Hostile and threatening interpretation biases in adolescent inpatients are specific to callous-unemotional traits and social anxiety

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Dapprich, Laura M. Derks, Martin Holtmann, Wolf-Gero Lange, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2507495/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 May, 2023 Read the published version in European Child & Adolescent Psychiatry → Version 1 posted 7 You are reading this latest preprint version Abstract Psychopathological syndromes, such as disruptive behavior and anxiety disorders in adolescence, are characterized by distorted cognitions and problematic behavior. Biased interpretations of ambiguous social situations can elicit both aggressive and avoidance behavior. Yet, it is not well understood whether different interpretation biases are specific to different syndromes, or whether they can co-occur. We assessed both hostile and threatening interpretation biases in identical social situations, and proposed that they are uniquely related to callous-unemotional (CU) traits and social anxiety, respectively. We also explored the role of gender and age herein. The sample consisted of 390 inpatients between 10 to 18 years of age with a variety of psychiatric disorders. Hostile and threatening interpretations were assessed with the Ambiguous Social Scenario Task (ASST) consisting of 10 written vignettes. Both CU-traits and social anxiety were assessed with self-report questionnaires. Results showed that, overall, CU-traits were related to more hostile interpretations, whereas social anxiety was related to more threatening interpretations. In addition, in boys, hostile and threatening interpretations correlated significantly positive with each other. Age was not related to interpretation biases. Together, these results generally support the content-specificity of interpretation biases in concepts relevant to disruptive behavior disorders and anxiety disorders, and indicate that different interpretation biases can co-occur specifically in boys. cognitive distortions adolescence social information processing internalizing disorders externalizing disorders Figures Figure 1 Introduction A wealth of theories and research have shown that distorted interpretations of social situations have a causal and maintaining role in both disruptive behavior disorders and anxiety disorders [ 1 ]–[ 5 ]. The core symptom of disruptive behavior disorders, such as oppositional defiant and conduct disorder, is aggressive behavior, which has been associated with the tendency to interpret ambiguous social situations as hostile, i.e. hostile interpretation bias [ 6 ]–[ 9 ]. Anxiety disorders have been associated with the tendency to interpret ambiguous situations as threatening, i.e. threatening interpretation bias [ 10 ], [ 11 ]. However, some studies found that aggressive children also showed threatening interpretation bias, and that anxious children also showed hostile interpretation bias [ 11 ]–[ 13 ]. Albeit counterintuitive, aggression and anxiety are closely related to each other; they are both part of the interwoven fight-or-flight system and they can reinforce each other [ 14 ]–[ 17 ]. Yet, hostile and threatening interpretation biases are usually assessed with separate, unrelated tasks. Research that studied different interpretation biases together in the same situation, and in relation to both disruptive behavior and anxiety disorders is scarce. Therefore, it is unclear whether interpretation biases are specific to distinct syndromes, or whether they can co-occur [ 13 ], [ 18 ]–[ 21 ]. In the current study, we assessed both hostile and threatening interpretation biases of identical social situations, and examined whether they are uniquely linked to callous-unemotional (CU) traits and social anxiety, respectively, in inpatients of children and adolescents with a variety of psychiatric disorders. CU-traits and social anxiety are clinically and developmentally relevant concepts in disruptive behavior and anxiety disorders, respectively. CU-traits are characterized by shallow affect, disregard for others and indifference towards performance in school and relationships. Children and adolescents with both elevated levels of CU-traits and disruptive behavior disorders are at highest risk for severe behavioral problems, treatment resistance, as well as antisocial personality disorder and psychopathy in adulthood [ 22 ]–[ 24 ]. Social anxiety is characterized by elevated fear of social evaluation [ 25 ]. It usually develops in early adolescence and, if left untreated, increases the risk on chronic anxiety and mood disorders later in life [ 26 ], [ 27 ]. On the behavioral level, CU-traits are strongly related to aggression and social anxiety is strongly related to avoidance. However, social anxiety has also been related to reactive aggression described as impulsive reactions to perceived threat [ 15 ]. CU-traits, in turn, are rather related to instrumental aggression described as deliberate acts to reach a certain goal [ 1 ], [ 28 ], [ 29 ]. CU-traits have also been related to avoidance, such as truancy [ 30 ], [ 31 ]. Thus, the behavioral outcomes of social anxiety and CU-traits can be very similar, but the underlying processes leading to aggression or avoidance are likely to differ. For instance, CU-traits are associated with hypoactive physiological responding to threat [ 32 ], while social anxiety is associated with hyperactive physiological responding to threat [ 33 ]. The interpretation of threat could provide more information about the cognitive processes contributing to aggression and avoidance in CU-traits and social anxiety. Previous research on the relationship between CU-traits and interpretation biases is inconclusive. A common way to investigate interpretation biases in children and adolescents are written vignettes describing ambiguous situations [ 34 ]. In a clinical sample of children with disruptive behavior disorders, no link between CU-traits and hostile interpretation bias of ambiguous situations was found [ 35 ]. In college students, CU-traits were related to stronger hostile interpretations [ 36 ]. Surprisingly, CU-traits have also been related to more threatening interpretation bias of social situations in delinquent adolescents [ 37 ]. Thus, there is some support for a link between CU-traits and interpretation biases. An investigation of different interpretation biases together might provide more clarity. Interpretation biases in childhood anxiety have been well-examined. According to the content-specificity hypothesis [ 38 ], the strength of interpretation biases increases when the described scenario matches a particular fear [ 20 ], [ 21 ]. For example, in a clinical sample of children with different anxiety disorders, children with higher levels of separation anxiety rated separation scenarios as the most threatening, whereas children with higher levels of social anxiety rated ambiguous social scenarios as the most threatening [ 39 ]. By using written vignettes, it has been well-established that these threatening interpretation biases of social situations increase, as the severity of social anxiety increases in both clinical and community samples [ 40 ]–[ 42 ], for conflicting results see [ 43 ]. Yet, it is unclear whether the content-specificity hypothesis holds true when comparing different interpretation biases of the same situations across concepts relevant to disruptive behavior and anxiety disorders. The current study investigated whether hostile and threatening interpretation biases of the same social situations are uniquely related to CU-traits and social anxiety, respectively, in inpatients of children and adolescents with different psychiatric disorders. By better understanding the cognitive processes accompanying disruptive behavior and anxiety in childhood, current prevention and intervention paradigms of childhood psychopathology could be improved. Based on some previous findings [ 36 ] and the content-specificity hypothesis [ 38 ], we expected that CU-traits and social anxiety are distinctly related to hostile and threatening interpretation biases, respectively. Hostile and threatening interpretation biases were assessed with the newly developed Ambiguous Social Scenario Task (ASST), which measures both interpretation biases simultaneously in response to written vignettes of ambiguous social scenarios. This paradigm has previously been validated in college students [ 36 ]. Given that CU-traits decrease with age and are more prevalent in boys [ 44 ], whereas social anxiety increases with age and is more prevalent in girls [ 21 ], [ 41 ], [ 43 ], we controlled for age and gender differences when analyzing the link between CU-traits, social anxiety and biases. Methods Participants Four-hundred-and-one inpatients of the LWL-University Hospital Hamm in Germany participated. Patients who were older than 18 years of age ( n = 3) or had a diagnosis of the schizophrenia spectrum and other psychotic disorders ( n = 8) were excluded. The final sample consisted of 390 inpatients (248 girls) between 10 to 18 years of age (M = 14.6 years, SD = 1.9). The most common primary diagnosis was Major Depressive Disorder (n = 174). The majority of the sample was diagnosed with comorbid disorders (n = 248). See Table 1 for the sample characteristics. Table 1 Sample characteristics Variable Final sample (N = 390) Age M (SD) 14.6 (1.9) Female n (%) 248 (64) No. of diagnoses M (SD) 2.24 (0.1) Primary diagnosis n (%) Major Depressive Disorder (F32.-, F33.-) 174 (44.3) Mixed Disorder of Conduct and Emotion (F92.-) 93 (23.7) Substance Abuse Disorder (F10.2, F11.2, F12.2, F15.2) 52 (13.2) Comorbidities n (%) 248 (63.1) No. of comorbidities M (SD) 1.24 (0.1) Note. Diagnoses are based on the International Classification of Disease 10th revision (ICD-10). Measurements Ambiguous Social Scenario Task – youth version (ASST - youth version; adapted from [ 36 ]) The ASST - youth version measures hostile, threatening and neutral interpretations in social situations. It contains 10 social scenarios, each with a hostile, a threatening and a neutral interpretation. Participants have to indicate for each situation how likely each of the three interpretations would come to their mind on a visual analogue scale from 0% (“very unlikely”) to 100% (“very likely”). Thus, all interpretations could be rated as very likely for the same scenario. An example situation is “You are asked something by the teacher in class. The teacher interrupts you in the middle of your answer.”. The answer options state 1) “Probably she found my answer boring.” (threatening interpretation), 2) “Stupid teacher!” (hostile interpretation) and 3) “Apparently, I told her everything she wanted to hear.” (neutral interpretation). The whole task can be found in the supplementary material (SI 1). For the analyses, separate mean scores for threatening, hostile and neutral interpretations were used. A validation study in students showed good convergent and discriminant validity for both threatening and hostile interpretations [ 36 ]. In the current study, the internal consistencies ranged from acceptable for the neutral ( α = .69) and hostile interpretations ( α = .77) to good for the threatening subscale ( α = .84). Spence Childrens Anxiety Scale (SCAS-D; Spence, 1998) The SCAS-D measures self-reported levels of anxiety based on six different subscales, i.e. social phobia, panic disorder, agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, separation anxiety disorder, and specific phobias. It consists of 38 items, which are rated on a 4-point Likert scale ranging from 0 ("never") to 3 ("always"). Previous research supported the 6-factor structure of the SCAS-D in terms of excellent validity and internal consistency [ 46 ]. For the present study, only the social anxiety scale was used consisting of 6 items (e.g., “I worry what other people think of me”). Its internal consistency was high in our sample ( α = .86). Inventory of Callous-Unemotional Traits (ICU; Frick, 2004) The ICU measures callous-unemotional (CU) traits. It consists of 24 items and is rated on a 4-point Likert scale ranging from 0 ("not at all true") to 3 ("definitely true"). Three factors of good psychometric properties can be distinguished, which are called Callousness, Uncaring and Unemotional (Essau et al., 2006; Kimonis et al., 2013). Example items are “I do not care if I get into trouble” and “I do not show my emotions to others”. For the current study, the total sore was used, which had an acceptable internal consistency ( α = .76). Procedure Patients who were admitted to the clinic within a pre-defined period of 6 months filled in a range of questionnaires as part of the diagnostic intake routine. Here, only the questionnaires that are relevant for the current purposes are described. The use of the data for the current study was approved by the local medical-ethical committee (No.: 4359-12). The whole procedure took about 1 hour. Participation was not rewarded. Statistical Approach The main research question, whether self-reported social anxiety and CU-traits were uniquely related to threatening and hostile interpretations, respectively, was examined with Pearson correlation coefficients, as well as multivariate multiple regression and univariate multiple regression analyses (complete cases only, n = 386). Multivariate regression controls for inflated Type I error of several univariate regressions, and takes into account that outcomes and predictors are interrelated. Univariate regressions are necessary to interpret the results for each outcome separately. Significant effects were followed-up with Welch’s robust two sample t-tests, plots and simple slope analyses. Data was prepared and analyzed using R (version 4.0.3; [ 50 ]) and RStudio (version 2022.07.1; [ 51 ]). The correlation coefficients were computed by using the function corr.test of the package psych (version 2.2.9; [ 52 ]). Holm adjustment was used to control for multiple testing. Multivariate multiple hierarchical regression analyses with both hostile and threatening interpretations as outcome were conducted by using the function lm of the stats package (version 4.0.3; [ 50 ]). In the first step, age and gender were entered as predictors (i.e. basic model). In the second step, main effects for both CU-traits and social anxiety, as well as their respective interactions with both age and gender were added (i.e. full model). The continuous predictors were standardized. The function anova of the psych package was used to compare the fit of the basic and full model (version 2.2.9; [ 52 ]). The functions Manova and summary were used to interpret the results of both multivariate and univariate regression analyses. Follow-up t-tests were computed by using the function t.test of the stats package (version 4.0.3; [ 50 ]). Significant interaction effects were plotted with the function ggplot of the package ggplot (version 3.3.6; [ 53 ]) and simple slopes were computed by using the function sim_slopes of the package interactions (version 1.1. 5; [ 54 ]). Transparency Statement The current project has been pre-registered on osf.io ( https://osf.io/7zxyf and https://osf.io/y532q?view_only=8f97db4aff3e4381aa9cda79423cd9cb ). Note that deviations from the first pre-registration are specified in the second pre-registration. Most importantly, we originally planned to not only study self-reported CU-traits and social anxiety, but also diagnoses of disruptive behavior disorders and social anxiety disorder. However, the number of patients that received social anxiety disorder as a main diagnosis was small (n = 7). Since analyses with this group size wouldn’t yield meaningful results, we focused on self-reported CU-traits and social anxiety only. Results Relationships between CU-traits, social anxiety, and interpretation biases Children with higher levels of CU-traits were more likely to interpret ambiguous situations as hostile, whereas children with higher levels of social anxiety were more likely to interpret the very same situations as threatening. CU-traits correlated significantly positive with hostile interpretations ( r = .38, p < .001), and social anxiety correlated significantly positive with threatening interpretations ( r = .68, p < .001). Furthermore, CU-traits correlated significantly negative with both threatening interpretations ( r = − .14, p = .04) and social anxiety ( r = − .19, p = .001). Multivariate Multiple Hierarchical Regression Analysis For Both Interpretation Biases The full model including age, gender, CU-traits and social anxiety improved the model fit of the basic model including only age and gender significantly, Pillai’s trace ( V ) = .52, F (16, 750) = 16.34, p < .001. Significant main effects for gender V = .04, F (2, 374) = 7.71, p < .001, CU-traits, V = .12, F (2, 374) = 24.32, p < .001, and social anxiety, V = .32, F (2, 374) = 86.95, p < .001, were found. Furthermore, an interaction between gender and social anxiety was found, V = .02, F (2, 374) = 3.34, p = .02. Next, univariate regression analyses with only hostile and threatening interpretations as outcomes were inspected to interpret the effects. Univariate Regression Analysis For Threatening Interpretation Bias Only The model for threatening interpretations was significant F (11, 375) = 32.74, p < .001 and the predictors explained 47.49% of the variance, 95% bootstrapped Confidence Interval (CI) [41.80, 54.29]. A significant main effect for social anxiety on threatening interpretations was found ( β = 0.62, p < .001) indicating that threatening interpretations increased as a function of self-reported social anxiety for both genders. Furthermore, a significant main effect of gender on threatening interpretations was found ( β = -0.13, p = .007). T-tests indicated that threatening interpretations were significantly higher in girls than in boys, t (310.18) = -9.17, p < .001, Cohen’s d = -. 96. See Table 2 for the descriptive statistics per gender. Univariate Regression Analysis For Hostile Interpretation Bias Only The model for hostile interpretations was significant, F (11, 375) = 6.62, p < .001 and the predictors explained 13.8% of the variance, 95% bootstrapped CI [9.82, 22.34]. A significant main effect for CU-traits on hostile interpretations was found ( β = 0.35, p < .001) indicating that hostile interpretations increased significantly as a function of CU-traits. Furthermore, a significant main effect for gender on hostile interpretations was found ( β = 0.15, p = .02). T-tests indicated that hostile interpretations were significantly higher in boys than in girls, t (306.62) = 3.66, p < .001, Cohen’s d =. 38. See Table 2 . Table 2 Descriptive statistics and gender differences of all measurements for the final sample (N = 390) Boys Girls n M (SD) Range n M (SD) Range p Cohen’s d Callous-unemotional traits 142 28 (9) 9–49 247 24 (8) 8–51 < .001 0.50 Social anxiety 141 6 (4) 0–18 246 11 (5) 0–18 < .001 1.18 Hostile interpretation bias 142 35 (16) 2–75 248 29 (17) 0–90 < .001 0.38 Threatening interpretation bias 142 39 (19) 0–86 248 58 (20) 3–99 < .001 0.96 Neutral interpretations 142 40 (16) 1–82 248 33 (14) 2–72 < .001 0.47 Note. Gender differences were tested with Welch’s t-test. A significant interaction for social anxiety and gender on hostile interpretations was found ( β = 0.13, p = .04). A plot showed that with increasing levels of social anxiety, hostile interpretations were more likely in boys, but less likely in girls (see Fig. 1). However, neither simple slopes nor correlations for boys and girls separately were significant. This indicates that differences in social anxiety between boys and girls were, after all, not related to hostile interpretations ( p’s > .05). Exploration Of Gender Differences The significant effects of gender on both hostile and threatening interpretations led us to further explore its role for the variables of interest. As shown in Table 2 , all measurements differed significantly for girls and boys. Furthermore, Pearson’s correlations for girls and boys separately showed that the correlations between CU-traits and hostile interpretations ( r = .34 for girls and r = .36 for boys), as well as between social anxiety and threatening interpretations (r = .66 for girls and r = .50 for boys) were still significant and positive (all p’s .05). Interestingly, threatening and hostile interpretations correlated significantly positive in boys ( r = .36, p .05). See Table 3 for the correlation matrix per gender. Table 3 Correlation matrix between all measurements per gender 1. 2. 3. 4. 5. 1. Callous-unemotional traits - -.09 .34*** -.08 -.20* 2. Social anxiety -.11 - -.08 .66*** -.21** 3. Hostile interpretation bias .36*** 0.11 - -.01 .21** 4. Threatening interpretation bias .01 .50*** .36*** - -.14 5. Neutral interpretations -.06 .06 .10 0.15 - Note. Values above diagonal depict correlations for girls, values below the diagonal depict values for boys. *** p < .001 ** p < .01 * p < .05 Discussion The current study investigated whether hostile and threatening interpretation biases are specific to callous-unemotional (CU) traits and social anxiety, respectively, in adolescent inpatients with a variety of different psychiatric disorders. Our results suggest that CU-traits are uniquely related to hostile interpretation bias, and that social anxiety is uniquely related to threatening interpretation bias. Although, boys who showed more hostile interpretation bias, also used more threatening interpretation bias. In line with the content-specificity hypotheses, CU-traits and social anxiety were related to distinct interpretation biases of the same situations. Adolescent inpatients who reported more callousness were more likely to interpret social situations as hostile, whereas adolescent inpatients who reported more fear of social evaluation were more likely to interpret the same situations as threatening. This is particularly important as research has shown that different interpretations of social cues might underlie different behavioral outcomes, such as aggression and avoidance [ 1 ]–[ 3 ], [ 5 ]. Thus, CU-traits and social anxiety might be characterized by a distinct cognitive processing of threat, which might steer different behavioral problems. The manifestation of interpretation biases differed across boys and girls. First, both CU-traits and hostile interpretation bias were higher in boys, and social anxiety and threatening interpretation bias were higher in girls. This is in line with the common finding that boys show more disruptive behavior [ 8 ], [ 44 ], [ 55 ], and that girls more often have (social) anxiety disorders [ 56 ] [ 41 ]. Second, boys showed more hostile interpretation bias with increasing levels of social anxiety, while girls showed less. This is in line with research showing that the link between anxiety and aggression is more pronounced in boys [ 17 ]. However, this effect diminished at gender-specific post-hoc analyses. Finally, boys who showed more hostile interpretation bias, also showed more threatening interpretation bias, while girls did not. Previous research has also found hostile and threatening thoughts to co-occur, but did not examine gender differences [ 57 ], [ 58 ]. This suggests that hostile and threatening interpretation biases can co-occur in boys independent of CU-traits and social anxiety. Ambiguous events might activate a general negative schema [ 59 ]. Stronger biases might then be a sign of a higher general psychopathological symptom level. In contrast to most previous research, we did not find an effect of age on interpretation biases [ 21 ], [ 44 ]. A possible explanation for the absence of a linear effect might be that interpretation biases follow a curvilinear course across age, as do both social anxiety and CU-traits. To be precise, a peak in social anxiety and CU-traits has been suggested as a normative part of puberty [ 49 ], [ 60 ], [ 61 ]. Indeed, the age range of our sample (10 to 18 years of age) covered different developmental stages from childhood to late adolescence. Longitudinal research is needed to determine the developmental course of interpretation biases across age. The current study comes with several strengths and limitations. A strength is the large clinical sample, which allowed us to investigate clinically relevant concepts across diagnostic categories in a well-powered study. Furthermore, we replicated and extended a previous validation study of the Ambiguous Social Scenario Task (ASST) in college students [ 36 ]. That is, we again found good psychometric properties of the ASST, as well as the expected relationships between hostile and threatening interpretation biases and clinically relevant concepts for disruptive behavior and anxiety. However, due to too little group sizes, we could not examine the roles of psychiatric disorders in interpretation biases. The inclusion of diagnostic categories might have increased the relatively low explained variance of the model on hostile interpretation biases in the current study. By examining different interpretation biases in relation to different psychiatric disorders, we would better understand whether interpretation biases are disorder-specific or transdiagnostic mechanisms [ 18 ]. Furthermore, future research should study the link between interpretation biases and actual social behavior to gain a more complete picture of the steps involved in social information processing and its consequences for behavior. The current study represents a first step examining different interpretation biases together in relation to psychiatric concepts relevant to disruptive behavior disorders and anxiety disorders in childhood and adolescence. A combined investigation of distinct interpretation biases in a clinical sample with a multitude of diagnoses is crucial to disentangle underlying mechanisms of distinct problematic behavior, as well as to identify transdiagnostic characteristics of psychological disorders. The current results suggest that interpretation biases can be differentiated in terms of callous versus anxious cognitive processing of social threat, and that gender might be an important factor to take into account. On the long-term, this knowledge might help to develop (gender) tailored interventions focusing on the modification of interpretation bias to improve treatment outcomes for callous and anxious youth. Declarations Funding. No funding was received for conducting this study. Conflicts of interest. The authors have no competing interests to declare. Author contribution. All authors contributed to the study conception and design. Data collection was supervised by L.D. and T.L. Data analysis was conducted by A.D. The first draft of the manuscript was written by A.D. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Availability of data and material: The anonymized data can be requested from the first author upon reasonable request. Part of the material is included in the supplementary material. Code availability. The used software is referenced in text. Ethics approval. This study was performed in line with the principles of the Declaration of Helsinki. Approval of using the data for the current study was granted by the local medical-ethical committee of the LWL-University Hospital Hamm (No.: 4359-12). Informed consent. Informed consent was obtained from legal guardians. Verbal informed consent was obtained from the participants before the start of the study. Consent for publication. Consent for publication was obtained. Acknowledgements. We thank all participants who participated, as well as the LWL-University Hospital Hamm for providing the data. Special thanks go to Luisa Lüken, who prepared the data for our study. References N. R. Crick and K. A. Dodge, “Social Information-Processing Mechanisms in Reactive and Proactive Aggression,” Child Dev. , vol. 67, no. 3, pp. 993–1002, Jun. 1996. N. R. Crick and K. A. 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Ollendick, “Psychometric properties of the Spence Child Anxiety Scale with adolescents from five European countries,” J. Anxiety Disord. , vol. 25, no. 1, pp. 19–27, Jan. 2011. P. J. Frick, “Inventory of Callous-Unemotional Traits,” 2004. E. R. Kimonis, J. Branch, B. Hagman, N. Graham, and C. Miller, “The psychometric properties of the Inventory of Callous–Unemotional Traits in an undergraduate sample,” Psychol. Assess. , vol. 25, no. 1, pp. 84–93, 2013. C. A. Essau, S. Sasagawa, and P. J. Frick, “Callous-unemotional traits in a community sample of adolescents,” Assessment , vol. 13, no. 4, pp. 454–469, 2006. R Core Team, “R: A language and environment for statistical computing.” R Organisation for Statistical Computing, Vienna, Austria, 2022. RStudio Team, “RStudio: Integrated Development Environment for R.” RStudio, Inc., Boston, MA, 2022. W. Revelle, “psych: Procedures for personality and psychological research.” Northwestern University, Evanston, Illinois, 2020. H. 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Psychol. , vol. 113, no. 3, pp. 464–470, 2004. A. T. Beck and E. A. P. Haigh, “Advances in cognitive theory and therapy: The generic cognitive model,” Annu. Rev. Clin. Psychol. , vol. 10, pp. 1–24, 2014. K. Beesdo-Baum et al. , “The natural course of social anxiety disorder among adolescents and young adults,” Acta Psychiatr. Scand. , vol. 126, no. 6, pp. 411–425, Dec. 2012. A. L. Dapprich, A. Tyborowska, H. C. M. Niermann, E. S. Becker, A. H. N. Cillessen, and K. Roelofs, “Behavioral inhibition as an early life predictor of callous-unemotional traits,” Int. J. Behav. Dev. , vol. 46, no. 4, pp. 333–345, Jul. 2022. Additional Declarations No competing interests reported. Supplementary Files msASSTclinicalsample180122SI.docx Cite Share Download PDF Status: Published Journal Publication published 31 May, 2023 Read the published version in European Child & Adolescent Psychiatry → Version 1 posted Editorial decision: Major revision 20 Mar, 2023 Reviews received at journal 28 Feb, 2023 Reviewers agreed at journal 13 Feb, 2023 Reviewers invited by journal 13 Feb, 2023 Editor assigned by journal 24 Jan, 2023 Submission checks completed at journal 24 Jan, 2023 First submitted to journal 23 Jan, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Dapprich","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYNACNhDB2MDMUAFiMDeQouUMhEGsFqDxjG1EaOGf3XvwA0OZXZ659OHGz4Xz7iU2SDfi1yJx51yyBMO55GLLvsRm6ZnbihMbZA4ScNiNHAMJxjbmxA1ngCTvtoTEBolE/Frkb+QY/2Bsq4dqmUOEFoMbOWZAWw5DtTQQocUQqMUi4dzxYssexmZpnmMJxm2EtMgBHXbjQ1l1njkP+8PPPDUJsv0SyQfwagGDBCAygHHYCKuH6jIgrGYUjIJRMApGKgAAJntE5qDfz1YAAAAASUVORK5CYII=","orcid":"","institution":"Radboud University Behavioural Science Institute","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Anna","middleName":"L.","lastName":"Dapprich","suffix":""},{"id":170249852,"identity":"ae070a43-d5a2-45e9-82e5-fcc3d995a897","order_by":1,"name":"Laura M. Derks","email":"","orcid":"","institution":"LWL-Universitätsklinik Hamm","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Laura","middleName":"M.","lastName":"Derks","suffix":""},{"id":170249853,"identity":"3de6defd-0e07-46f4-a61d-08d5cfd74f12","order_by":2,"name":"Martin Holtmann","email":"","orcid":"","institution":"LWL-Universitätsklinik Hamm","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Holtmann","suffix":""},{"id":170249854,"identity":"69a06301-eef8-4fb1-bd78-7c5d4677310f","order_by":3,"name":"Wolf-Gero Lange","email":"","orcid":"","institution":"Radboud University Behavioural Science Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wolf-Gero","middleName":"","lastName":"Lange","suffix":""},{"id":170249855,"identity":"3e1681c2-71e2-4e76-9d06-313c6d07b271","order_by":4,"name":"Tanja Legenbauer","email":"","orcid":"","institution":"LWL-Universitätsklinik Hamm","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tanja","middleName":"","lastName":"Legenbauer","suffix":""},{"id":170249856,"identity":"f23a9d8c-22ec-4a40-8378-99631b076147","order_by":5,"name":"Eni S. Becker","email":"","orcid":"","institution":"Radboud University Behavioural Science Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eni","middleName":"S.","lastName":"Becker","suffix":""}],"badges":[],"createdAt":"2023-01-23 15:44:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2507495/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2507495/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00787-023-02227-3","type":"published","date":"2023-05-31T21:01:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":32140541,"identity":"66e55f31-e086-4d70-b7e7-0de3cc05b368","added_by":"auto","created_at":"2023-01-27 22:47:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":113032,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSignificant interaction between social anxiety and gender on hostile interpretation bias (n = 386)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote. \u003c/em\u003eFollow-up analyses showed that the increase and decrease in hostile interpretation bias as a function of social anxiety was not significant for boys and girls, respectively.\u003c/p\u003e","description":"","filename":"Picture1.png","url":"https://assets-eu.researchsquare.com/files/rs-2507495/v1/5e084ae1c03d079b2998ea41.png"},{"id":44735442,"identity":"33d0c04b-0cb2-4661-b680-9a3a1ec12029","added_by":"auto","created_at":"2023-10-16 22:25:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":541354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2507495/v1/8553d7be-aa2e-4b99-8545-a1466f210a53.pdf"},{"id":32140542,"identity":"7bd3bdc4-9ada-46a2-9f16-cd9dbeaaf84b","added_by":"auto","created_at":"2023-01-27 22:47:36","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":49096,"visible":true,"origin":"","legend":"","description":"","filename":"msASSTclinicalsample180122SI.docx","url":"https://assets-eu.researchsquare.com/files/rs-2507495/v1/5771553dc19bd0253b5e167f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hostile and threatening interpretation biases in adolescent inpatients are specific to callous-unemotional traits and social anxiety","fulltext":[{"header":"Introduction","content":"\u003cp\u003eA wealth of theories and research have shown that distorted interpretations of social situations have a causal and maintaining role in both disruptive behavior disorders and anxiety disorders [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The core symptom of disruptive behavior disorders, such as oppositional defiant and conduct disorder, is aggressive behavior, which has been associated with the tendency to interpret ambiguous social situations as hostile, i.e. \u003cem\u003ehostile interpretation bias\u003c/em\u003e [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Anxiety disorders have been associated with the tendency to interpret ambiguous situations as threatening, i.e. \u003cem\u003ethreatening interpretation bias\u003c/em\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, some studies found that aggressive children also showed threatening interpretation bias, and that anxious children also showed hostile interpretation bias [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Albeit counterintuitive, aggression and anxiety are closely related to each other; they are both part of the interwoven fight-or-flight system and they can reinforce each other [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Yet, hostile and threatening interpretation biases are usually assessed with separate, unrelated tasks. Research that studied different interpretation biases together in the same situation, and in relation to both disruptive behavior and anxiety disorders is scarce. Therefore, it is unclear whether interpretation biases are specific to distinct syndromes, or whether they can co-occur [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In the current study, we assessed both hostile and threatening interpretation biases of identical social situations, and examined whether they are uniquely linked to callous-unemotional (CU) traits and social anxiety, respectively, in inpatients of children and adolescents with a variety of psychiatric disorders.\u003c/p\u003e \u003cp\u003eCU-traits and social anxiety are clinically and developmentally relevant concepts in disruptive behavior and anxiety disorders, respectively. CU-traits are characterized by shallow affect, disregard for others and indifference towards performance in school and relationships. Children and adolescents with both elevated levels of CU-traits and disruptive behavior disorders are at highest risk for severe behavioral problems, treatment resistance, as well as antisocial personality disorder and psychopathy in adulthood [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Social anxiety is characterized by elevated fear of social evaluation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It usually develops in early adolescence and, if left untreated, increases the risk on chronic anxiety and mood disorders later in life [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. On the behavioral level, CU-traits are strongly related to aggression and social anxiety is strongly related to avoidance. However, social anxiety has also been related to reactive aggression described as impulsive reactions to perceived threat [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. CU-traits, in turn, are rather related to instrumental aggression described as deliberate acts to reach a certain goal [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. CU-traits have also been related to avoidance, such as truancy [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Thus, the behavioral outcomes of social anxiety and CU-traits can be very similar, but the underlying processes leading to aggression or avoidance are likely to differ. For instance, CU-traits are associated with hypoactive physiological responding to threat [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], while social anxiety is associated with hyperactive physiological responding to threat [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The interpretation of threat could provide more information about the cognitive processes contributing to aggression and avoidance in CU-traits and social anxiety.\u003c/p\u003e \u003cp\u003ePrevious research on the relationship between CU-traits and interpretation biases is inconclusive. A common way to investigate interpretation biases in children and adolescents are written vignettes describing ambiguous situations [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In a clinical sample of children with disruptive behavior disorders, no link between CU-traits and hostile interpretation bias of ambiguous situations was found [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In college students, CU-traits were related to stronger hostile interpretations [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Surprisingly, CU-traits have also been related to more threatening interpretation bias of social situations in delinquent adolescents [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Thus, there is some support for a link between CU-traits and interpretation biases. An investigation of different interpretation biases together might provide more clarity.\u003c/p\u003e \u003cp\u003eInterpretation biases in childhood anxiety have been well-examined. According to the \u003cem\u003econtent-specificity hypothesis\u003c/em\u003e [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], the strength of interpretation biases increases when the described scenario matches a particular fear [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. For example, in a clinical sample of children with different anxiety disorders, children with higher levels of separation anxiety rated separation scenarios as the most threatening, whereas children with higher levels of social anxiety rated ambiguous social scenarios as the most threatening [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. By using written vignettes, it has been well-established that these threatening interpretation biases of social situations increase, as the severity of social anxiety increases in both clinical and community samples [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], for conflicting results see [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Yet, it is unclear whether the content-specificity hypothesis holds true when comparing different interpretation biases of the same situations across concepts relevant to disruptive behavior and anxiety disorders.\u003c/p\u003e \u003cp\u003eThe current study investigated whether hostile and threatening interpretation biases of the same social situations are uniquely related to CU-traits and social anxiety, respectively, in inpatients of children and adolescents with different psychiatric disorders. By better understanding the cognitive processes accompanying disruptive behavior and anxiety in childhood, current prevention and intervention paradigms of childhood psychopathology could be improved. Based on some previous findings [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and the content-specificity hypothesis [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], we expected that CU-traits and social anxiety are distinctly related to hostile and threatening interpretation biases, respectively. Hostile and threatening interpretation biases were assessed with the newly developed Ambiguous Social Scenario Task (ASST), which measures both interpretation biases simultaneously in response to written vignettes of ambiguous social scenarios. This paradigm has previously been validated in college students [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Given that CU-traits decrease with age and are more prevalent in boys [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], whereas social anxiety increases with age and is more prevalent in girls [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], we controlled for age and gender differences when analyzing the link between CU-traits, social anxiety and biases.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e Four-hundred-and-one inpatients of the LWL-University Hospital Hamm in Germany participated. Patients who were older than 18 years of age (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3) or had a diagnosis of the schizophrenia spectrum and other psychotic disorders (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8) were excluded. The final sample consisted of 390 inpatients (248 girls) between 10 to 18 years of age (M\u0026thinsp;=\u0026thinsp;14.6 years, SD\u0026thinsp;=\u0026thinsp;1.9). The most common primary diagnosis was Major Depressive Disorder (n\u0026thinsp;=\u0026thinsp;174). The majority of the sample was diagnosed with comorbid disorders (n\u0026thinsp;=\u0026thinsp;248). See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for the sample characteristics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSample characteristics\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinal sample (N\u0026thinsp;=\u0026thinsp;390)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge \u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248 (64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of diagnoses \u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.24 (0.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary diagnosis \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor Depressive Disorder (F32.-, F33.-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174 (44.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed Disorder of Conduct and Emotion (F92.-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (23.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance Abuse Disorder (F10.2, F11.2, F12.2, F15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248 (63.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of comorbidities \u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.24 (0.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNote.\u003c/em\u003e Diagnoses are based on the International Classification of Disease 10th revision (ICD-10).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAmbiguous Social Scenario Task \u0026ndash; youth version (ASST - youth version; adapted from [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e])\u003c/h2\u003e \u003cp\u003eThe ASST - youth version measures hostile, threatening and neutral interpretations in social situations. It contains 10 social scenarios, each with a hostile, a threatening and a neutral interpretation. Participants have to indicate for each situation how likely each of the three interpretations would come to their mind on a visual analogue scale from 0% (\u0026ldquo;very unlikely\u0026rdquo;) to 100% (\u0026ldquo;very likely\u0026rdquo;). Thus, all interpretations could be rated as very likely for the same scenario. An example situation is \u0026ldquo;You are asked something by the teacher in class. The teacher interrupts you in the middle of your answer.\u0026rdquo;. The answer options state 1) \u0026ldquo;Probably she found my answer boring.\u0026rdquo; (threatening interpretation), 2) \u0026ldquo;Stupid teacher!\u0026rdquo; (hostile interpretation) and 3) \u0026ldquo;Apparently, I told her everything she wanted to hear.\u0026rdquo; (neutral interpretation). The whole task can be found in the supplementary material (SI 1).\u003c/p\u003e \u003cp\u003eFor the analyses, separate mean scores for threatening, hostile and neutral interpretations were used. A validation study in students showed good convergent and discriminant validity for both threatening and hostile interpretations [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In the current study, the internal consistencies ranged from acceptable for the neutral (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.69) and hostile interpretations (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.77) to good for the threatening subscale (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.84).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSpence Childrens Anxiety Scale (SCAS-D; Spence, 1998)\u003c/h2\u003e \u003cp\u003eThe SCAS-D measures self-reported levels of anxiety based on six different subscales, i.e. social phobia, panic disorder, agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, separation anxiety disorder, and specific phobias. It consists of 38 items, which are rated on a 4-point Likert scale ranging from 0 (\"never\") to 3 (\"always\"). Previous research supported the 6-factor structure of the SCAS-D in terms of excellent validity and internal consistency [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. For the present study, only the social anxiety scale was used consisting of 6 items (e.g., \u0026ldquo;I worry what other people think of me\u0026rdquo;). Its internal consistency was high in our sample (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.86).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInventory of Callous-Unemotional Traits (ICU; Frick, 2004)\u003c/h2\u003e \u003cp\u003eThe ICU measures callous-unemotional (CU) traits. It consists of 24 items and is rated on a 4-point Likert scale ranging from 0 (\"not at all true\") to 3 (\"definitely true\"). Three factors of good psychometric properties can be distinguished, which are called Callousness, Uncaring and Unemotional (Essau et al., 2006; Kimonis et al., 2013). Example items are \u0026ldquo;I do not care if I get into trouble\u0026rdquo; and \u0026ldquo;I do not show my emotions to others\u0026rdquo;. For the current study, the total sore was used, which had an acceptable internal consistency (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.76).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003ePatients who were admitted to the clinic within a pre-defined period of 6 months filled in a range of questionnaires as part of the diagnostic intake routine. Here, only the questionnaires that are relevant for the current purposes are described. The use of the data for the current study was approved by the local medical-ethical committee (No.: 4359-12). The whole procedure took about 1 hour. Participation was not rewarded.\u003c/p\u003e\n\u003ch3\u003eStatistical Approach\u003c/h3\u003e\n\u003cp\u003eThe main research question, whether self-reported social anxiety and CU-traits were uniquely related to threatening and hostile interpretations, respectively, was examined with Pearson correlation coefficients, as well as multivariate multiple regression and univariate multiple regression analyses (complete cases only, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;386). Multivariate regression controls for inflated Type I error of several univariate regressions, and takes into account that outcomes and predictors are interrelated. Univariate regressions are necessary to interpret the results for each outcome separately. Significant effects were followed-up with Welch\u0026rsquo;s robust two sample t-tests, plots and simple slope analyses.\u003c/p\u003e \u003cp\u003eData was prepared and analyzed using R (version 4.0.3; [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]) and RStudio (version 2022.07.1; [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]). The correlation coefficients were computed by using the function \u003cem\u003ecorr.test\u003c/em\u003e of the package \u003cem\u003epsych\u003c/em\u003e (version 2.2.9; [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]). Holm adjustment was used to control for multiple testing. Multivariate multiple hierarchical regression analyses with both hostile and threatening interpretations as outcome were conducted by using the function \u003cem\u003elm\u003c/em\u003e of the \u003cem\u003estats\u003c/em\u003e package (version 4.0.3; [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]). In the first step, age and gender were entered as predictors (i.e. basic model). In the second step, main effects for both CU-traits and social anxiety, as well as their respective interactions with both age and gender were added (i.e. full model). The continuous predictors were standardized. The function \u003cem\u003eanova\u003c/em\u003e of the \u003cem\u003epsych\u003c/em\u003e package was used to compare the fit of the basic and full model (version 2.2.9; [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]). The functions \u003cem\u003eManova\u003c/em\u003e and \u003cem\u003esummary\u003c/em\u003e were used to interpret the results of both multivariate and univariate regression analyses. Follow-up t-tests were computed by using the function \u003cem\u003et.test\u003c/em\u003e of the \u003cem\u003estats\u003c/em\u003e package (version 4.0.3; [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]). Significant interaction effects were plotted with the function \u003cem\u003eggplot\u003c/em\u003e of the package \u003cem\u003eggplot\u003c/em\u003e (version 3.3.6; [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]) and simple slopes were computed by using the function \u003cem\u003esim_slopes\u003c/em\u003e of the package \u003cem\u003einteractions\u003c/em\u003e (version 1.1. 5; [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]).\u003c/p\u003e\n\u003ch3\u003eTransparency Statement\u003c/h3\u003e\n\u003cp\u003eThe current project has been pre-registered on osf.io (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/7zxyf\u003c/span\u003e\u003cspan address=\"https://osf.io/7zxyf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e and \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/y532q?view_only=8f97db4aff3e4381aa9cda79423cd9cb\u003c/span\u003e\u003cspan address=\"https://osf.io/y532q?view_only=8f97db4aff3e4381aa9cda79423cd9cb\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Note that deviations from the first pre-registration are specified in the second pre-registration. Most importantly, we originally planned to not only study self-reported CU-traits and social anxiety, but also diagnoses of disruptive behavior disorders and social anxiety disorder. However, the number of patients that received social anxiety disorder as a main diagnosis was small (n\u0026thinsp;=\u0026thinsp;7). Since analyses with this group size wouldn\u0026rsquo;t yield meaningful results, we focused on self-reported CU-traits and social anxiety only.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRelationships between CU-traits, social anxiety, and interpretation biases\u003c/h2\u003e \u003cp\u003eChildren with higher levels of CU-traits were more likely to interpret ambiguous situations as hostile, whereas children with higher levels of social anxiety were more likely to interpret the very same situations as threatening. CU-traits correlated significantly positive with hostile interpretations (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.38, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and social anxiety correlated significantly positive with threatening interpretations (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.68, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Furthermore, CU-traits correlated significantly negative with both threatening interpretations (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.04) and social anxiety (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.19, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMultivariate Multiple Hierarchical Regression Analysis For Both Interpretation Biases\u003c/h3\u003e\n\u003cp\u003eThe full model including age, gender, CU-traits and social anxiety improved the model fit of the basic model including only age and gender significantly, Pillai\u0026rsquo;s trace (\u003cem\u003eV\u003c/em\u003e)\u0026thinsp;=\u0026thinsp;.52, \u003cem\u003eF\u003c/em\u003e(16, 750)\u0026thinsp;=\u0026thinsp;16.34, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Significant main effects for gender \u003cem\u003eV\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.04, \u003cem\u003eF\u003c/em\u003e(2, 374)\u0026thinsp;=\u0026thinsp;7.71, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, CU-traits, \u003cem\u003eV\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.12, \u003cem\u003eF\u003c/em\u003e(2, 374)\u0026thinsp;=\u0026thinsp;24.32, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, and social anxiety, \u003cem\u003eV\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.32, \u003cem\u003eF\u003c/em\u003e(2, 374)\u0026thinsp;=\u0026thinsp;86.95, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, were found. Furthermore, an interaction between gender and social anxiety was found, \u003cem\u003eV\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.02, \u003cem\u003eF\u003c/em\u003e(2, 374)\u0026thinsp;=\u0026thinsp;3.34, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.02. Next, univariate regression analyses with only hostile and threatening interpretations as outcomes were inspected to interpret the effects.\u003c/p\u003e\n\u003ch3\u003eUnivariate Regression Analysis For Threatening Interpretation Bias Only\u003c/h3\u003e\n\u003cp\u003eThe model for threatening interpretations was significant \u003cem\u003eF\u003c/em\u003e(11, 375)\u0026thinsp;=\u0026thinsp;32.74, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001 and the predictors explained 47.49% of the variance, 95% bootstrapped Confidence Interval (CI) [41.80, 54.29]. A significant main effect for social anxiety on threatening interpretations was found (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.62, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) indicating that threatening interpretations increased as a function of self-reported social anxiety for both genders. Furthermore, a significant main effect of gender on threatening interpretations was found (\u003cem\u003eβ\u003c/em\u003e = -0.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.007). T-tests indicated that threatening interpretations were significantly higher in girls than in boys, \u003cem\u003et\u003c/em\u003e(310.18) = -9.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e = -. 96. See Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for the descriptive statistics per gender.\u003c/p\u003e\n\u003ch3\u003eUnivariate Regression Analysis For Hostile Interpretation Bias Only\u003c/h3\u003e\n\u003cp\u003eThe model for hostile interpretations was significant, \u003cem\u003eF\u003c/em\u003e(11, 375)\u0026thinsp;=\u0026thinsp;6.62, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001 and the predictors explained 13.8% of the variance, 95% bootstrapped CI [9.82, 22.34]. A significant main effect for CU-traits on hostile interpretations was found (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.35, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) indicating that hostile interpretations increased significantly as a function of CU-traits. Furthermore, a significant main effect for gender on hostile interpretations was found (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.15, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.02). T-tests indicated that hostile interpretations were significantly higher in boys than in girls, \u003cem\u003et\u003c/em\u003e(306.62)\u0026thinsp;=\u0026thinsp;3.66, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e =. 38. See Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescriptive statistics and gender differences of all measurements for the final sample (N\u0026thinsp;=\u0026thinsp;390)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eBoys\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eGirls\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eM (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCallous-unemotional traits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u0026ndash;51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHostile interpretation bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u0026ndash;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThreatening interpretation bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u0026ndash;99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral interpretations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u0026ndash;72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNote.\u003c/em\u003e Gender differences were tested with Welch\u0026rsquo;s t-test.\u003c/p\u003e \u003cp\u003eA significant interaction for social anxiety and gender on hostile interpretations was found (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.04). A plot showed that with increasing levels of social anxiety, hostile interpretations were more likely in boys, but less likely in girls (see Fig.\u0026nbsp;1). However, neither simple slopes nor correlations for boys and girls separately were significant. This indicates that differences in social anxiety between boys and girls were, after all, not related to hostile interpretations (\u003cem\u003ep\u0026rsquo;s\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05).\u003c/p\u003e\n\u003ch3\u003eExploration Of Gender Differences\u003c/h3\u003e\n\u003cp\u003eThe significant effects of gender on both hostile and threatening interpretations led us to further explore its role for the variables of interest. As shown in Table \u003cspan\u003e2\u003c/span\u003e, all measurements differed significantly for girls and boys. Furthermore, Pearson\u0026rsquo;s correlations for girls and boys separately showed that the correlations between CU-traits and hostile interpretations (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.34 for girls and \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.36 for boys), as well as between social anxiety and threatening interpretations (r\u0026thinsp;=\u0026thinsp;.66 for girls and \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.50 for boys) were still significant and positive (all \u003cem\u003ep\u0026rsquo;s\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). The correlations between self-reported CU-traits and social anxiety were not \u003cspan\u003esignificant for girls and boys separately (\u003c/span\u003e\u003cem\u003ep\u0026rsquo;s\u003c/em\u003e\u003cspan\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05). Interestingly, threatening and hostile interpretations correlated significantly positive in boys (\u003c/span\u003e\u003cem\u003er\u003c/em\u003e\u003cspan\u003e\u0026thinsp;=\u0026thinsp;.36,\u0026nbsp;\u003c/span\u003e\u003cem\u003ep\u003c/em\u003e\u003cspan\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), but not in girls (\u003c/span\u003e\u003cem\u003er\u003c/em\u003e\u003cspan\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.01,\u0026nbsp;\u003c/span\u003e\u003cem\u003ep\u003c/em\u003e\u003cspan\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05). See Table\u0026nbsp;\u003c/span\u003e\u003cspan\u003e3\u003c/span\u003e\u003cspan\u003e\u0026nbsp;for the correlation matrix per gender.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003e\u003cem\u003eCorrelation matrix between all measurements per gender\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ctable width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.20289855072464%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e1.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e2.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e3.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e4.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.014492753623188%\"\u003e\n \u003cp\u003e5.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.20289855072464%\"\u003e\n \u003cp\u003e1. Callous-unemotional traits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e-.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e.34***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e-.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.014492753623188%\"\u003e\n \u003cp\u003e-.20*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.20289855072464%\"\u003e\n \u003cp\u003e2. Social anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e-.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e-.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e.66***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.014492753623188%\"\u003e\n \u003cp\u003e-.21**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.20289855072464%\"\u003e\n \u003cp\u003e3. Hostile interpretation bias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e.36***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e-.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.014492753623188%\"\u003e\n \u003cp\u003e.21**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.20289855072464%\"\u003e\n \u003cp\u003e4. Threatening interpretation bias\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e.50***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e.36***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.014492753623188%\"\u003e\n \u003cp\u003e-.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.20289855072464%\"\u003e\n \u003cp\u003e5. Neutral interpretations\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e-.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.768115942028986%\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.623188405797102%\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.014492753623188%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e\u003cspan\u003e\u0026nbsp;Values above diagonal depict correlations for girls, values below the diagonal depict values for boys.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e*** \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003cp\u003e** \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01\u003c/p\u003e\n\u003cp\u003e* \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study investigated whether hostile and threatening interpretation biases are specific to callous-unemotional (CU) traits and social anxiety, respectively, in adolescent inpatients with a variety of different psychiatric disorders. Our results suggest that CU-traits are uniquely related to hostile interpretation bias, and that social anxiety is uniquely related to threatening interpretation bias. Although, boys who showed more hostile interpretation bias, also used more threatening interpretation bias.\u003c/p\u003e \u003cp\u003eIn line with the content-specificity hypotheses, CU-traits and social anxiety were related to distinct interpretation biases of the same situations. Adolescent inpatients who reported more callousness were more likely to interpret social situations as hostile, whereas adolescent inpatients who reported more fear of social evaluation were more likely to interpret the same situations as threatening. This is particularly important as research has shown that different interpretations of social cues might underlie different behavioral outcomes, such as aggression and avoidance [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thus, CU-traits and social anxiety might be characterized by a distinct cognitive processing of threat, which might steer different behavioral problems.\u003c/p\u003e \u003cp\u003eThe manifestation of interpretation biases differed across boys and girls. First, both CU-traits and hostile interpretation bias were higher in boys, and social anxiety and threatening interpretation bias were higher in girls. This is in line with the common finding that boys show more disruptive behavior [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], and that girls more often have (social) anxiety disorders [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Second, boys showed more hostile interpretation bias with increasing levels of social anxiety, while girls showed less. This is in line with research showing that the link between anxiety and aggression is more pronounced in boys [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, this effect diminished at gender-specific post-hoc analyses. Finally, boys who showed more hostile interpretation bias, also showed more threatening interpretation bias, while girls did not. Previous research has also found hostile and threatening thoughts to co-occur, but did not examine gender differences [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. This suggests that hostile and threatening interpretation biases can co-occur in boys independent of CU-traits and social anxiety. Ambiguous events might activate a general negative schema [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Stronger biases might then be a sign of a higher general psychopathological symptom level.\u003c/p\u003e \u003cp\u003eIn contrast to most previous research, we did not find an effect of age on interpretation biases [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. A possible explanation for the absence of a linear effect might be that interpretation biases follow a curvilinear course across age, as do both social anxiety and CU-traits. To be precise, a peak in social anxiety and CU-traits has been suggested as a normative part of puberty [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Indeed, the age range of our sample (10 to 18 years of age) covered different developmental stages from childhood to late adolescence. Longitudinal research is needed to determine the developmental course of interpretation biases across age.\u003c/p\u003e \u003cp\u003eThe current study comes with several strengths and limitations. A strength is the large clinical sample, which allowed us to investigate clinically relevant concepts across diagnostic categories in a well-powered study. Furthermore, we replicated and extended a previous validation study of the Ambiguous Social Scenario Task (ASST) in college students [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. That is, we again found good psychometric properties of the ASST, as well as the expected relationships between hostile and threatening interpretation biases and clinically relevant concepts for disruptive behavior and anxiety. However, due to too little group sizes, we could not examine the roles of psychiatric disorders in interpretation biases. The inclusion of diagnostic categories might have increased the relatively low explained variance of the model on hostile interpretation biases in the current study. By examining different interpretation biases in relation to different psychiatric disorders, we would better understand whether interpretation biases are disorder-specific or transdiagnostic mechanisms [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, future research should study the link between interpretation biases and actual social behavior to gain a more complete picture of the steps involved in social information processing and its consequences for behavior.\u003c/p\u003e \u003cp\u003eThe current study represents a first step examining different interpretation biases together in relation to psychiatric concepts relevant to disruptive behavior disorders and anxiety disorders in childhood and adolescence. A combined investigation of distinct interpretation biases in a clinical sample with a multitude of diagnoses is crucial to disentangle underlying mechanisms of distinct problematic behavior, as well as to identify transdiagnostic characteristics of psychological disorders. The current results suggest that interpretation biases can be differentiated in terms of callous versus anxious cognitive processing of social threat, and that gender might be an important factor to take into account. On the long-term, this knowledge might help to develop (gender) tailored interventions focusing on the modification of interpretation bias to improve treatment outcomes for callous and anxious youth.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding.\u003c/strong\u003e No funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest.\u003c/strong\u003e The authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution.\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study conception and design. Data collection was supervised by L.D. and T.L. Data analysis was conducted by A.D. The first draft of the manuscript was written by A.D. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e The anonymized data can be requested from the first author upon reasonable request. Part of the material is included in the supplementary material.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability.\u003c/strong\u003e The used software is referenced in text.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval.\u003c/strong\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval of using the data for the current study was granted by the local medical-ethical committee of the LWL-University Hospital Hamm (No.: 4359-12).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent.\u003c/strong\u003e Informed consent was obtained from legal guardians. Verbal informed consent was obtained from the participants before the start of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u0026nbsp;\u003c/strong\u003eConsent for publication was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements.\u0026nbsp;\u003c/strong\u003eWe thank all participants who participated, as well as the LWL-University Hospital Hamm for providing the data. Special thanks go to Luisa L\u0026uuml;ken, who prepared the data for our study. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eN. R. Crick and K. A. Dodge, \u0026ldquo;Social Information-Processing Mechanisms in Reactive and Proactive Aggression,\u0026rdquo; \u003cem\u003eChild Dev.\u003c/em\u003e, vol. 67, no. 3, pp. 993\u0026ndash;1002, Jun. 1996.\u003c/li\u003e\n\u003cli\u003eN. R. Crick and K. A. 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Dev.\u003c/em\u003e, vol. 46, no. 4, pp. 333\u0026ndash;345, Jul. 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"cognitive distortions, adolescence, social information processing, internalizing disorders, externalizing disorders","lastPublishedDoi":"10.21203/rs.3.rs-2507495/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2507495/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePsychopathological syndromes, such as disruptive behavior and anxiety disorders in adolescence, are characterized by distorted cognitions and problematic behavior. Biased interpretations of ambiguous social situations can elicit both aggressive and avoidance behavior. Yet, it is not well understood whether different interpretation biases are specific to different syndromes, or whether they can co-occur. We assessed both hostile and threatening interpretation biases in identical social situations, and proposed that they are uniquely related to callous-unemotional (CU) traits and social anxiety, respectively. We also explored the role of gender and age herein. The sample consisted of 390 inpatients between 10 to 18 years of age with a variety of psychiatric disorders. Hostile and threatening interpretations were assessed with the Ambiguous Social Scenario Task (ASST) consisting of 10 written vignettes. Both CU-traits and social anxiety were assessed with self-report questionnaires. Results showed that, overall, CU-traits were related to more hostile interpretations, whereas social anxiety was related to more threatening interpretations. In addition, in boys, hostile and threatening interpretations correlated significantly positive with each other. Age was not related to interpretation biases. Together, these results generally support the content-specificity of interpretation biases in concepts relevant to disruptive behavior disorders and anxiety disorders, and indicate that different interpretation biases can co-occur specifically in boys.\u003c/p\u003e","manuscriptTitle":"Hostile and threatening interpretation biases in adolescent inpatients are specific to callous-unemotional traits and social anxiety","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-01-27 22:47:31","doi":"10.21203/rs.3.rs-2507495/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-03-20T16:44:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-02-28T14:53:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1e5c623f-7084-4240-9919-5018604033d3","date":"2023-02-13T15:04:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-02-13T14:58:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-01-24T07:44:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-01-24T07:44:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Child \u0026 Adolescent Psychiatry","date":"2023-01-23T15:31:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"218778ae-61c5-4a89-aa35-a38f0dafda9a","owner":[],"postedDate":"January 27th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T22:10:17+00:00","versionOfRecord":{"articleIdentity":"rs-2507495","link":"https://doi.org/10.1007/s00787-023-02227-3","journal":{"identity":"european-child-and-adolescent-psychiatry","isVorOnly":false,"title":"European Child \u0026 Adolescent Psychiatry"},"publishedOn":"2023-05-31 21:01:09","publishedOnDateReadable":"May 31st, 2023"},"versionCreatedAt":"2023-01-27 22:47:31","video":"","vorDoi":"10.1007/s00787-023-02227-3","vorDoiUrl":"https://doi.org/10.1007/s00787-023-02227-3","workflowStages":[]},"version":"v1","identity":"rs-2507495","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2507495","identity":"rs-2507495","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}