good to excellent internal consistency. Both groups were characterized by increased dwell-time to happy compared to neutral faces (i.e., bias toward positive faces). Never-depressed participants showed a bias away from sad stimuli (i.e., increased dwell-time to neutral compared to sad faces), that was not evident in the depressed group. Moreover, depressed individuals dwelled longer on sad stimuli than never-depressed participants. Within depressed participants, bias to sad faces was associated with both childhood trauma and recent negative life events. Results demonstrate that an attentional bias towards sad faces in depression can be reliably assessed using free-viewing eye-tracking technique and its magnitude is exacerbated by the experience of stressful life events.

The association between parenting and the error-related negativity across childhood and adolescence.

Anxiety is the most common form of psychopathology, and it is often characterized by chronic impairment across the lifespan. Researchers have identified core neural markers that confer risk for anxious outcomes. An increased error-related negativity (ERN) in anxious individuals has been shown to prospectively predict onset of anxiety disorders across development. Hence, it is critical to examine environmental factors that may shape the ERN. In the current study, we use a large sample of 170 female adolescents aged 10-17 to investigate whether the ERN mediates the relationship between parenting style and anxiety diagnostic status. This study replicates previous findings, and it extends previous work by suggesting that this relationship is more robust in young children as compared to adolescents. Interventions targeting the ERN via parenting may be most effective during childhood.

Increased dehydroepiandrosterone (DHEA) is associated with anxiety in adolescent girls.

The pubertal period is a time of rapid increase in the incidence of anxiety disorders, and thus, pubertal hormones may play a role in the precipitation of anxious psychopathology. DHEA, a steroid hormone that surges in adolescence, has been previously linked to anxiety, although the direction of this effect has been mixed. Using a cross-sectional design in a sample of 286 adolescent girls, the present study examined associations between salivary DHEA concentrations and self-report and interview-based measures of anxiety while controlling for pubertal status, menarche status, assessment time of day, and other hormones including testosterone, estradiol, and progesterone. Increased salivary DHEA concentrations were associated with more self-reported anxiety symptoms, increased anxiety symptom counts based on clinical interview, and increased probability of an anxiety disorder. Out of all anxiety symptom domains examined, generalized anxiety disorder symptoms were the best predictor of salivary DHEA concentrations after controlling for pubertal development. Collectively, our findings suggest relevance for DHEA in the development of anxiety in the pubertal period, as well as a robust relationship between DHEA and emerging symptoms of pathological worry during adolescence. The present study underscores the importance of examining associations between DHEA concentrations and anxiety in longitudinal designs.

Parental Presence Impacts a Neural Correlate of Anxiety (the Late Positive Potential) in 5-7 Year Old Children: Interactions with Parental Sensitivity to Child Anxiety.

Anxiety disorders tend to onset early in development and often result in chronic impairment across the lifespan. Thus, there is substantial interest in identifying early neural markers of anxiety and leveraging these markers to better understand processes leading to anxiety. The late positive potential (i.e., LPP) indexes sustained attention to motivationally relevant stimuli; and the LPP to negative images is increased in individuals with anxiety. In the current study, we examined how parental presence impacts the LPP to threatening images in children (52.6% male) between 5 and 7 years-old (N = 78). Moreover, we explored interactions with parental sensitivity to child anxiety symptoms. Results suggest that when children are in the presence of their parent (compared to the presence of an experimenter), they displayed a larger LPP to threatening images. LPP activity was modulated by parental response to their child's anxiety symptoms, such that children with parents who were overly reactive to their children's anxiety symptoms had the greatest LPP response when viewing threatening stimuli in their parent's presence. Additionally, exploratory analyses indicated that children with clinical and subclinical anxiety were characterized by an increased LPP to negative images, but only when the LPP was measured with parents in the room. Findings are novel and extend previous work by suggesting that parents who react strongly when observing their children's anxiety symptoms in turn increase their child's engagement with threatening stimuli, thereby placing them at greater risk for anxiety.