The Journal ofPsychologlt & Behavioral Sciences, Vot.23, 201 3

EMOTIONAL SELF.EFFICACY, ANXIETY, AND AUTISM

The Emotional Self-Efficacy in Chitdren with Autism and ComorbidAnxiety Disorders

Eric Chang & Sharon HuiUniversity of California, Los Angeles

Previous research suggests that cognitive behavioral therapy (CBT) is effective in improvingemotional regulation and reducing anxiety in typically developing children with anxiety disorderi(Suveg et al', 2009). This studyexamines if changes in emotional self-efficacy (ESE) of children withAutism Spectrum Disorders (ASD) comorbid Arxiety Disorders can predict ieduction in anxiety. Wehypothesize that a modified version of CBT would be effective in incieasing ESE, and there would bea predictive relationship between ESE and anxiety. Forty-four children (aged 7-ll) were randorrlyassigned to Immediate Treatment (IT) or Waitlist (WL) conditions. Measures of anxiety and ESE werecollected at pre- and post-assessments. Results show significant differences in ESE between the IT andWL conditions at post assessments, with the IT condition scoring significantly higher on ESE than theWL (t(42) = 2.507, p < .05). Additionally, ESE was negatively correlated wittr arxiety (R : -.622, p <.05). CBT is effective in improving ESE. The conelation of

-gSe and anxiety found in children withASD comorbid anxiety disorders is similar to that of previous research in typically developing

children with anxiety disorders.

Autism Spectrum Disorders (ASD) is highly comorbid Autism Spectrum Disorders (ASD) and Anxietywith anxiety disorders. According to wood et al. at least Children with Autism Siectrum Disordeis (ASD)30Yo of individuals with ASD also had an anxiety disorder exhibit impairment in social behaviors and speecirdiagnosis (2009)' This comorbidity suggests that anxiety development, as well as, the display of repetitive behaviorsmay be a significant focus'of treatment for positive andrestrictedinterests(AmencanpsychiatricAssociation,soutcome (Wood et al., 2009). Recent studjes have Diagnostic and Statistical Manual-IV, Text revision,2000).presented that anxiety is associated with enhanced negative Children with high functioning autism (e.g. Asperger'semotional reactivity, and there is a positive correlation disorder,) generally demonstrate intact cognitive abilitiesbetween anxiety severity and negative emotionality (e.g. (DeRosier, Swick, Davis, McMillen, & Matthews,20ll).Carthy, Horesh, Apter, & Gross, 2010; Suveg, Sood, This may contribute to the higher rates of anxiety andcomer, & Kendall, 2009; Suveg, Hoffma,- zeman, & depression symptoms that children with high functioningThomassin, 2009)' It has been suggested that emotion eSo experienr" in comparison to tre general populationdysregulation can predict anxiety disorder; emotion (Kim, Siatmari, Bryson, Streiner, & wilson, 2000). It isdysregulation may also mediate stressful life events and suggested that 30-86% of individuals with ASD also haveanxiety (Mclaughlin & Hatzenbuehler, 2009). an anxiety disorder diagnosis (Wood et a1.,.2009).Emotional self-efficacy (ESE) is the perception of one's Anxiety is associatil with enhanced negative emotionalability to control and manage one's emotional responses reactivity (carthy et al., 2010). Enhanced negativeand experiences' The actual belief regarding one's ability emotional reactivity (marked by heightened intensity andto regulate has a predicting relationship to one's-reportei frequency of negative emotional responses) is reported inanxiety severity (Landon, Ehrenreich, & Pincus, zoof;. It ls youitr rvitt anxliety disorders in comparison to youthfurther suggested that FSE may have a protective influence without anxiety disorders (carthy et al., 2010). There arein childhood internalizing disorders, slch as anxiety and two clinical features across anxiety disorders: heighteneddepression (Landon et al', 2007). As cogaitive Behavioral negative emotional experiences that are centered on themesTherapy (CBT) is an effective treatmint in improving of"acruat or perceived threat; and, the inability to lower thisemotional regulation .and. reducing anxiety in typical emotion, evin though the emotion is recognized to bechildren with anxiety disorders (Suveg etal.,)009; ranoon excessive (carthy et"al., 2010). The negative emotionalityet al', 2007'1, a modified version of CBT treatment has also observed in typically developed youth with anxietyproven to be effective in lowering anxiety in children with disorders also ionelaies positively with anxiety sfverityASD-comorbid anxiety disorders (wood et al., 2009). (carthy et al., 2010). van Dam, Earleywine, and AltarribaThe current study will first examine whether a modified tzor ri suggested that anxiety interferes with overall:version of cBT is also effective in improving the ESE in cogoiiile control, decreases one,s ability to inhibit'childrenwithASDcomorbidanxietydisorders.Second,the attintion to distractions, impairs one,s performance in

"relationship between ESE and the anxiety levels_of chiliren rapid, intuitive emotion processing, and greatly limits thewith ASD comorbid anxiety disorders will also be auitity to process emotional information. Children with' examined' ASD comorbid anxiety disorders are likely to experience.i

55

l'correspondence concerning this article should be addressed to.Sharon c. Hui, Deparhnent ofEducational psychology and counseling, califomia State$University, Northridge, CA, 91330. Email: sharonhuiOT@gmail.com

great difficulties given their social deficits and thechallenges that arxiety brings into a situation. Excessiveanxiety can also imply harm to a youth's schoolperformance and social functioning (Wood, 2006). Ifuntreated, anxiety disorders may have a negative impact onphysical health and wellness, as well as psychological co-morbidity of clinical depression and substance abuse(Carthy et al., 2010). Children with anxiety disorders arevulnerable to frequent and intensified experiences ofthreatand negative emotionality, which increases the risk foremotion dysregulation (Carthy et ,a1., 2010). Theyexperience more difficulties in using self-regulatorystrategies to manage emotions than non-clinical children(Landon et al., 2007).

Emotion Dysregulation, Emotion Regulation, andAnxiety

According to Soenke, Hahn, Tull, and Gratz (2010),emotion dysregulation is defined as the "non-acceptance ofnegative emotions, difficulties engaging in goal-directedbehaviors when distressed, limited access to emotionregulation strategies perceived as effective, and lack ofemotional clarity" (p. 401). Emotional dysregulationpredicted generalized arxiety disorder in adults (Soenke etal., 2010). Anxiety and emotion dysfunction are highlycorrelated (Soenke et ah, 2010; Suveg et al., 2009).Emotion dysregulation is a fundamental feature of anxietydisorders, as it mediates stressful life events and changes ininternalizing symptoms across time (Carthy et al., 2010;Mclaughlin & Hatzenbuehler, 2009).

Emotion regulation is defined as the attempts in alteringemotions that are occurring, when and how these emotions(i.e. anxiety) are experienced or expressed (Carthy et al.,2010). There are five catagories of emotion regulationstrategies: situation selection, situation modification,attention deployment, cognitive chonge, and responsemodulation (Gross, 1998). Situation selection is theacceptance or the avoidance of an emotional situation. Forexample, children who have social anxiety disorder mayavoid playing with others during recess, employing anavoidance strategy to decrease their chances of feelinganxious during peer interaction. Situation modification is aproblem solving strategy where active attempts to modifuthe stimuli/situation is employed to alter its emotionalimpact. Attention deployment is the use of distraction toalter responses to the stimuli/situation. Cognitive change isa strategy that involves modifying the thoughts and beliefsabout a stimuli/situation to alter its emotional response.Response modulation is the direct attempt to modi$r theemotional responses; examples of this strategy are:suppression of the expression of one's emotion, ventingone's emotion, and relaxing. Children with anxietydisorders display an emotion regulation profile that reflectsthe following: increased reliance on avoidance and onseeking help of others; decreased use of problem solvingand of reappraisal; and increased frequency of failures to

Chang & Hui

56

apply any regulation strategy in negative emotionalsituations (Carthy et al., 2010). Children with anxietydisorder are more likely to report lower confidence in theiremotion management abilities (Landon et al., 2007). Animpaired feeling of control over their anxiety has also beensuggested by Cathy et al., (2010), Landon et al., (2007),and Weems, Costa, Watts, Taylor & Cannon, (2007).

Self-Efficacy (SE) and Emotional Self-efficacy (ESE)Self-Efficacy is the belief of one's perceived capability

to achieve certain expectations. It is the perceived ability toproduce a desired action, regardless ofone's actual abilities(Landon et al., 2007). Beliefs .regarding the ability tocontrol or regulate one's anxiety are an important predictorof anxiety severity (Landon et a1.,2007). Specific self-efftcacy in controlling and regulating one's emotion wasfound to predict the frequency ofregulation strategies used(Landon et al. 2007; Carthy et al., 2010). Impairedregulation of self-efficacy significantly contributes to theemotional difficulties that anxious individuals experience.It is suggested that the impairment observed in anxiousindividuals may lie in their perceived regulation efficacyand not necessarily in their actual abilities (e.g. Carthy etal., 2010; Werner, Goldin, Ball, Heimberg & Gross,20l l).Individuals with social anxiety disorder report a lower self-efficacy when using cognitive change and expressivesuppression to regulate their emotions than those withoutsocial anxiety disorder (Wemer et al., 2011). Anxiouschildren reported a lower self-efficacy in regulating theirnegative emotions (i.e. sadness, worry, and anger)compared with non-anxious children; they also reportedless use of adaptive regulation methods and moredysregulated expressions of sadness, worry and anger(Carthy et al., 2010). There is also a relationship betweenlower self-efficacy and higher anxiety in youth (Landon etal., 2007). As an effective social-cognitive factor, Landonet al. (2007) have suggested that an increased level of self-efficacy has protective influences against internalizingproblems (i.e. anxiety and depression). Self-efficacy seemsto be an important area in understanding internalizingchildhood disorders, however, there has been a minimalresearch on this topic.

Emotional self-efficacy (ESE) is the perceivedcapability to cope with negative emotions (Landon et al.,2007). ESE appears to be the most salient self-efficacysubcategory for children with anxiety disorders. A lowerESE is associated with an increase in physical symptomsreported, which suggests that children with an anxietydisorder who are less confrdent in their ability to cope withnegative emotions also experience high fear about thephysical symptoms of anxiety, such a shortness of breath(Landon et aI., 2007). Furthermore, youth with anxietydisorders are reported to have a lower ESE than youthwithout anxiety disorders, suggesting that ESE may play animportant role in anxiety treatments (Landon et a1.,2007).A treatment model that increases children's perception of

EMOTIONAL SELF-EFFICACY, ANXIETY, AND AUTISM

The Journal ofPsycholog & Behaviorol Sciences, Vol.23, 2013

EMOTIONAL SELF-EFFICACY. ANXIETY. AND AUTISM 57

abilities to manage their emotions will improve their ESE.Hence, it is hypothesized that the specific and well-operationalized arxiety and mood management skillstaught in Cognitive Behavior Therapy (CBT) mayconcurrently improve children's s€nse of ESE. The highlevels of ESE in childhood could be a positive predictor oftreatment success (Landon et al., 2007). The predictiverelationship between ESE and anxiety will be examined inthe current study.

Cognitive Behavior Therapy (CBT) and the CurrentStudy

Cognitive Behavioral Therapy (CBT) has proven to beeffective in lowering anxiety in children with ASDcomorbid anxiety disorders (Wood et al., 2009). Previousstudies have also supported CBT's effectiveness inimproving emotional regulation and reducing anxiety intypical children with anxiety disorders (e.g. Suveg et al.,2009; Landon et a1.,2007). The current study will examinewhether CBT is also effective in improving the levels ofESE in children with ASD comorbid anxiety disorders.Also, the relationship between the ESE levels in childrenwith ASD with comorbid anxiety disorders will beexamined.

Method

The current study reports on the same databaseanalyzed in the following research: Wood, J. J., Drahota,A., Sze, K., Har, K., & Chiu, A. (2009). Cognitivebehavioral therapy for anxiety in children with autismspectrum disorders: A randomized, controlled trial. Journalof Child Psychologt and Psychiatry, 50(3),224-234. TheWood et al. (2009) study was approved by a university-based IRB. Parent participants gave written informedconsent and children participants gave written assent toparticipate.

ParticipantsForty children (7-11 years; 3l males, 9 females) on the

autism spectrum with at least one anxiety disorder and theirparents participated in the current study. The families wereresiding in a major metropolitan area of the Western UnitedStates at the time of study. Participant selection adhered to

"the following inclusion criteria: children participants musta) have a diagnosis of autism, Asperger syndrome, or PDD-NOS; b) also have one of the following anxiety disorders:

, separation anxiety disorder, social phobia, or obsessive-. compulsive disorder; c) not be using any psychiatric

:,r, nedication at the baseline assessment, or they must betaking a stable dose at least one month prior to the baseline

.:assessment; d) maintained the same medication dosage:i,tlroughout the study if medication was being used.,lParticipants were also selected based on the following

, ,;iexclusion criteria: children were not included in the study if.'tii$ttrey a) had a verbal IQ less than 70, based on the Wechsler.::' '-,i

Intelligence Scale for Children-IV; b) were cunentlyattending psychotherapy, social skills training, orbehavioral intervention; c) were currently in family therapyor parenting class; d) began taking psychiatric medicationanytime during the course of the study; e) for any reasonthey could no longer participate in the interventionpfogram.

Intervention ProgramTherapists included eleven doctoral students in clinical

or educational psychology, and two doctoral-levelpsychologists. All therapists had a minimum of one-yearclinical experience, and prior experiepce working withchildren on the autism spectrum. Therapists were trainedfor at least 8 hours on the intervention, read the treatmentmanual, listened to audiotapes of a model therapistconducting the treatment, and attended weekly hour-longmeetings with clinical supervisors who developed theprotocols. Therapists worked with families for 16 weeks.Every week, they met for a 90-minutes session (30 minuteswith the child, and one hour with the parents) to implementa modified version of the Building Confidence CBTprogram (Wood & Mcleod,2008). The first three sessionsincluded basic coping skills, and the next eight sessionsincluded in vivo exposures, in which the child attempted toconfront increasingly challenging activities. The remainingsessions were individualized to the child, depending on theclinical needs. Throughout the intervention, parents weretrained to support their children using communicationtechniques and positive reinforcements. During in vivoexposure exercises, both children and parents had theopportunities to practice learning skills with the supportsfrom their therapists. The intervention program was alsodesigned to encourage parents' support for their children'sindependence and autonomy in their daily living.

MeasurementsThe Autism Diagnosis Interview-Revised (ADI-R; Le

Couteur, Lord, & Rutter, 2003), Autism DiagnosticObservation Schedule-Module 3 (ADOS; Lord, Rutter,Dilavore, & Risi, 2002), a parent-report checklistpertaining to children's circumscribed interests, and areview of all available previous assessment records wereused to examine and determine children's ASD diagnoses.A subject matter expert Dr. Ami Klin, who has recentlypublished on the topic, was consulted to distinguish thedifference between autism, Asperger syndrome, and PDD-NOS (Klin, Pauls, Schultz, & Volkmar, 2005). ADI-R andADOS were administered by doctoral-level personnel withappropriate training and certification in theiradministration. In addition, the Anxiety DisordersInterview Schedule (ADIS-C/P; Silverman & Albano,.1996) was used by trained graduate students to assesschildren participants' disorders in semi-structureddiaenostic interviews.

Two parent-reported measurements were used toanalyze the relationship between anxiefy and ESE inchildren with ASD comorbid anxiety disorders: theMultidimensional Anxiety Scale for Children-Parentversion (MASC-P; March, 1998) and the ESE subscalefrom the Self-Efficacy Questionnaire for Parent (SEQ-P;Muris, 2001). The MASC-P is a 4-point Likert scale, 39-item questionnaire that assesses children's anxiety; itdemonstrates robust psychometric properties (March,Parker, Sullivan, Stallings, & Conners, 1997),and, it is oneof the most widely used measures in tlinical trials amongyouth populations with anxiety disorders (Thaler, Kazemi,& Wood, 2010); it has also shown particular strength inidentifying social anxiety symptoms and agreement withthe DSMIV social phobia diagnosis (Thaler et al., 2010).Social Phobia is the most diagnosed baseline anxietydisorder among the current study's participants (see Tablel). The other measurement used in this study, the ESEsubscale from the SEQ-P, consists of 8 questions that wereidentified to be reliable and valid for ESE measurement(Muris, 2001); examples of the items include: "How wellcan your child control his/her feelings?" and "How wellcan your child make him/herself feel calm again whenfeeling very scared?" For the current study, parentscompleted the aforementioned measures at baseline (for theimmediate treatment group) or 3 months after baseline (forthe waitlist group), and again at post-treatment (last day oftreatment) or within one week of treatment completion.

ProcedureTo determine eligibility in the shrdy, parents completed

the baseline diagnostic interview and paper-pencilmeasures. Eligible children were block-randomized by acomputer program into either immediate treatment (IT) orwaitlist (WL) group. The randomization was operated suchthat when one child was assigned to one condition, anotherchild with the same age and gender would be automaticallyassigned to the other condition. Therapists wererandomized to the children's cases. Parents were offered$20 for participating in the two assessments.

Results

An independent sample t-test was performed todetermine the effect of modified CBT on participants'emotional self-efficacy. Prior to implementing modified-CBT. the ESE scores did not differ between the immediatetreatment (IT) group (M:12.0, SD:3.18) and the waitinglist (WL) group conditions (M: 12.5, SD:2.83), t(41) ='0.564, p = 0.576. Following intervention, the ESE of thechildren in the IT condition (M:15.45, SD:4.19) wassignificantly different from the WL group (M:12.'15, SD:2.94), t(42):2.507, p: 0.016. A correlation analysis

Chang & Hui58

Table 1.Demographics, diagnosis, and medication usagefor children in theimmediate treatment (IT) and waitlist (WL) conditions

i7No.(%) %No. (%) lit

EMOTIONAL SELF-EFFICACY. ANXIETY. AND AUTISM

n= l7 n=21Child scx (rnle)Cbild age

Pamts(fnnle)P$?ot &radBlld ftommllogc

tz(7t%)9.lt

r3 (76%)8 (4?%)E(4? )l | (65%)

l5 (65%) .13922 -.09(sD=t4zl ($D= r.s?)t4182%t l8 (?8%)l?0tqrl 13 (60%)

.t0

.83

ParcntmldAumnicd 14 (E2%)Child cdric borkgroundCaucadm 8(41%t

t"ciodt,rira 2(12%,Asian/Pacifrc lshrdtr 4 (n%\A&kwAmrien 0Multirrisl 3 (lE%)

Asirnrcatxrsiu IAriao{-r&p 0Aftim 0AmaricadCatmiuLatinocasasianMiddbEr$mrc$csieMuhiracial (>3)

Autistrl cpoctnm disoxkrsAutirtic disordcrPDD"NOSAspaprsydrcm

Basdine rnxicty disrdcrsSoPSADocDGAD

0l9(51%, lr (48%) t"l36(35%) ll ($%)2tr2$) l (4%)

19 (E3%) ,00

l r (4ll%) 2-503 (t3%lz{e )| \45,16/o6ft\

II2

I0

n{%%) 129t6 Qo%l 2.069 (39m') .2s8 (35%) 3Jl

15 (65%) 6lo 4.39*6Q6%) r.251(4%', J6

@ucuubiddiagrcADHD 9(53%jDyahymia/MDD 3 (18%)oDD/CD Z(2%\vrsD o

hydlhFic ncdication uscSSRIAtypirl aatigrycboticSlimula$ or8lotrroxltirc

2 (rz%t 3 (r3%l .013 (lE%) 3 (13%) .164 (U%t ? (30%) 33

Note. (f : immediate treatment condition; WL = waitlist condition. SoP =social phobia; SAD = separation anxiety disorder; OCD - obsessive-compulsive disorder; GAD = generalized anxiety disorder; ADHD =attention deficit hyperactivity disorder; MDD = major depressive disorder;ODD: oppositional defiant disorder; CD = conduct disorder; PTSD =post-traumatic stress disorder.*ru <.05-

was conducted to determine the relationship between ESEand anxiety symptoms. A negative correlation betweenESE scores (M = l4.l,,SD = 3.56) and anxiety scores (M:54.90, SD : 13.38) was obtained (r: -0.622,p < 0.05, l/:44\.

A linear regression analysis was used to assess thepredictive relationship between ESE and anxiety. Changesin ESE was a sigrrificant predictor of anxiety aftertreatment: ESE scores (M: 14.1, SD:3.56); ANX scores(M : 54.90, SD : 13.38), p < 0.05 (Figure I ).

The Efiect of ESE on Anxlety Reduction

Treatnent Phaga

80

70

60

ac40

E--20

'10

0

The Journal of Psychology & Behavioral Sciences, Vol.23, 20I 3

EMOTIONAL SELF-EFFICACY. ANXIETY. AND AUTISM 59

Figure l.Predictive Relationship between Emotional-Self Efficacy and Anxiety.

Discussion

(Landon et a1.,2007). The relationship between lower self-efficacy level in youth and higher risk for internalizingproblems (e.g. depression and anxiety) suggests that themodified CBT interventions may improve the overallcoping skills of youth with internalizing disorders.

Limitations qnd Future ResearchThere are a few limitations to this study. First, the

generalizability is hindered by the relevantly small samplesize and the participating families' characteristics. At thetime of study, all 40 participating families were residing ina major metropolitan area of the Western United States.There was a great possibility that the parepts' educationlevels and their household income levels might notrepresent the general American population. In addition,parent-reported measurements were collected to analyzethe relationship between anxiety and ESE in children withASD comorbid anxiety disorders. Data collected fromchild-reported measurements may or may not yield thesame conclusion.

Nevertheless, the significant correlation between ESEand anxiety found in children with ASD comorbid anxietydisorders is similar to that of previous research in typicallydeveloping children with anxiety disorders (Carthy et al.,2010). This suggests that future studies examining theadditional positive impact of interventions (not limited toCBT) in improving the ESE of children with or withoutASD may yield promising results.

Author Note

Eric Chang, Department of Psychology, University ofCalifornia, Los Angeles; Sharon C. Hui, Department ofEducational Psychology and Counseling, California StateUniversity, Northridge.

This research reports on the same database analyzed inthe following article: Wood, J. J., Drahota, A., Sze, K.,Har, K., & Chiu, A. (2009). Cognitive behavioral therapyfor anxiety in children with autism spectmm disorders: Arandomized, controlled trial. Journal of Child Psycholog,tand Psychiatry, 50(3),224-234. This research is supportedby the Behavioral Interventions for Anxiety in Childrenwith Autism (BIACA) Project at University of California,Los Angeles.

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$ The impairment of anxious individuals was suggested$ to be the perception of their emotion regulation efficacy,$ not the absence of emotion regulation abilities (e.g. Carthy$ et al.. 2010; Werner et al., 201l). Hence, treatment that$ focuses to increase ESE for clinically anxious youth was$ hypothesized to yield promising outcomes in decreasingF anxietv of the anxious vouth in the studv of Landon et al.

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EMOTIONAL SELF-EFFICACY, ANXIETY. AND AUTISM