Implementing school-based cognitive behavior therapy for anxiety in students with autism or suspected autism via a train-the-trainer approach: Results from a clustered randomized trial

Abstract

Autistic youth frequently experience interfering anxiety, and schools may be an ideal setting to deliver mental health care. A type 1 hybrid-effectiveness, cluster randomized trial was used to examine the effectiveness of school-based Facing Your Fears compared to usual care. Change in provider cognitive behavior therapy knowledge and treatment fidelity (adherence and provider competence) were also examined. Seventy-seven interdisciplinary school providers across 25 elementary/middle schools were trained via a train-the-trainer approach. Eighty-one students, ages 8–14 years, with autism or suspected autism and anxiety participated. Students who received school-based Facing Your Fears displayed significantly greater reductions in anxiety compared to students in usual care according to caregiver and child report (Screen for Anxiety and Related Emotional Disorders). Significant reductions in total anxiety (p = 0.012), separation (p = 0.002), and social anxiety (p = 0.003) subscales occurred, according to parent report. Student self-report indicated significant reductions on the social anxiety subscales (p = 0.001). Interdisciplinary school providers demonstrated significantly increased cognitive behavior therapy knowledge following training (p < 0.001). Mean adherence and competence ratings were strong. The positive effectiveness and implementation outcomes are encouraging. Training interdisciplinary school providers to deliver school-based Facing Your Fears has the potential to increase access to care for anxious autistic students. Future directions and limitations are discussed.

Lay Abstract

Autistic youth frequently experience anxiety that can negatively affect them at home, with friends, and at school. Autistic youth have difficulty accessing mental health care, and this is particularly true for youth from traditionally underserved backgrounds. Providing mental health programs in schools may increase access to care for autistic youth with anxiety. The purpose of the study was to train interdisciplinary school providers to deliver school-based Facing Your Fears, a cognitive behavior therapy program for anxiety in autistic youth. Seventy-seven interdisciplinary school providers across 25 elementary/middle schools were trained by their colleagues and members of the research (train-the-trainer approach). Eighty-one students with autism or suspected autism, ages 8–14 years, were randomly assigned to either school-based Facing Your Fears or usual care. Students in school-based Facing Your Fears showed significant reductions in anxiety compared to students in usual care according to caregiver and student report. Other measures involved examining change in provider cognitive behavior therapy knowledge after training and determining how well interdisciplinary school providers were able to deliver school-based Facing Your Fears. Results indicated that interdisciplinary school providers showed significant improvements in cognitive behavior therapy knowledge after training. Interdisciplinary school providers were able to deliver most of school-based Facing Your Fears activities and with good quality. The positive outcomes in this study are encouraging. Training interdisciplinary school providers to deliver school-based Facing Your Fears may increase access to care for anxious autistic students. Future directions and limitations are discussed.

Keywords

anxiety autism spectrum disorders education services interventions—psychosocial/behavioral school-age children

Introduction

Approximately 40% of autistic youth may develop interfering anxiety (van Steensel et al., 2011), which can negatively affect friendships, home life, and school participation (Adams et al., 2018). Worries about making mistakes, using the school bathroom, hearing the fire alarm, or initiating social interactions can make it difficult for autistic students to fully engage in academics or social experiences (Adams et al., 2018; Syriopoulou-Delli et al., 2018).

Treatment for youth with autism and anxiety

Cognitive behavior therapy (CBT) is an evidence-based practice (EBP) and gold-standard psychosocial intervention for the treatment of anxiety in non-autistic and autistic youth (James et al., 2020; Perihan et al., 2022). Over the past 20 years, numerous randomized controlled trials (RCTs) have examined the efficacy and effectiveness of modified CBT for autistic youth with anxiety. Individual (Wood et al., 2020) and small group delivery (Chalfant et al., 2007) of modified CBT has resulted in significant reductions in anxiety for autistic youth according to multiple informants (clinicians, parent, and child self-report), although maintenance of treatment effects can be variable (Sharma et al., 2021). In a study comparing adapted CBT for autism with standard-of-practice CBT, adapted CBT outperformed standard CBT on measures of anxiety, suggesting there are advantages to adapting CBT for autistic youth (Wood et al., 2020). However, both conditions achieved higher positive treatment response rates relative to treatment as usual, indicating that standard CBT for youth with autism may be effective without adaptations.

Lack of access to evidence-based care

Despite strong evidence for the effectiveness of modified CBT approaches, autistic youth have encountered barriers accessing mental health care, including lack of trained providers, long wait lists and cost of therapeutic services, and difficulties caregivers may have in securing time off from work (Elkins et al., 2011; Magaña et al., 2013; Montes et al., 2009). These barriers are even more pronounced for autistic youth from historically underserved racial/ethnic backgrounds, as they receive fewer services than their White and more affluent peers (Parish et al., 2012; Pickard et al., 2019). In this population, barriers may include less access to resources (e.g. books, the Internet, information in their native language, a social support network), less knowledge about services, specialty clinicians, navigating health care systems, as well as increased cost, and lack of bilingual/bicultural clinicians (Magaña et al., 2013). In addition, mental health symptoms may go undetected or misinterpreted for students of color, potentially leading to punishment-based interventions (Reyes et al., 2022). For instance, school providers missed the presence of internalizing symptoms in students of color and showed a bias toward identifying externalizing disorders instead (Chavira et al., 2004), potentially leading to reactive/punishment-based strategies for symptom management. Specifically, students from minority backgrounds and limited English proficiency status, with disabilities, including autism, were more likely to receive one or more in school suspensions and/or out of school suspensions than their peers (Miller & Meyers, 2015). Thus, school can provide access to mental health care by reducing many of these structural barriers, and this is critically important as many autistic youth access mental health services only in schools (Ali et al., 2019; Boyd et al., 2018).

School-based anxiety interventions

Previous studies suggest that CBT may be effective for anxiety in autistic students in schools (Perihan et al., 2022). Delivery models vary and include interventions implemented by researchers embedded in schools (Clarke et al., 2017), researchers paired with teaching assistants (Luxford et al., 2017), educators coached by school psychologists (Drmic et al., 2017), and interdisciplinary school providers (ISPs) (Reaven et al., 2022).

Increasing school provider capacity is essential. Two approaches to doing so include (1) broadening the pool of school providers who are trained in CBT (e.g. speech/language pathologists; special education teachers) and (2) using a “train-the-trainer” (TTT) implementation strategy to support eventual sustainability. The TTT approach (e.g. training a cohort of experienced school providers in an EBP who then train their colleagues to deliver the same EBP) may increase EBP sustainability as expert consultation is reduced, and staff turn-over is managed (Shire & Kasari, 2014).

Current study

This study is a type 1 hybrid-effectiveness trial, where the primary goal is to examine effectiveness outcomes while also exploring important implementation outcomes, such as the feasibility, acceptability, and reach of implementation efforts (Curran et al., 2012). The main purpose is to train ISPs to deliver the Facing Your Fears-School Based program (FYF-SB) to traditionally underserved students with autism or suspected autism and anxiety via a TTT approach. FYF-SB was adapted from clinic-based FYF (Reaven et al., 2011) and was piloted in public schools with encouraging results (Reaven et al., 2022). This study aimed to examine the effectiveness and implementation outcomes of FYF-SB compared to usual care (UC). All effectiveness and implementation outcomes were grounded in the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to understand the broader translation potential and impact of FYF-SB (Glasgow et al., 2013). Specific constructs in RE-AIM included the reach of the intervention to anxious students; the effectiveness of FYF-SB compared to UC; the feasibility of adopting FYF-SB within schools; the extent to which ISPs implement FYF-SB with good adherence; and whether ISPs reported an intent to maintain their use of FYF-SB.

Specific objectives were to examine: (1) the effectiveness of FYF-SB compared to UC; (2) change in provider CBT knowledge following training; and (3) adherence and competence of FYF-SB delivery. It was hypothesized that (1) students who participated in FYF-SB would display greater reductions in anxiety compared to students assigned to UC; (2) CBT knowledge would significantly improve for ISPs following training; and (3) average treatment adherence ratings would meet or exceed 80% and competence of delivery would be at least adequate.

Method

Community involvement

Autistic adults, caregivers of autistic youth, and ISPs were involved in the research in two ways: (1) an advisory board (AB) and (2) in 14 focus groups conducted prior to this study (Reaven et al., 2019). The AB was comprised of eight community members, including an autistic adult, caregivers of autistic youth, school administrators, and school providers. The AB met twice annually and provided input on FYF-SB, recruitment approaches, and strategies for dissemination. The AB also reviewed focus group data and provided input prior to a second round of focus groups (Reaven et al., 2019). This qualitative approach resulted in recommendations regarding the logistics/parameters of delivering FYF-SB in schools, suggestions for who should facilitate FYF-SB, which students should participate in the program, and how much caregiver involvement would be reasonable to request. The AB and focus group participants did not choose any specific measures for the study, although they did reflect on how “success” would be defined for the students, including results from student, caregiver, and teacher report of anxiety, behavior changes (e.g. elopements, outbursts, tardies, and attendance), and fewer calls home.

Participants

Three groups of participants were included trainers (n = 14), ISPs (n = 77), and students with autism or suspected autism and anxiety (n = 81).

Trainers

Trainers were selected by school administrators for the pilot study (Reaven et al., 2022). Trainers worked at least 3 years in their field and agreed to participate for 2 years—the first year delivering FYF-SB with training and consultation from the researchers and the second year (current study) training colleagues on FYF-SB (see Table 1).

Table 1.

Trainer demographics (N = 14).

Variable	Mean	SD	Percentage
Age (years)	40.07	9.37
Gender (female)			100
Ethnicity (Hispanic)			7.1
Race
White			92.9
Black/African American			7.1
Native Hawaiian			7.1
Multiple races			7.1
Highest education
Bachelors			7.1
Masters			50.0
Professional (JD, PhD, MD)			35.7
Position
Special education teacher			14.2
Social worker			14.3
School psychologist			35.7
Speech language pathologist			35.7
Years on the job	12.75	9.44

ISPs

Inclusion criteria include (1) currently working with students with autism or suspected autism and anxiety; (2) degreed professional in any of the following areas: special education, speech/language pathology, occupational or physical therapy, school psychology, social work, counseling, or behavioral consultation; and (3) ability to attend a 12-h training, deliver at least 80% of FYF-SB lessons and participate in ongoing consultation. Of the 77 trained ISPs, 69 ISPs participated¹ (see Table 2). There were no demographic differences in ISP characteristics across conditions (p > 0.05).

Table 2.

Interdisciplinary school providers (N = 69).

	Percent total (N = 69)	District 1 (N = 25)	District 2 (N = 18)	District 3 (N = 26)	Fall (n = 34)	Spring (n = 35)
Gender (female)Age in years (range = 25–60) (M/SD)	91.3039 (9.51)	92.00	88.90	92.30	94.1	88.6
Ethnicity
Hispanic or Latino	4.3	8.0	5.6	–	2.9	5.7
Non-Hispanic	95.7	92.0	94.4	100.0	97.1	94.3
Race
White	91.3	92.0	88.9	96.0	88.2	94.3
Asian	2.9	4.0	–	4.0	5.9	–
Black/African American	2.9	4.0	5.6	–	–	5.7
Multiple race	1.4	–	5.6	–	2.9	–
Not reported	1.4	–	–	–	–	–
Professional position
School psychologist	30.4	24.0	27.8	38.5	35.3	25.7
Other mental health provider	10.1	8.0	22.3	3.8	11.7	8.6
Speech pathologist	24.6	20.0	22.2	30.8	23.5	25.7
Occupational therapist	4.3	8.0	–	3.8	2.9	5.7
Special educator	29.0	40.0	22.2	23.1	26.5	31.4
School administrator	1.4	–	5.6	–		2.9

Students

Inclusion criteria include (1) no documented intellectual disability; (2) clinical anxiety according to student, caregiver, or teacher report; and (3) clinically significant deficits in reciprocal social behavior according to the Social Responsiveness Scale–Second Edition (SRS-2; Constantino & Gruber, 2012). Clinical anxiety was defined as significant elevations for caregiver or child report on the Screen for Child Anxiety and Related Emotional Disorder (SCARED; Birmaher et al., 1999), or the Parent-Rated Anxiety Scale for Autism Spectrum Disorder (PRAS-ASD; Scahill et al., 2019), or the School Anxiety Scale–Teacher Report (SAS-TR; Lyneham et al., 2008). Students were excluded if they had (1) significant behavior or psychiatric challenges that prevented them from participation or (2) lack of caregiver permission for participation.

Ninety-nine student names (8–14 years) were provided. Five of the students were excluded during screening because of lack of interest. Thirteen students did not enter the study following initial screening. Of the remaining 81 students, 39 were randomized to FYF-SB and 42 to UC (see Figure 1 for consort diagram). No adverse events were reported.

Figure 1.

Student consort diagram.

All students received services through an Individualized Education Program (IEP) and had a medical diagnosis of autism, and/or an educational identification of autism, and/or suspected autism (according to ISP impressions). A medical diagnosis of autism was not required because many potentially eligible students may not have had the opportunity to obtain a formal autism diagnosis. Autistic students are likely being served under other eligibility categories so this approach allowed the researchers to serve youth who may have been miscategorized, expanding the “reach” of FYF-SB. Almost half of the students (n = 39; 48.1%) had a prior autism diagnosis according to caregiver report.

Student demographic information is presented in Table 3. Participants were primarily male (81%), non-Hispanic (69%), and White (62%) with an average age of about 10 years old. Approximately 56% identified as non-Hispanic and White. Tests (via chi-square or means comparisons) for baseline differences between FYF-SB and UC across gender, age, ethnicity, race, SRS, IEP identification, and parent education were all statistically equivalent (p > 0.05).

Table 3.

Students with autism or suspected autism and caregiver demographics (N = 81).

Variable	Total % (N = 81)	District 1 % (N = 27)	District 2 % (N = 25)	District 3 % (N = 29)	Fall % (N = 39)	Spring % (N = 42)
Gender (male)	81.5	88.9	80.0	75.9	76.3	86.0
Age (years), mean (SD)	10.71 (1.76)	11.05 (1.77)	10.01 (1.60)	11.01 (1.76)	10.92 (1.90)	10.53 (1.62)
Ethnicity
Hispanic or Latino	30.9	22.2	44.0	17.2	21.1	39.5
Non-Hispanic	69.1	77.8	56.0	82.8	78.9	60.5
Race
White	61.7	70.4	32.0	79.3	73.7	51.2
Asian	1.2	3.7	–	–	–	2.3
Black/African American	11.1	11.1	24.0	–	13.2	9.3
Multiple race	13.6	14.8	8.0	17.2	10.5	16.3
Native Hawaiian/Pacific Islander	1.2	–	–	3.4	–	2.3
Not reported	11.1	–	36.0	–	2.6	18.6
SRS mean T-score (SD)	70.56 (11.35)	70.92 (9.57)	66.81 (12.78)	74.88 (10.76)	72.42 (11.10)	68.58 (11.45)
Autism spectrum diagnosis	39 (48%)				21 (54%)	18 (46%)
Consenting caregiver education
Some high school	7.4	7.4	16.0	-	7.9	7.0
High school graduate	14.8	3.7	28.0	13.8	21.1	9.3
Associate degree	11.1	14.8	4.0	13.8	2.6	18.6
Some college, no degree	25.9	22.2	24.0	31.0	23.7	27.9
College undergraduate	21.0	25.9	8.0	27.6	18.4	23.3
Some graduate/terminal master’s	8.6	11.1	4.0	10.3	10.5	7.0
Professional degree	8.6	14.8	8.0	3.4	15.8	2.3

SRS: Social Responsiveness Scale.

Fall/spring groups were not statistically different across all variables. Autism diagnoses were equally distributed across conditions (chi-square > 0.05).

Procedure

The Colorado Multiple Institutional Review Board (COMIRB) approved the study, along with internal review boards for each district. Recruitment did not begin until full approval had been obtained from all districts.

Three public school districts in Colorado were selected because of their diverse student populations (e.g. Hispanic/Latino, African American/Black, multiple races, and low socioeconomic status (SES)) and history of collaboration with the study authors. School administrators were informed that one purpose of this study was to reach historically underserved autistic students so selected schools had many students from diverse backgrounds (i.e. students who identify as a minoritized race or ethnicity and students qualifying for free and reduced lunch) increasing the likelihood that underserved autistic students would be included in the study. Twenty-five schools and 27 school teams (two schools had enough students to warrant two groups) participated. Colorado’s racial and ethnic minority enrollment across elementary and middle schools is currently 47%. Of the 25 schools, the average racial and ethnic minority enrollment was 55.07% (state average 47.1%). Participating schools’ average enrollment of students from the Hispanic/Latina/o community was 35.8% (state average 33.9%). The average enrollment of students from the African American community was 9.02% (state average 4.5%). The average rate of students from participating schools that were eligible for free or reduced lunch was 47.56%, with a state average of 37.2%. The use of free and reduced lunch is often used as one metric of SES, and in this study was used to help identify schools educating students with limited resources.

Once schools were identified, ISPs were selected and informed consent was obtained. Twenty-seven teams were randomized to either FYF-SB (N = 13) or UC (N = 14). Randomization occurred within three primary blocks (school districts) and two secondary blocks within each school district (elementary/middle schools). A random number generator program was used to allocate each school within each block to either FYF-SB or UC. One co-author (R.E.B.) completed the allocation sequence assignment of schools to condition and was not involved in consenting, or any procedures including training, or completion of baseline/post-intervention measures. All other authors consented and enrolled participants. Schools assigned to FYF-SB delivered the program during a fall semester, while schools in UC were slated to deliver FYF-SB during the following spring semester. Due to COVID-19, the spring cohort initiated but did not complete FYF-SB.

ISPs participated in a 12-h training delivered by the trainers in partnership with the research team.² Like school administrators, ISPs were also informed that one purpose of the study was to intentionally recruit autistic students from historically marginalized and underserved communities, due to long-standing disparities in access to care. Following the training, ISPs were asked to identify two to five students with known or suspected autism and anxiety and then obtained permission from the families for the researchers to contact them to determine initial eligibility. If the student met eligibility criteria, then informed consent and pre-intervention measures were completed. Caregiver measures were completed through REDCap, an electronic platform for English-speaking families with Internet access. Paper copies were completed by other families. For Spanish-speaking caregivers, a bilingual clinical psychologist completed the measures by phone. Once pre-intervention paperwork was completed, a researcher went to the student’s school, obtained student assent, and supported completion of student baseline measures. All student measures were completed at school using paper copies.

School teams recorded each FYF-SB session and uploaded the videos to a Health Insurance Portability and Accountability Act (HIPAA)-compliant shared drive to allow coding of program adherence and quality. ISPs delivering FYF-SB participated in twice monthly consultations with the trainers and one researcher. After program/UC completion, REDCap links were sent (or paper copies) to the families and teacher informants to complete measures. A researcher went to the students’ schools to assist with post-intervention/UC measure completion. Measures were completed within 2–6 weeks of the final session, or in the case of UC, after the completion of the fall semester. Caregivers and teachers were given gift cards for completion of pre-/post-measures. ISPs (including trainers) were provided gift cards for attending the training and consultations.

FYF-SB program

Students are taught to identify anxiety symptoms, anxiety-provoking situations, and learn coping strategies to manage anxiety (e.g. somatic management, positive self-statements, emotion regulation strategies). They are encouraged to “face their fears” via graded exposure practice. For example, if a student is afraid of flushing toilets in the school bathroom, then exposure practice would involve gradually going into the bathroom, standing near the toilets, listening while others flush the toilets and/or gradually flushing the toilet themselves. Direct teaching of specific skills often occurs alongside exposure practice. Student worksheets included pictorial displays of information, multiple choice lists, and brief “hands-on” activities to enhance the accessibility of CBT content for different learners. Images of youth from diverse racial and ethnic backgrounds were incorporated throughout the materials. FYF-SB is shorter in duration than FYF and is a 12-week, 40-min program with two caregiver contacts, and it was delivered during the school day. Caregiver contacts were comprised of one in-person group session for caregivers of participating children that occurred at the beginning of the program at each individual school. A second “contact” involved caregivers being sent a short video explaining additional session content for them to view independently. Far fewer caregiver sessions were included in FYF-SB compared to FYF, and input from community partners indicated that increased direct caregiver involvement was not feasible in the school environment (Reaven et al., 2019). In efforts to maintain ongoing caregiver awareness of the program, a templated weekly handout was also provided to caregivers and other school staff following each session. Caregiver handouts were translated into caregivers’ preferred language (e.g. Spanish).

UC

Students assigned to UC were allowed to receive anxiety-based interventions or other programs, through school or privately. Although specific information regarding outside therapies was not documented, IEP data indicated that mental health support ranged from 0 to 4 h per month.

Training

A TTT manual was created to support trainers to co-facilitate the training with the researchers. The TTT manual included annotated PowerPoint materials and detailed directions for how to facilitate small group activities and session-by-session review. The 12-h training was comprised of didactic instruction, small group work, and video examples of program content. Content was developed by the researchers and included the identification of anxiety in autistic students and an overview of FYF-SB. Three separate but identical trainings were held in each district for convenience. Adherence checklists indicated that over 90% of elements were completed in each training. Trainer responsibilities included leading portions of didactics, experiential activities, FYF-SB session review, and participating as a panelist to discuss student eligibility and program delivery.

Consultation

Twice monthly consultations (20–30 min) were led by the trainers with support from the researchers. Consultation format consisted of answering questions about program content, provision of positive and constructive feedback from the trainer/researcher (based on review of recorded sessions), brief discussion of upcoming lessons, and guidance around behavior management. Trainers were requested to lead as much of the discussion as they were able to, with researchers supporting their explanations.

Measures

Demographic data

Caregivers completed brief questionnaires regarding student age, race/ethnicity, gender, and caregiver education and family income. ISPs documented similar demographic information, as well as their work experience and professional background.

Student eligibility measures

Screening for symptoms of autism

The SRS-2 (Constantino & Gruber, 2012) is a parent-reported 65-item questionnaire used to identify the presence and severity of autism behaviors, via a 4-point Likert-type scale. Total T-scores above 60 were used as a cutoff for study inclusion, reflecting at least mild autistic symptoms (Reaven et al., 2022). Previous research indicates that this cutoff identified 90% of children diagnosed with autism (Constantino et al., 2007). Test–retest reliability is r = 0.88 after 3 months and r = 0.83 after 27 months. For youth in special education, the SRS-2 demonstrated adequate predictive validity with a sensitivity and specificity of 0.78 (Charman et al., 2007). Adequate internal consistency (Cronbach’s alpha ranged from 0.94–0.96) and content validity have been reported (Constantino & Gruber, 2012).

Screening for cognitive functioning

Students with known ID were excluded. Of the 81 students, 55.6% had IEPs that included intelligence quotient (IQ) data (N = 45). An additional 10 students were administered the Wechsler Abbreviated Scale of Intelligence 2 (WASI-2) by a researcher to obtain IQ data.³ The mean (SD) full-scale score was 94.63 (16.71), mean verbal IQ scale was 97.22 (14.76), and mean nonverbal IQ was 98.78 (17.65).

Effectiveness outcomes (primary)

Three different anxiety measures were used to measure effectiveness. Although there was some overlap across measures, multi-informant perspectives were obtained (e.g. student, caregiver, and teacher) in keeping with best practices (Connolly & Bernstein, 2007). Each measure was administered pre-/post-FYF-SB/UC.

SCARED-P/C

The Screen for Child Anxiety and Related Emotional Disorders–Parent/Child (SCARED-P/C) is a 41-item measure comprised of five anxiety subscales: Panic, Generalized Anxiety, Separation Anxiety, Social Anxiety, and School Anxiety (Birmaher et al., 1999). A Total Score above 25 is clinically meaningful. The SCARED demonstrates excellent psychometric properties for non-autistic youth (Birmaher et al., 1999; Hale et al., 2011), and results from previous work with autistic youth yielded good sensitivity (0.71) and specificity (0.67), strong internal consistency (e.g. Cronbach’s alpha scores for the child total score: 0.92 and parent total score: 0.90), as well as strong convergent validity with a gold-standard clinical interview among parents of autistic youth (Stern et al., 2014).

PRAS-ASD

The PRAS-ASD is a 25-item, parent report measure to assess anxiety in autistic youth (Scahill et al., 2019). Total scores between 0 and 75 are obtained and scores above 44 are clinically relevant. Test–retest reliability is good (0.88; 0.86) and has strong internal consistency (Cronbach’s alpha = 0.93). There is also adequate structural fit via exploratory and confirmatory factor analysis and strong convergent validity with other anxiety measures.

The SAS-TR

SAS-TR is a 16-item teacher-reported measure of anxiety that assesses student behavior from 5 to 12 years of age (Lyneham et al., 2008). Although primarily used with non-autistic students, the SAS-TR has been used with autistic students (Luxford et al., 2017). A total score for anxiety (ranging from 0 to 48) can be obtained along with two subscale scores reflecting social and generalized anxiety, with scores above 17 considered clinically relevant. Teacher informants were designated by either caregivers or ISPs as someone with direct contact with the student and none were ISPs. The SAS-TR has strong internal reliability with a Cronbach’s coefficient of 0.93 for Total scores. Intraclass correlations over an 8-week period were as follows: Total Score intraclass correlation coefficient (ICC) = 0.78, Social Anxiety subtest ICC = 0.81, and Generalized Anxiety subtest ICC = 0.73 (Lyneham et al., 2008).

Implementation outcomes (secondary)

Assessment of CBT knowledge

CBT knowledge was measured via a 20-item multiple choice test pre-/post-training (Reaven et al., 2022). There were two nearly identical versions of the test. Half of the ISPs received version A pre-training, while the other half received version B. Alternate versions were administered to ISPs post-training. Only minor word changes and item order distinguished the two versions.

Treatment adherence and competence

A checklist format was used to assess treatment adherence by recording the presence/absence of all program activities for the 12 sessions. The checklist is organized by session, and all activities for each session are listed. Following the viewing of an FYF-SB session, raters recorded whether each activity for that session was completed. Global ratings of competence were assigned at the end of every session using a 5-point Likert-type scale and encompassed the overall quality by which providers delivered activities. Behavioral anchors for competences were: (1) poor (ISP handled activity poorly and demonstrated lack of understanding or expertise), to (3) adequate (ISP delivered the activity in a “good enough” way), and to (5) excellent (ISP delivered the activity with exemplary skill) quality. Four of the study authors (J.R., A.B.-S., C.M., and L.H.) coded treatment adherence and competence.

Adherence above 80% or greater was considered acceptable. Inter-rater reliability for treatment adherence was calculated based on comparisons of 17 randomly selected sessions distributed across the possible range of recorded intervention videos coded by trainers and researchers. Competence was calculated as an average of ratings across coded sessions. Agreement for overall competence in program delivery was defined as being within 1 point between coders on a 5-point Likert-type scale (see Reaven et al., 2022). The classification of Kappa followed recommended guidelines indicating 0.81 to 1.0 = outstanding, 0.61 to 0.80 = substantial, 0.41 to 0.60 = moderate, 0.21 to 0.40 = fair, and less than 0.21 = poor agreement (Landis & Koch, 1977). In addition to adherence and competence, program dosage was also collected.

Data analysis plan

Effectiveness

To ensure equivalence between the conditions, differences on the background and characterization measures at baseline were tested; this included, race, ethnicity, gender, severity of autism symptoms (SRS-2), and degree of anxiety (SCARED). We further evaluated baseline differences on all outcome measures between participants who had either a medical diagnosis or educational classification of autism compared to those without an autism diagnosis or classification; autism status was also used as a covariate during model testing to perform sensitivity analysis. We used t-tests, chi-squared, and Fischer’s exact tests as needed. Effects of the intervention were then tested using linear mixed models including maximum likelihood estimation and with each outcome analysis undertaken as an intent-to-treat (ITT) basis. Generalized linear mixed models (GLMMs) were used to estimate treatment effect (FYF-SB) compared to UC. In all models, group membership (FYF-SB vs UC) and time (pre- vs post-study participation) were included as fixed effects. Due to the clustered design proposed here, we included school site as a random effect. We also allowed each participants’ intercept to vary independently. Covariates were included as needed to increase precision of the models and measures that differed by group membership at baseline were included as fixed effects to adjust for confounding. In this framework, the test of interest was the interaction between group (FYF-SB vs UC) and time (pre vs post). In the case of significant interaction terms, the results were stratified to ease interpretation. Fixed effects were evaluated if the interaction term was not significant. GLMM has many benefits for clustered RCT designs, given that missing data are handled within the model itself, ability to model random effects such as school clusters, and ability to model many different distribution models (Gibbons et al., 2010). Estimates of effect sizes were based on the following formula d = B/(SE√(n − 1) (Hedges, 2007). To account for multiple testing and the possibility of increasing type 1 errors, we further evaluated our outcomes using a Holm–Bonferroni correction and note differences when indicated (Holm, 1979).

Sample size and power

A power analysis was completed from prior work that identified consistently large effect sizes (Cohen’s d ranged from 0.66 to 0.87) for FYF (Reaven et al., 2012). For the present analysis, we assumed: (1) a similar large effect size, (2) the sample size proposed in this application (minimum n = 76 children), (3) clustering at the school level with three students per cluster, and (4) a repeated measure design with no corrections or adjustments. With these assumptions, we would achieve 99% power to detect an effect of the intervention.

Implementation

The impact of the training was assessed in several ways. First, the ISPs’ CBT knowledge was compared pre-/post-participation in the training with paired sample t-tests. Second, treatment fidelity was assessed by examining adherence to the FYF-SB protocol and the overall competence in delivery. Specifically, adherence was calculated as the percentage of all treatment activities that were completed in coded sessions, with 60% of completed sessions coded for adherence.

Results

Effectiveness outcomes

SCARED–P/C report

Initial testing showed no baseline statistical differences between groups on demographic or psychological functioning. Results of the ITT sample indicated that significant reductions in anxiety were reported from pre- to post-intervention for students assigned to FYF-SB compared to UC, according to Parent SCARED Total score for the interaction of time by group: F(1, 66.52) = 6.61, p = 0.012, Cohen’s d = 0.30. In addition, there were interaction effects of three subscales of the Parent SCARED: Panic: F(1, 70.49) = 5.00, p = 0.028, Cohen’s d = 0.27; Separation: F(1, 68.71) = 10.48, p = 0.002, Cohen’s d = 0.40; and Social Anxiety: F(1, 68.27) = 9.37, p = 0.003, Cohen’s d = 0.37. Finally, significant main effect of time for reduced generalized anxiety disorder (GAD) and school anxiety was reported by parents (p < 0.001), although group and interaction effects were non-significant. Application of the Holm–Bonferroni correction showed that all interactions except SCARED-Panic remained significant when adjusting for multiple comparisons. Similarly, all main effects for Parent SCARED remained significant using this method of adjustment.

Similar to parent report, significant reductions occurred pre- to post-intervention according to child report for Separation (F(1, 69.70) = 5.96, p = 0.017, Cohen’s d = 0.39) and Social Anxiety subscales (F(1, 71.54) = 11.29, p = 0.001), Cohen’s d = 0.40). Significant main effect differences for time were found on child report for Total (p = 0.009) and Generalized Anxiety Subscale of the SCARED (p = 0.006), while group and interaction effects were non-significant. The Holm–Bonferroni adjustment for multiple comparison similarly showed that Child SCARED-Social Anxiety effects, but not Separation effects, remained significant when adjusting for multiple comparisons for the interactions.

PRAS-ASD and SAS-TR

Only a significant main effect of time was shown for PRAS-ASD, in which scores were significantly lower over times, F(1, 57.82) = 9.00, p = 0.004, Cohen’s d = 0.23. In SAS-TR, a significant main effect for time was also shown with no other significant effects F(1, 64.83) = 7.61, p = 0.008, Cohen’s d = 0.23 (see Table 4). A sensitivity analyses using autism diagnosis as a covariate in the models tested for time and group outcomes and showed negligible differences on parameter estimates, suggesting the model remained robust with the addition of the autism diagnostic variable.

Table 4.

Linear mixed model analyses for treatment outcomes.

Variable	Facing your fears school-based				Usual care waitlist control				Time		Group		Interaction		Cohen’s d
	Pre mean	Pre SD	Post mean	Post SD	Pre mean	Pre SD	Post mean	Post SD	F	p-value	F	p-value	F	p-value
SCARED (Parent)
Total	29.66	15.21	19.33	11.63	27.34	14.52	25.42	15.87	13.75	<0.001	0.26	0.62	6.61	0.01	0.30^a
Panic	4.97	5.13	2.74	3.94	4.29	3.94	4.86	5.20	1.45	0.23	0.47	0.50	5.00	0.03^b	0.27
GAD	9.61	4.70	7.28	3.96	9.78	5.19	8.86	5.47	12.24	<0.001	0.47	0.50	1.68	0.20	0.19
Separation	5.47	3.97	2.81	2.43	4.77	3.62	4.51	3.91	14.63	<0.001	0.35	0.56	10.48	0.002	0.40^a
Social anxiety	7.13	4.11	5.03	3.75	6.21	4.13	6.47	3.95	4.69	0.03^b	0.10	0.75	9.37	0.003	0.37^a
School	2.47	2.24	1.44	1.54	1.95	2.15	1.58	2.00	11.15	0.001	0.14	0.71	2.73	0.10	0.15
SCARED (Child)
Total	28.40	15.14	21.90	12.74	27.67	15.31	27.06	13.73	7.25	0.009	0.40	0.53	1.12	0.29	0.15
Panic	6.24	5.43	5.59	4.32	6.48	4.91	6.74	4.86	0.33	0.57	0.51	0.48	0.37	0.55
GAD	6.29	3.92	4.81	3.68	6.62	3.61	5.86	3.60	8.17	0.006	0.85	0.36	0.59	0.45	0.18
Separation	6.53	3.98	4.83	3.39	5.79	3.53	6.28	3.82	2.66	0.11	0.14	0.71	5.96	0.02^b	0.39
Social anxiety	7.00	3.56	4.91	3.79	6.29	3.44	6.95	3.08	2.43	0.12	0.59	0.45	11.29	0.001	0.40^a
School	2.21	1.89	1.80	1.91	2.26	2.25	2.32	2.06	0.93	0.34	0.50	0.48	0.54	0.47
PRAS	27.12	16.36	19.40	14.04	29.89	14.56	25.44	15.21	9.00	0.004	0.68	0.42	2.95	0.09	0.23
SAS-TR^a	14.55	10.01	16.41	8.83	11.92	11.25	17.97	7.95	7.61	0.008	0.05	0.82	1.80	0.18	0.37

SCARED: Screen for Child Anxiety and Related Emotional Disorder; GAD: generalized anxiety disorder; PRAS: Parent-Rated Anxiety Scale; SAS-TR: School Anxiety Scale–Teacher Report.

Effect size reported only for interaction when also present with a significant main effect.

These significant findings were no longer significant when adjusted for multiple comparisons using the Holm–Bonferroni correction method for interactions or main effects.

Implementation outcomes

Assessment of CBT knowledge

Of the 69 ISPs who participated in the study, 61 individuals completed pre-/post-assessments of CBT knowledge. Dependent t-test comparisons showed significantly increased CBT knowledge from pre (M = 77.60, SD = 10.50) to post (M = 87.92, SD = 7.78); t(60) = −6.29, p < 0.001, Cohen’s d = 0.81.

Treatment fidelity (adherence and competence)

The number of FYF-SB sessions completed ranged from 6 to 12 (M = 10). Eleven of 13 school teams completed at least 9/12 sessions and are considered treatment completers. Two school teams completed 6 of 12 sessions, and experienced scheduling difficulties and competing demands that interfered with program completion. Of the 137 total sessions completed, 60% were coded for fidelity. Only 16% of coded sessions occurred in the last half of the program, reflecting challenges that school teams had with recording exposure practice. Adherence was calculated based on percentage of activities that ISPs delivered per session across the 12-week program. Adherence percentages ranged from 73% to 95% for completed sessions, with a mean of 84.13% across the 13 groups.

Competence ratings ranged from 3.63 to 5.00 (M = 4.12; SD = 0.46). One hundred percent of recorded and observed sessions had ratings of 3 or higher, indicating that sessions were delivered in a “good enough” manner. Inter-rater reliability ratings were coded by researchers for overall session quality for 17 sessions and showed substantial agreement, where all but one quality rating was within 1 point of agreement for all coded sessions (κ = 0.77). Similarly, all activities of 17 sessions were coded, and all but 2 sessions were either matched (12/17) or within 1 point of rating regarding the completion of treatment activities (4/17), with an overall substantial agreement reliability rating of κ = 0.76.

Attendance

Although school teams were asked to track student attendance to group, data were inconsistently collected. School teams were instructed to provide make-up sessions when students were absent to help them get caught up on program content (e.g. meeting with students individually to review missed content). Two caregiver contacts were included one contact was an in-person caregiver meeting held at each school for caregivers of participating students and a second contact that involved watching a brief video online. More than half of caregivers attended one or more parent contact (54%) and 8% attended both caregiver contacts (in-person meeting and watching the video).

Discussion

This is the first known study to train mental health and non-mental school providers via a TTT approach to deliver CBT to students with autism or suspected autism and anxiety in elementary and middle public schools. The study was a type 1 hybrid type effectiveness, clustered randomized trial, and examined effectiveness and implementation outcomes.

Effectiveness outcomes

Caregiver and student SCARED ratings indicated significant reductions in anxiety for students in FYF-SB compared to UC. Significant reductions in total anxiety and on the separation and social anxiety subscales occurred according to caregiver report. Student self-report only partially aligned with caregiver report. Significant reductions occurred on the SCARED social anxiety domain for both caregivers and students, but significant reductions in the total SCARED score were not apparent according to student report. Although the exact reasons for these discrepancies are unknown, there is some evidence from previous work comparing the self-report of autistic students to their parents’ report, indicating that parents may report higher anxiety symptoms than their children and that youth with higher meta-cognitive ability have greater alignment with their caregiver’s report of social anxiety (Blakeley-Smith et al., 2012). Continued exploration of the relationship between caregiver and student report of anxiety is suggested.

Results of a second caregiver report measure indicated no significant differences in anxiety between groups (PRAS-ASD). This result is confusing since the PRAS-ASD is highly correlated with the SCARED and was developed for autistic youth (Scahill et al., 2019). Furthermore, teacher informants did not indicate significant reductions in anxiety for students assigned to FYF-SB compared to UC; however, the SAS-TR indicated that anxiety for students in UC appeared to worsen over time. Although caregivers and students observed changes in anxiety, it may be that these changes were not robust enough to be generalized throughout settings and/or noticed by teachers outside of the intervention group.

Finally, it is important to note that program dosage for FYF-SB is significantly less than clinic-based FYF. Clear decreases in dosage as well as reduced caregiver participation may have impacted the overall effectiveness of FYF-SB. In fact, results of the current trial are less robust when compared to previous efficacy trials (Reaven et al., 2012, 2018).

Implementation outcomes

As predicted, CBT knowledge significantly improved for ISPs following the training. Most school teams were able to provide the minimum dosage (75% of sessions) of FYF-SB with good adherence and competence, suggesting that ISPs were generally able to complete the program and deliver FYF-SB as intended.

Implications

Overall, positive effectiveness and implementation outcomes were achieved even though FYF-SB differs from FYF in training processes, facilitator characteristics, intervention dosage, and caregiver participation. Mental health and non-mental school providers were trained to deliver FYF-SB by school trainers with support from the researchers, which has the potential to increase capacity of school providers to treat anxiety in autistic youth. The inclusion of natural change agents represents an important step in meeting the needs of autistic students. The TTT model may be especially powerful as school trainers can provide their colleagues with contextual knowledge in a way that outside researchers cannot. The current research was conducted in public schools with many students from historically underserved communities. Providing EBPs in public schools for autistic students with anxiety has the potential to increase much needed access to mental health care.

Limitations

There were several limitations of the study. First and most importantly, although students were randomized to condition, the primary effectiveness outcomes in this study were not administered by an independent evaluator blind to condition. Caregiver, student, and teacher report were collected, but all informants were aware of whether the student had received FYF-SB. Therefore, the extent to which social desirability played a role in informant ratings is unknown.

In addition, students with autism or suspected autism and anxiety were referred for study participation, and even though the SRS-2 was used to determine the presence and severity of social/communication differences consistent with autism, it is possible that not all students had autism. Caregiver report indicated that just over 48% had a previous diagnosis of autism and just over 55% had an educational identification of autism. Without completion of a comprehensive assessment for autism, the extent to which students presented with conditions other than autism is unknown. Future work may want to weigh the costs and benefits of conducting more rigorous assessment of participants.

Furthermore, student demographic information indicated that even though school administrators and providers were specifically informed that a main purpose of the study was to increase service access for autistic students from historically underserved communities, most of the student sample was White and Non-Hispanic. This suggests that increased efforts, including intentional partnerships and outreach to communities of color, may need to occur to enroll students from traditionally underserved communities in school-based mental health programs.

Finally, although treatment adherence data indicated that most school teams delivered FYF-SB as intended and with at least satisfactory facilitator competence, only 16% of coded sessions included exposure practice. Exposure is often considered to be the most important component of CBT for anxiety (Abramowitz, 2013); although schools had good reasons for being unable to record exposure practice (e.g. for fear that non-study participants would inadvertently be recorded during the exposure), without viewing the actual exposure practices, the extent to which ISPs delivered this core component is unclear.

Future directions

The current mental health crisis paired with limited access to mental health care for many communities clearly supports the ongoing need for rigorous research. The effectiveness outcomes in this trial were mixed and less robust than obtained in previous clinic-based trials (e.g. Reaven et al., 2012), a finding not unexpected given that hybrid-effectiveness trials often involve more uncontrolled variables and unforeseen adaptations (Wood et al., 2015). However, future research should explore ways to increase the effectiveness of FYF-SB, while balancing positive implementation outcomes. Investigating strategies to involve caregivers more actively could support student outcomes by facilitating the carryover of CBT strategies to other settings. An additional direction would be to explore the optimal dosage for delivery of FYF-SB. Although exit interviews from the pilot study indicated that the 40-min 12 weekly sessions were recommended (Pickard et al., 2021), future research could investigate the differential impact of varied intervention dosage on treatment outcome. Examining the relationship between program dosage, adherence and facilitator competence on child outcome will be important. Finally, additional research is needed to explore the sustainment of the TTT approach without researcher involvement, and the extent to which study findings generalize to other school communities.

Conclusion

This study adds to the growing literature examining the delivery of EBPs for students with autism or suspected autism and anxiety in public schools. The encouraging outcomes suggest that a short-term intervention like FYF-SB can positively impact anxiety in autistic youth. More research is needed in the form of head-to-head comparisons of FYF-SB and other interventions, the role of intervention dose and fidelity on treatment outcomes, sustainability of the TTT approach, and examining the role of caregiver participation in school-based mental health interventions.

Footnotes

Acknowledgements

The authors thank the administrators from the participating school districts as well as the many school providers, students and caregivers who participated in this study.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.R. and A.B.-S. receive royalties from Paul Brookes Publishing for the publication of the original Facing Your Fears manual.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Health Resources and Services Administration (HRSA) (PI: J.R.—1 R41MC31075-01-00). J.R. was supported, in part, by the HRSA under the Leadership Education in Neurodevelopmental Disabilities (LEND) (grant T73MC11044) and by the Administration on Intellectual and Developmental Disabilities (AIDD) under the University Center of Excellence in Developmental Disabilities (UCDEDD) (grant 90DD0632) of the US Department of Health and Human Services (HHS). This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government.

Trial registration

The clinical trial registration for this study is NCT03685474 ().

ORCID iDs

Judy Reaven

Katherine Pickard

Aubyn Stahmer

Data access and responsibility

The principal investigator, J.R., had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Notes

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