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Internalizing and externalizing behaviors in school-aged children are related to state anxiety during magnetic resonance imaging

By Robin Eijlers, Elisabet Blok, Tonya White, Elisabeth M.W.J. Utens, Henning Tiemeier, Lonneke M. Staals, Johan M. Berghmans, Rene M.H. Wijnen, Manon H.J. Hillegers, Jeroen S. Legerstee, Bram Dierckx

Posted 11 Aug 2021
medRxiv DOI: 10.1101/2021.08.11.21261892

Magnetic resonance imaging (MRI) procedures often evoke anxiety in children. Further, anxious children may be less likely to participate in MRI research, leading to a possible selection bias, and may be more likely to move during image acquisition, resulting in lower image quality and possible information bias. Therefore, state anxiety is problematic for functional and structural MRI studies. Children with behavioral problems, such as internalizing and externalizing behaviors, may be more likely to experience state anxiety prior to and during MRI scanning. Therefore, our first aim was to investigate the relationship between internalizing/externalizing behavior and children's MRI-related state anxiety. Our second aim was to investigate the relationship between internalizing and externalizing behavior and MRI research participation. Our final aim was to investigate the effect of internalizing and externalizing behavior as well as MRI-related anxiety on image quality in children. We included 1,241 six- to ten-year-old children who underwent a mock MRI. Afterwards, if not too anxious, these children were scanned using a 3-Tesla GE Discovery MRI system (n = 1,070). Internalizing and externalizing behaviors were assessed with the Child Behavior Checklist. State anxiety was assessed with a visual analogue scale. Internalizing behaviors were positively associated with child state anxiety, as reported by child, parent, and researcher. For state anxiety reported by the parent and researcher, this relationship was independent of externalizing behaviors. Externalizing behaviors were related to state anxiety reported by the researcher, but this difference was not independent of internalizing behaviors, pointing towards a relationship via the shared variance with internalizing behaviors. Further, children with more internalizing and externalizing behaviors were less likely to participate in the actual MRI scanning procedure. Lastly, internalizing and externalizing behaviors, as well as MRI-related state anxiety were associated with worse image quality. These results underscore the potential for biases and methodological issues caused by MRI-related state anxiety in children.

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