Self-Efficacy As a Target for Neuroscience Research on Moderators of Treatment Outcomes in Pediatric Anxiety

Abstract

Objective:

Despite the advances in the field of neuroscience, many questions remain regarding the mechanisms of anxiety, as well as moderators of treatment outcome. Long-term adverse outcomes for anxious youth may relate to pathophysiologically based information processing patterns and self-referential beliefs, such as self-efficacy. In fact, there are no studies highlighting the relationship between self-efficacy and neurocircuitry in youth. The purpose of this study was to explore the relationships between self-efficacy, brain morphometry, and youth anxiety.

Methods:

Parent, child, and clinician ratings of anxiety symptoms and child-reported self-efficacy were analyzed in a sample of 8- to 17-year-old youth (n = 51). Measures were collected from all youth at baseline and during and after treatment for the patients. Anxious patients (n = 26) received 12 sessions of cognitive behavioral therapy (CBT). Moreover, imaging data obtained from all participants before treatment were utilized in analyses.

Results:

Patients reported lower self-efficacy than healthy volunteers. Across the entire sample, anxiety was negatively related to total, social, and emotional efficacy. Both social and emotional efficacy predicted anxiety posttreatment. In addition, social efficacy predicted social anxiety symptoms posttreatment and social efficacy increased across treatment. There were no significant relations between self-efficacy and neurocircuitry.

Conclusions:

Self-efficacy is an important treatment target for anxious youth. Although self-efficacy was not related to brain morphometry, self-efficacy beliefs may constitute an important mechanism through which CBT and psychopharmacological interventions decrease fear and anxiety symptoms in youth.

Introduction

Anxiety disorders are the most common group of childhood psychiatric disorders (Merikangas et al. 2010; Ghandour et al. 2019). When excessive and left untreated, fear and anxiety adversely affect child development and predict later psychopathology (Pine et al. 1998; Bittner et al. 2007; Merikangas et al. 2010). Due to cross-species conservation in brain–behavior relations, research in neuroscience has informed our understanding of mechanisms and treatment outcomes in anxiety; nevertheless, many questions remain. A review on the development of brain structures in children at risk for anxiety reported dysfunction in the amygdala and prefrontal regions associated with anxiety (Blackford and Pine 2012). Perturbations in the structure and function of the medial prefrontal cortex (mPFC) are observed in pediatric anxiety disorders (McClure et al. 2007), areas related to fear neurocircuitry. The mPFC plays a critical role in fear extinction and has been clearly linked to anxiety and fear (Sotres-Bayon et al. 2006; Quirk and Mueller 2008; Gee et al. 2013; Shechner et al. 2014).

Based on neuroscientific findings, LeDoux and Pine (2016) proposed a two-system pathophysiological framework for understanding anxiety in the brain. This framework suggests that there is one circuit for generating conscious feelings that involves the prefrontal cortex, insula, and parietal cortex and the other circuit is responsible for behavioral and physiological responses. Psychopharmacological interventions may impact either circuit; however, research suggests that common psychological and behavioral factors influence medication effectiveness (De Nadai et al. 2017).

Lateral and medial prefrontal areas may relate to individual differences in conscious awareness and self-referential processes (Sebastian et al. 2008). Long-term adverse outcomes for anxious youth relate to patterns of information processing, including self-referential beliefs (Mogg and Bradley 1998; Clark 1999; Vasey and MacLeod 2001; Ehrenreich and Gross 2002). Research suggests that the mPFC is involved in self-referential processing in adults and youth (Mitchell et al. 2005; D'Argembeau et al. 2007; Sebastian et al. 2008). However, children activate the mPFC during self-knowledge retrieval more than adults, suggesting developmental variability (Pfeifer et al. 2007). Further, considerable research demonstrates associations between anxiety and self-efficacy (e.g., Muris 2002; Gaudiano and Herbert 2007; Maric et al. 2013; Ollendick et al. 2017). Self-efficacy is defined as one's sense of competence and confidence in performing behaviors to achieve a desired outcome (Bandura 1977). Efficacy beliefs are an important determinant of behavior and have been linked to anxious and depressive symptoms in youth (Bandura 1977; Hannesdóttir and Ollendick 2007; Muris 2002; Rudy et al. 2012) as well as a mediator in psychopharmacology research in adults (Cox et al. 1991). Moreover, domain-specific self-efficacy may be associated with different anxiety phenotypes, as Muris (2002) reported significant relations between social efficacy and symptoms of social anxiety, whereas emotional efficacy was more closely related to generalized anxiety and panic disorder.

Self-efficacy is an important psychological target in cognitive behavioral therapy (CBT) and may be related to specific brain regions (Suveg et al. 2009; Brown et al. 2014; Ollendick et al. 2017) Indeed, studies indicate that response to CBT for anxiety is associated with changes in brain regions mediating threat processing, extinction, and inhibitory learning (Monk et al. 2006; Maslowsky et al. 2010). Clark and Beck (2010) discuss the convergence of cognitive theory with these pathophysiological findings, presenting evidence of an association between cognitive therapy and increased activation in the mPFC. Several treatment outcome studies highlight the effectiveness of CBT for youth (Kendall et al. 2008; Ollendick et al. 2015; Silk et al. 2018); youth develop positive views about their abilities when successfully completing exposures and participating in CBT. However, the precise psychological and pathophysiological mechanisms that underlie these changes need further delineation. The few studies examining self-efficacy as a moderator or mediator of treatment outcome provide support of efficacy as an important target (Prins and Ollendick 2003; Lau et al. 2010; Rudy et al. 2012; Kendall et al. 2016; Ollendick et al. 2017). Broadly, some studies reported that anxiety varies depending on levels of self-efficacy (Kent and Gibbons 1987; Galla and Wood 2012), whereas other studies have reported that efficacy does not relate strongly to anxiety (Landon et al. 2007) and changes in youth self-efficacy during treatment do not predict decreases in anxiety (Suveg et al. 2009). Further research is needed to help describe the nuanced relationship of self-efficacy with youth anxiety and changes that occur across CBT, as well as corresponding neurobiological correlates.

Currently, there are no studies that explore self-efficacy in relation to pathophysiological measures in youth. Linking self-efficacy to specific neurobiological functioning can help clinical researchers develop behavioral tasks that target those areas of the brain and ultimately apply precision medicine efforts to benefit patients with lower self-efficacy and higher anxiety. First, we hypothesized that healthy volunteers (HVs) would report higher self-efficacy than anxious patients. In addition, we expected higher self-efficacy scores to be significantly related to lower anxiety across the full sample. Second, we expected social and emotional efficacy within anxious youth to predict posttreatment total anxiety symptoms, and more specifically that social efficacy would predict posttreatment social anxiety symptoms. Third, we expected social and emotional efficacy to improve across treatment for the anxious youth. We examined self-efficacy and brain morphometry in HVs and patients in secondary exploratory analyses to provide preliminary evidence on the potential link between self-efficacy and neurobiological correlates in children. This is a novel approach to identifying pathophysiological markers of self-efficacy in relation to anxiety in youth. In our final hypothesis, we expected morphometry of the mPFC to relate to self-efficacy, based on prior research demonstrating that self-referential processing engages this area (Keenan et al. 2000; Gusnard et al. 2001; D'Argembeau et al. 2007; Sebastian et al. 2008). However, given the lack of research on efficacy and brain morphometry, we also ran exploratory analyses to look for other associations.

Methods

Participants

Data were obtained from research participants in a larger randomized control trial (RCT) approved by the National Institute of Mental Health (NIMH) Institutional Review Board. Data were obtained from treatment-seeking patients and HVs between the ages of 8 and 17 (M = 12.62 [2.72] were utilized [see White et al. (2017) for more details on the RCT]). Patients had a primary anxiety diagnosis (Generalized Anxiety, Social Anxiety, and/or Separation Anxiety) and were randomized to CBT and either 9 weeks of active or control Attention Bias Modification Training (ABMT). All participants had an intelligent quotient (IQ) >70, were medication free, and were assessed by licensed clinicians using semi-structured interviews (Silverman and Albano 1996; Kaufman et al. 2000). Inclusion criteria for the anxious group included a primary anxiety diagnosis. Current Major Depressive Disorder, Obsessive-Compulsive Disorder, or Posttraumatic Stress Disorder were exclusionary criteria, as were Psychosis or Bipolar Disorder.

Parents and youth participated in two screening visits during which the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL; Kaufman et al. 2000) and the anxiety subscales of the Anxiety Disorders Interview Schedule for Children (ADIS-C/P; Silverman and Albano 1996) were administered to determine eligibility and whether inclusion criteria were met. In addition, during the visits, youth and their parents completed questionnaires on anxiety, depression, mood, and behavior. Measures of anxiety included a semi-structured interview, self-reports, parent reports, and clinician ratings. After parents and youth provided consent and/or assent, all youth participated in research visits to provide behavioral, neuroimaging, and self-report questionnaire data, and anxious youth received 12 weeks of CBT/ABMT. The anxious sample included youth who completed the 12-week treatment and had also completed the self-efficacy measure at three time-points (n = 26). Of the 26 anxious youth assessed pretreatment, all 26 were diagnosed with Generalized Anxiety Disorder and/or Social Anxiety Disorder. Comorbid diagnoses included Separation Anxiety (n = 6), Specific Phobia (n = 11), and Selective Mutism (n = 3). Anxiety and self-efficacy ratings were included in the analyses from baseline (pretreatment), week 3 (pre-exposure), and week 12 of treatment (posttreatment). The HV sample completed the baseline assessment and relevant questionnaires (n = 25). Recruitment for the study is ongoing, and the data used in this study constitute only a subset of the sample.

Measures

Anxiety Disorders Interview Schedule for Children (Silverman and Albano 1996)

The ADIS-IV-C/P is a semi-structured diagnostic interview that evaluates DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association 1994) anxiety disorders and associated psychopathology in children and adolescents. Composite diagnoses are determined by using information collected from both parent and child interviews. A clinical diagnosis requires symptom criteria and a clinical severity rating (CSR) >4 (on a 0–8 scale). The psychometric properties of the ADIS-IV-C/P are well documented (Silverman et al. 2001). For this study, the anxiety subscales of the ADIS-IV-C/P were administered at baseline to determine anxiety diagnoses and study eligibility.

The Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (Kaufman et al. 2000)

The K-SADS-PL is a semi-structured interview that is used to measure current and past symptoms of mood, anxiety, psychotic, and disruptive behavior disorders in children ages 6–18 years old. The K-SADS-PL possesses good reliability and validity (Ambrosini 2000). Kaufman et al. (2000) reported test–retest coefficients in the good to excellent range across disorders (0.63–1.00). The K-SADS-PL was administered at baseline to determine the presence of any psychiatric diagnoses and to determine study eligibility.

Pediatric Anxiety Rating Scale (Research Units on Pediatric Psychopharmacology Anxiety Study Group 2002)

The Pediatric Anxiety Rating Scale (PARS) is a 50-item checklist assessing symptoms of anxiety in youth. The total score incorporates five of the seven dimensions of global severity/impairment: (1) number of anxiety symptoms reported, (2) frequency of symptoms, (3) severity of distress associated with anxiety symptoms, (4) severity of physical symptoms, (5) avoidance, (6) interference at home, and (7) interference outside of the home. Each dimension is on a six-point Likert scale and is rated by the clinician based on information gathered from the parent and the child. The sum score is calculated based on subscales 2, 3, 5, 6, and 7 and total scores can range from 0 to 25, where higher scores reflect greater levels of anxiety. Scores above 11.5 indicate the presence of an anxiety disorder. This measure demonstrates good internal consistency (intraclass correlation coefficient [ICC] = 0.97) and moderate test–retest reliability (0.55) and is sensitive to treatment effects (Research Units on Pediatric Psychopharmacology Anxiety Study Group 2002). The PARS was administered at baseline and at weeks 3, 8, and 12 of treatment.

The Screen for Child Anxiety and Related Emotional Disorders (Birmaher et al. 1997)

The Screen for Child Anxiety and Related Emotional Disorders (SCARED-P/C) is a 41-item, dual informant measure of pediatric anxiety symptoms. The questionnaire consists of five subscales assessing symptoms of generalized anxiety, social anxiety, separation anxiety, panic, and school refusal. Items are rated on a 0–2 Likert scale. The total score can range from 0 to 82, with higher scores reflecting greater levels of anxiety and scores above 25 suggestive of an anxiety disorder. The SCARED-P/C report has acceptable to good internal consistency (α = 0.74–0.94) and good to excellent test–retest reliability (r = 0.70–0.90), as reported by Birmaher et al. (1997). The SCARED was administered at baseline and at weeks 3, 8, and 12 of treatment. Prior research suggests that generating a composite score could help minimize potential disagreement across informants, given informant discrepancy (Rappaport et al. 2017). Therefore, average scores were created by using the parent and child responses.

Self-Efficacy Questionnaire for Children (Muris 2001)

The Self-Efficacy Questionnaire for Children (SEQ-C) contains 24 items designed to measure children's perceptions of their social self-efficacy (ability to relate to and get along with other peers), emotional self-efficacy (ability to regulate unpleasant emotions), and academic self-efficacy (ability to succeed in school and display appropriate learning behaviors). The three subscales each contain eight items in which children rate their competence level on a five-point Likert-type scale (1 = not at all to 5 = very well). Scores are summed to yield a measure of self-efficacy for each domain. The SEQ-C has good internal consistency (α = 0.95). Cronbach's alphas for our sample using the 24-item version of the scale were all in the excellent range (α = 0.90 [social self-efficacy], α = 0.87 [academic self-efficacy], and α = 0.91 [emotional self-efficacy]). The SEQ-C was administered at baseline, week 3, and 12 of treatment.

Cognitive behavioral treatment

All youth with a clinical diagnosis of anxiety were assigned to one of two licensed psychologists, both of whom had at least 5 years of experience using CBT in the treatment of pediatric anxiety disorders. Each psychologist provided 12 weeks of CBT and were blinded to whether the patient was receiving active or placebo ABMT. Each treatment session ranged from 40 minutes to an hour. In-session exposures started at session 4 and continued until the last treatment session. Sessions 3, 8, and 12 were designated assessment sessions; the psychologist, patients, and parents completed assessment forms to track symptoms. The treating psychologist completed the PARS for each patient at the designated assessment sessions.

Statistical procedures

First, means and standard deviations across measures were calculated by using IBM SPSS Statistics Version 25. Bivariate correlation analyses were conducted to explore the relationships between the study variables (age, gender, efficacy, and anxiety) and t-tests measured group differences on the variables. Paired t-tests were used to determine changes in efficacy across treatment. Finally, separate hierarchical regressions were carried out to explore self-efficacy as a predictor of anxiety symptoms in youth. Child age and sex were included in regression analyses as covariates along with pretreatment anxiety. Age and gender were entered in step one of each model. In step two, child- and parent-averaged anxiety reported on the SCARED at baseline was included as a control variable. Social or emotional efficacy was entered at step 3 as a predictor of treatment outcome (child anxiety). Given our sample size, we had the most power to examine correlations and predictors of treatment. Future research will explore self-efficacy as a mediator of treatment outcome.

Imaging procedures

A high-resolution T1-weighted magnetization-prepared rapid-acquisition gradient-echo scan (sagittal acquisition, repetition time = 7.7 ms, echo time = 3.42 ms, slices = 176, 1 mm³ isotropic voxels, matrix = 256 × 256, flip angle = 7°) was acquired for each participant by using a General Electric 3-T MR750 scanner (Waukesha, WI) with a 32-channel head coil. All images were first segmented and labeled by using Version 5.3.0 of FreeSurfer image analysis software suite (Dale et al. 1999; Fischl et al. 2002; Fischl 2004). All processed images were visually inspected for image artifacts by three independent raters. The quality of the images was rated on a scale of 0 (no issues)–3 (significant issues). Ratings were highly reliable across all three raters (α = 0.88, 95% confidence interval [0.81–0.84]). For all images that did not unanimously receive a rating of 0 or 3, images were re-inspected as a group until consensus was met. A total of 37 images were processed; three anxious patients were excluded after visual inspection due to motion artifacts or poor segmentation. The final sample included 18 anxiety patients and 16 HVs with usable data. After standard processing in FreeSurfer, all images were smoothed by using a 20 mm full width at half maximum Gaussian filter and resampled to 10,242 vertices per hemisphere (based on five recursive subdivisions of a regular icosahedron) by using the nearest neighbor method (Winkler et al. 2018). Lastly, left and right hemispheres were merged so the analyses could be conducted across the whole brain and images were masked in only the cortical surface in the analyses. Associations between social and emotional self-efficacy and measures of brain structure were conducted by using the Permutation Analysis of Linear Models (PALM; Winkler et al. 2014), a computation tool that uses permutation approaches to conduct uni- and multivariate analyses.

Results

Mean comparisons between HVs and patients

Means, standard deviations, and demographic variables are presented in Table 1, demonstrating significant differences between the HVs and anxious youth on both child-reported anxiety measures as well as total self-efficacy, social efficacy, and emotional efficacy. HVs reported lower anxiety (M = 7.21 [6.33]) and higher self-efficacy (M = 95.22 [12.66]) as compared with the anxious patients report of anxiety (M = 29.72 [12.41]) and self-efficacy (M = 75.02 [15.4]). Similarly, parent-reported anxiety on the SCARED and clinician-reported anxiety on the PARS were higher for anxious patients than HVs.

Table 1.

Description Statistics for Patients and Healthy Volunteers

Variables
	Patients (n = 26)		Healthy volunteers (n = 25)		All (n = 51)
	Mean	SD	Mean	SD	Mean	SD
Age	12.72	2.34	12.51	3.11	12.62	2.72
IQ	113.17	10.78	113.58	12.24	113.28	11.529
PARStot^***	15.08	3.32	1.50	2.97	8.85	7.52
SCARED_Child^***	29.72	12.41	7.21	6.33	18.68	15.01
SCARED_Parent^***	28.86	11.76	5.64	6.33	17.48	15.03
SCARED_Avg^***	44.15	14.45	10.03	7.46	27.42	20.68
SEQtot^***	75.02	15.40	95.22	12.66	85.39	17.22
SEQemo^***	21.71	5.15	31.83	4.62	26.67	7.04
SEQsoc^***	26.24	7.08	32.46	4.49	29.29	6.67

***

p ≤ 0.001 significant difference between the HV and patient groups.

SD, standard deviation; IQ, intelligent quotient; SCARED, Screen for Child Anxiety and Related Emotional Disorders; SEQ, Self-Efficacy Questionnaire; HV, healthy volunteer.

Relationship between age, gender, IQ, self-efficacy, and anxiety

Results of bivariate correlation analyses with the whole sample did not demonstrate any significant relationships of age, gender, or IQ, with self-efficacy or child-reported anxiety on the SCARED. PARS total anxiety at baseline was negatively related to total self-efficacy (r = −0.67, p < 0.001), social efficacy (r = −0.59, p < 0.001), and emotional efficacy (r = −0.77, p < 0.001). Child-reported anxiety on the SCARED was also significantly related to total self-efficacy (r = −0.60, p < 0.001), social efficacy (r = −0.45, p < 0.001), and emotional efficacy (r = −0.73, p < 0.001). Lastly, parent-reported anxiety on the SCARED was significantly related to total self-efficacy (r = −0.50, p < 0.001), social efficacy (r = −0.49, p < 0.001), and emotional efficacy (r = −0.64, p < 0.001). The parent–child SCARED composite score was highly correlated with total efficacy (r = −0.61, p < 0.001), social efficacy (r = −0.51, p < 0.001), and emotional efficacy (r = −0.76, p < 0.001). Of note, in this sample there was high parent–child informant agreement on the SCARED total score (r = 0.65, p < 0.001) as well as a high correlation between child-rated self-efficacy and clinician-rated anxiety on the PARS, suggesting a strong relationship between child anxiety and self-efficacy.

Correlation analyses within each group demonstrated significant relationships between the variables. For the HVs, total self-efficacy was negatively related to child-reported anxiety (r = −0.59, p < 0.002) as well as parent/child averaged anxiety (r = −0.48, p < 0.05), suggesting that higher levels of self-efficacy are related to lower levels of anxiety. Similar results were obtained for emotional efficacy, as it was negatively related to child-reported anxiety (r = −0.63, p < 0.001) and parent/child averaged anxiety (r = −0.54, p < 0.01). Lastly, social efficacy was also negatively related to child-reported anxiety (r = −0.44, p < 0.05) and clinician-reported anxiety (r = −0.55, p < 0.01). Correlations for the patient group showed a different pattern of relationships. Child IQ was positively related to clinician-reported anxiety (r = 0.59, p < 0.01), suggesting that children with higher IQ scores had higher levels of anxiety per clinician report. Gender was also significantly correlated with anxiety for the patient group, with males reporting less anxiety (r = −0.44, p < 0.03). Emotional efficacy was negatively related to clinician-reported anxiety (r = −0.42, p < 0.05), demonstrating that patients with higher emotional efficacy had lower levels of anxiety. Fisher's Z transformation analyses were completed to transform the sampling distribution of Pearson's r to a normal distribution. This facilitated tests of significant differences between the correlation coefficients from patients and HVs. There were no significant differences between the groups on total self-efficacy, social efficacy, and emotional efficacy and the PARS anxiety score (z = −0.24, z = 0.97, z = 0.72, p > 0.05, respectively) or SCARED-C/P anxiety scores (z = −1.56, p > 0.05, z = 1.27, p > 0.05, z = 1.42, p > 0.05, respectively).

Self-efficacy predicting posttreatment anxiety

Hierarchical regression analyses were used to examine the role of self-efficacy as a predictor of treatment outcome (child, parent, and clinician report). The models with social efficacy and emotional efficacy predicting posttreatment anxiety symptoms on the PARS, and SCARED-P, were not significant. Table 2 presents a summary of the significant hierarchical regression analyses, with emotional and social efficacy as predictors of anxiety reported on the SCARED-composite controlling for pretreatment anxiety. Using the SCARED composite score, the model with emotional efficacy as a predictor was significant [F(4, 17) = 3.90, p = 0.02], demonstrating a main effect of emotional efficacy on average anxiety on the SCARED posttreatment (β = −1.67, t = −2.63, p = 0.02). There were also main effects for age (β = −3.89, t = −2.56, p = 0.02) and gender (β = −17.37, t = −2.13, p = 0.05). A separate model with social efficacy reported at pretreatment as a predictor of total anxiety posttreatment while controlling for pretreatment anxiety was also significant [F(4, 17) = 4.01, p = 0.02], with main effects showing that greater social efficacy at pretreatment predicted lower anxiety posttreatment (β = −1.22, t = −2.73, p = 0.01). Lastly, the model with social efficacy as a predictor was significant [F(4, 17) = 11.36, p = 0.00], demonstrating a main effect of social efficacy on social anxiety symptoms posttreatment (β = −0.43, t = −3.26, p = 0.01).

Table 2.

Social and Emotional Efficacy Predicting Posttreatment Anxiety

Emotional efficacy predicting SCARED parent/child average anxiety
	Model 1			Model 2			Model 3
Predictors	B	SE B	β	B	SE B	β	B	SE B	β
Age	−3.20	1.75	−0.43	−3.25	1.73	−0.43	−3.89	1.52	−0.52^*
Gender	−16.57	8.47	−0.46	−12.09	9.11	−0.33	−17.37	8.16	−0.48^*
SCAREDAvg				0.39	0.31	0.28	0.18	0.28	0.13
EmoEfficacy							−1.67	0.63	−0.49^*
R ²	0.20			0.27			0.48
F for change in R ²	2.44			1.52			6.93^*

Social efficacy predicting SCARED parent/child average anxiety
Age	−3.20	1.75	−0.43	−3.25	1.73	−0.43	−3.17	1.54	−0.42
Gender	−16.57	8.47	−0.46	−12.09	9.11	−0.33	−11.33	8.10	−0.31
SCAREDAvg				0.39	0.31	0.28	0.42	0.27	0.27
SocEfficacy							−1.22	−0.45	−0.47^**
R ²	0.20			0.57			0.74
F for change in R ²	0.18			21.42^***			10.64^**

Social efficacy predicting SCARED parent/child average social anxiety
Gender	−1.06	3.22	−0.09	0.36	2.23	0.03	−0.38	1.80	−0.03
Age	−0.40	0.66	−0.16	−0.08	0.46	−0.07	−0.18	0.37	−0.07
SCAREDAvg				0.84	0.18	0.75^*	0.58	0.17	0.52
SocEfficacy							−0.43	0.13	−0.48^**
R ²	0.01			0.29			0.52
F for change in R ²	0.11			7.11^*			8.22^*

Model controls for SCARED scores at baseline.

p ≤ 0.05, ^** p ≤ 0.01, ^*** p ≤ 0.001.

SCARED, Screen for Child Anxiety and Related Emotional Disorders; SE, standard error.

Similar results were obtained in the regression models predicting child-reported anxiety on the SCARED. The model with emotional efficacy as a predictor of posttreatment anxiety [F(4, 18) = 4.68, p = 0.01] was significant, showing a main effect of emotional efficacy on anxiety (β = −1.56, t = −3.33, p = 0.00). In addition, there was a main effect of gender on anxiety (β = −16.67, t = −2.9, p = 0.01). A separate model with social efficacy reported at pretreatment as a predictor of anxiety posttreatment controlling for pretreatment anxiety was significant [F(4, 18) = 3.12, p = 0.04]. There was a main effect of social efficacy on anxiety symptoms posttreatment (β = −0.92, t = −2.48, p = 0.02). Lastly, social efficacy significantly predicted social anxiety symptoms (β = −0.30, t = −2.87, p = 0.01).

Changes in self-efficacy across treatment

A paired-samples t-test was conducted to compare self-efficacy means across treatment. Within patients, the social efficacy scores significantly increased from pre-exposure (M = 24.45 [6.88]) to posttreatment (M = 29.79 [15.68]), [t(23) = 2.21, p = 0.04], suggesting some preliminary benefits of treatment on child-reported social efficacy. Emotional efficacy did not significantly change across treatment. As noted earlier, we expected efficacy to increase across treatment as children learn to manage their anxiety and gain more mastery experiences in anxiety-provoking situations while completing exposures. There were no significant changes in efficacy between baseline and week 3 (pre-exposure) of treatment (M = 26.05, [7.00], t[23] = 1.35, p = 0.19); however, significant changes from week 3 (pre-exposure) to week 12 (posttreatment) provide preliminary support for a positive effect of exposures on social efficacy (Fig. 1).

FIG. 1.

Change in social and emotional efficacy across treatment. *t(22) = −2.21, p = 0.038.

Relationship between self-efficacy and neurocircuitry

We tested separate linear models with social and emotional efficacy entered separately as predictors of cortical thickness, surface area, and subcortical gray matter volume. All models included age and gender as covariates. For analyses of cortical thickness and surface area, associations with social and emotional efficacy were assessed at each vertex on the cortical surface. Analyses of subcortical gray matter volume were based on measures of regional volume for each subcortical structure, and total brain volume was controlled. For analyses of cortical thickness and area, the data were randomly shuffled 2000 times, and inference was accelerated by the fitting of a generalized Pareto distribution to the tail of the permutation distribution (Winkler et al. 2016). Due to the lower dimensionality of the subcortical volumes, and lesser concern about speed, 10,000 shufflings were performed. For each permutation, the general linear model was fit and a test statistic for each contrast was calculated. Significance was assessed based on the permutation distribution of maximum test statistic across the whole brain. For associations with thickness and surface area, we used the threshold free cluster enhancement on the surfaces as the test statistic for each vertex (Smith and Nichols 2009). All analyses used familywise error rate correction.

Results of our PALM analyses included social efficacy and emotional efficacy separately predicting measures of cortical thickness and surface area, as well as subcortical volume with age and gender as covariates. There were no significant associations between social or emotional efficacy with cortical thickness, and surface area or subcortical volume observed. These results remained non-significant whether or not total intercranial volume was included as a covariate and across all correction methods. This included even the least stringent correction, which did not correct for the number of contrasts and modalities tested.

Discussion

This study examined self-efficacy as a predictor of treatment outcome and neurobiological correlates of self-efficacy in anxious youth. As in prior studies, our results suggest that self-efficacy represents an important treatment target in psychotherapy (Zlomuzica et al. 2015; Kendall et al. 2016; Ollendick et al. 2017). We found that self-efficacy was related to child- and clinician-rated anxiety for HVs and patients. As expected, patients had lower self-efficacy at baseline compared with HVs. When controlling for baseline anxiety, age, and sex, emotional and social efficacy predicted child and parent averaged anxiety; similar results were found with child-reported anxiety posttreatment. Further, social efficacy predicted social anxiety symptoms posttreatment, controlling for pretreatment levels of anxiety. That is, self-efficacy predicts treatment outcome above and beyond pretreatment symptoms of anxiety. Lastly, social efficacy scores after treatment were higher than pretreatment ratings, suggesting that efficacy increased across treatment. However, there were no significant associations between self-efficacy and the mPFC. Taken together, these findings suggest that self-efficacy is an important target in maximizing treatment outcomes for anxious youth, yet more research is needed to determine correlations with neurocircuitry.

Social efficacy improved from pre- to posttreatment, showing significant improvements when the exposures started; however, there were no changes in emotional efficacy in our sample. More research is necessary to determine whether successfully completing exposures and learning to manage emotional responses is the key to changing one's self-efficacy. Earlier research by Muris (2001) suggests that self-efficacy is positively correlated to active coping and negatively correlated to passive coping, perhaps indicative of changes in avoidance behavior and emotional regulation capacities. The consistent finding is that efficacy changes across treatment as anxiety changes, and though efficacy is still significant after controlling for earlier anxiety in this sample, more research is needed to determine whether a low sense of efficacy results in anxiety or whether high levels of anxiety lead to a diminished sense of efficacy. Moreover, there are additional factors besides anxiety that impact levels of youth self-efficacy.

As suggested in prior research, relationships between self-efficacy and anxiety may vary based on age and gender (e.g., Rudy et al. 2012; Habibi et al. 2014). In our sample, age and gender were significant predictors of total anxiety; however, we did not find any age or gender differences in self-efficacy scores. Given the mixed results in the literature (Landon et al. 2007), gender should be further explored as a potential correlate of self-efficacy. Self-efficacy could account for some of the gender differences found in anxiety symptoms. Prior research has suggested that there are mean level differences in efficacy scores between boys and girls (Muris 2002; Bacchini and Magliulo 2003; Saunders et al. 2004). Bacchini and Magliulo (2003) found that 13- to 19-year-old adolescent boys reported higher levels of emotional efficacy than girls. Muris (2002) reported that 12- to 19-year-old girls exhibited lower levels of emotional efficacy as well. However, Coleman (2003) reported that among 10- to 12-year-old children, girls reported higher social efficacy than boys. In this study, self-efficacy was an important target in CBT treatment regardless of age or gender; nonetheless, it is important to explore development trends and whether girls and boys respond differently to efforts to increase efficacy during treatment. Children are socialized differently based on gender and culture in regard to expressing and dealing with emotions and social interactions (Eisenberg et al. 1998; Chaplin et al. 2005; Corwyn and Bradley 2016; Raval et al. 2019) and therefore we can anticipate that these socialization practices impact overall emotional and social efficacy.

Notably, this is the first study to explore self-efficacy as a predictor of cortical thickness, surface area, and subcortical volume in youth. No associations emerged relating self-efficacy to brain structure. The lack of imaging correlates presented in this study should be considered in light of the sample size. In general, associations between psychological variables and measures of brain structure have been found to be largely unreliable and small, thus requiring very substantial sample sizes to detect (Masouleh et al. 2019). More specifically, previous findings investigating neuroanatomical differences associated with anxiety have been largely inconsistent, with some reporting larger (De Bellis et al. 2000; Qin et al. 2014; Gold et al. 2017) and smaller (Mueller et al. 2013; Strawn et al. 2015; Gold et al. 2017) structural measures and still others finding no significant associations (De Bellis et al. 2000; Strawn et al. 2013, 2014; Cardinale et al. 2019) within the same neural regions (i.e., prefrontal cortex, hippocampus, and amygdala). Thus, it may be the case that a significantly larger sample size is needed to detect any associations between self-efficacy and neural structure within anxious youth.

Nonetheless, understanding the neural substrates associated with self-efficacy as a psychological construct could provide insight to identifying treatment mechanisms. A meta-analysis by Northoff et al. (2006) reported that functioning within the anterior cingulate and medial prefrontal cortices relates to self-referential processing and cognitive control of emotions in adults. Similarly, Pfeifer et al. (2007) reported that the mPFC was more active in children during a self-knowledge retrieval task. Identifying the neural substrates of self-efficacy in relation to anxiety can help clinical researchers develop novel tasks that tap into those domains and ultimately move toward enhancing anxiety treatment for youth. CBT is only effective for about 50%–60% of youth (Walkup et al. 2008; Southam-Gerow et al. 2010; Ollendick et al. 2015). Perhaps, modifications of treatment that focus on improving self-efficacy can help strengthen the effects of CBT and reach non-responders. For example, fear extinction is a key component of exposures utilized in CBT for anxiety (Hofmann 2008; Craske et al. 2014). Preliminary research using self-efficacy to improve emotional learning demonstrated that increasing perceived self-efficacy using verbal mediation facilitated the extinction of fear in healthy participants (Zlomuzica et al. 2015). Future studies should examine whether this finding is consistent with youth and whether changes in self-efficacy are linked to fear extinction in clinically anxious populations. Functional imaging studies among youth might extend findings by using procedures similar to those employed in this study. Much more work is needed on brain function as it relates to neural substrates, self-efficacy, and anxiety in youth.

Despite the important contributions that this research makes, limitations of this study must be acknowledged. First, this is a relatively small subsample from a larger RCT in which data are still being collected. The small sample size, particularly for the exploratory brain morphometry analyses, precludes us from running more in-depth moderator and mediator analyses as we do not have adequate power at this time. Future work is necessary. A second limitation is that the patients in this study received CBT along with ABMT, which makes it hard to determine the exact treatment component that changed the efficacy beliefs. Though prior research does demonstrate changes in youth efficacy after CBT (Gaudiano and Herbert 2007; Kendall et al. 2016; Ollendick et al. 2017), there is no literature to suggest that attention biases are related to self-efficacy in youth. In future research, we will use between-group analyses to look at differences in efficacy beliefs across the CBT and control ABMT group versus the CBT and active ABMT group. However, future work should also have a non-CBT comparison treatment or waitlist control group. A final limitation worth noting is the reliance on a self-report measure of broad-based self-efficacy. In addition to self-report questionnaires, objective ratings of efficacy and coping are necessary. The SEQ-C was designed for youth to complete about themselves but does not include situation-specific items. It may be most useful to probe events that occur in children's daily lives by using digitally based event sampling, such as Ecological Momentary Analysis, to collect data from youth (Silk et al. 2011; Tan et al. 2012) to get precise measurements of efficacy beliefs.

Conclusions

In summary, this research is an essential step that examines the relationship between self-efficacy and anxiety across treatment, and it is the first study to integrate brain morphometry measures. Given the mixed findings reported in the literature regarding the relationship between self-efficacy and anxiety in youth (Suveg et al. 2009; Ollendick et al. 2017), we sought to determine the role of emotional and social efficacy in predicting later anxiety symptoms after CBT. One unique aspect of this research was exploring potential brain morphometry related to self-efficacy in youth. Although there were not any significant relationships with brain morphometry, it is imperative to identify the brain mechanisms involved with self-referential beliefs and reductions in clinical anxiety symptoms in youth. More specifically, it is important to determine whether structural and functional imaging research can identify specific brain correlates, such as the mPFC, of efficacy in youth. As noted, continued research with larger samples will prove to be most useful.

Clinical Significance

Self-efficacy beliefs constitute an important mechanism through which CBT decreases fear and anxiety symptoms in youth. These results highlight the importance of youth self-efficacy and belief in one's ability to cope with emotions and social situations, and it validates the need for more research exploring pathophysiological correlates of self-efficacy in anxious youth. Treatments should specifically aim at increasing efficacy whether that be through mastery experiences with exposures or by using verbal mediation. Moreover, researchers suggest the importance of conducting pharmacological studies while studying psychological constructs (Cox et al. 1991), such as self-efficacy, as this study and prior research highlight the importance of self-efficacy in anxiety treatment. More recent research looking at psychopharmacological adherence in psychiatric patients demonstrates an indirect association between self-efficacy and medication adherence (De Las Cuevas et al. 2017), suggesting that this is an important area of study. Increases in self-efficacy as a treatment target for anxious youth can have a significant clinical impact.

Footnotes

Acknowledgments

The authors thank the participants and their families who are involved in this student and the staff of the Emotion and Development Branch. The clinicians and researchers within the Section on Development and Affective Neuroscience (SDAN) at NIMH are essential in completing this research.

Disclaimer

The authors confirm that this article has been read and approved by all named authors and that there are no other people who satisfied the criteria for authorship but are not listed. They further confirm that the order of authors listed in this article has been approved by all the authors.

Disclosures

No competing financial interests exist.

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