Facing Your Fears in Schools: Implementing a CBT Program for Students With ASD or Other Special Learning Needs

Children with Autism Spectrum Disorder (ASD) are at high risk for developing clinically
significant anxiety. Anxiety markedly interferes with peer relationships, family functioning
and participation in academic programming. Youth with ASD demonstrate significant reductions
in anxiety following participation in treatments rooted in evidence-based practice (EBP) such
as cognitive behavior therapy (CBT). The treatment program, Facing Your Fears (FYF), is one
such EBP. However, substantial disparities in access to psychiatric services exist,
particularly for youth from minority and/or low income families. Schools may be the ideal
location to access these services because they represent one of the only consistent resources
available to many low resourced families.

The current proposal is innovative for several reasons: (1) There are very few published
studies examining the effectiveness of treatments for children with ASD and anxiety in
schools, and none that have focused on under-resourced communities; (2) There are no known
studies that have identified students for an intervention program according to special
education eligibility criteria, combined with other inclusion criteria, an approach which
will likely serve more students, and in turn, potentially increase the feasibility of FYF-SB;
(3) a "train the trainer" model will result in increased capacity for low resourced schools
to serve underserved youth; and (4) Finally, the current study is one of the first to examine
organizational constructs that are potentially associated with adoption of FYF-SB, the
results of which would help determine critical next steps in implementation research.

Overview of Facing Your Fears (FYF): The clinical version of FYF is a 14-week, family-focused
CBT group intervention (1 ½ hours each session) aimed toward managing anxiety in children
ages 8-14 with high-functioning ASD. FYF is composed of three books (e.g., facilitators,
parents and children) and a digital versatile disc (DVD). The 14 weeks are divided into two,
seven-session intervention blocks: (1) an introduction to anxiety symptoms with an emphasis
on the individual expression of anxiety symptoms, as well as an introduction to common CBT
strategies, and (2) a focus on using specific tools and strategies (i.e. deep breathing,
positive coping statements and graded exposure--facing fears a little at a time) to improve
emotion regulation and manage anxiety symptoms. Although FYF was originally developed for
youth with ASD, there is no mention of ASD in the curriculum, as the focus is exclusively on
management of anxiety. Importantly, careful attention was paid to the delivery of core
concepts, given the social, communicative and cognitive challenges of youth with ASD (Moree &
Davis, 2010). The use of written worksheets, multiple choice lists, emphasis on creative and
varied outlets for expression, use of video modeling and a focus on strengths and talents
make FYF ideal for students with special learning needs.

Facing Your Fears: School-Based (FYF-SB): FYF-SB will be very similar to FYF, but will be
modified for delivery in school settings. Phase 1 study, currently in completion, will enable
input to be obtained from school personnel, district leaders and parents as a way to
determine the best ways to adapt the intervention for schools. Thus the logistical details of
how the intervention will be offered to students within each participating school district
has been discussed in detail with each of the 3 participating districts' leaders and key
personnel.

Research Methods:

Aim 1: Implement FYF-SB in school settings and assess effectiveness Train teams of
School-Based Trainers to deliver FYF-SB to students and then train other professionals.
Cross-disciplinary school providers will be selected by district administrators to serve as
School-Based Trainers ("Trainers"). The Trainers (10 per district will be recruited to
account for attrition) will be trained to deliver FYF-SB to small groups of 2-4 students with
ASD or special learning needs and anxiety during the initial pilot study of the intervention.
These school-based professionals will become the "trainers" for their own individual
districts, once they have completed their own training activities.

Becoming a School-Based Trainer for the project will involve: (1) Attending a two day
interactive workshop, focused on the principles of CBT and core components of FYF-SB. The
training will take place during non-academic periods. The workshop will be interactive and
dynamic (per Becker & Stirman, 2011), including group discussion, experiential exercises,
small group activities and videotaped examples. (2) Participating in ongoing consultation and
technical assistance throughout at least one academic year with the research team; (3)
Meeting expectations for fidelity on the intervention (average fidelity score >80%, based on
a minimum of 3 observations). School-Based Trainers who do not meet the fidelity requirements
will be asked to participate in additional training in order to continue in that role.
School-Based Trainers can always decide to become School-Based Providers (delivering the
intervention to students, but not train others) instead and/or can always decide to
participate in the project or not, as their participation is purely voluntary.

Aim 2 - Randomize schools across three districts to either FYF-SB or Usual Care (UC) and
assess outcomes. The second part of the implementation phase is to evaluate the effectiveness
of FY-SB; thus, a small randomized controlled trial will be conducted across school
districts. Trainers will participate in "train the trainer" activities to prepare them for
training their own school teams in the delivery of FYF-SB. Ten schools across each district
will be randomized to either FYF-SB or Usual Care. The five schools (and their School-Based
Trainers and School Providers) that are randomized to FYF-SB, will receive training and
consultation from the Trainers, and school providers will deliver FYF-SB to a cohort of
target students. Schools that are randomized to Usual Care will identify students who meet
inclusion criteria for the study, and will take pre- and post-wait assessment data. The UC
Sites will have the opportunity to deliver FYF-SB the next semester if they so choose.
Investigators anticipate 60 providers will be trained across the districts.

FYF-SB will be delivered in elementary and middle schools across three main districts: Cherry
Creek School District (CCSD), Denver Public Schools (DPS) and Littleton Public Schools (LPS).
All three districts have economically and ethnically diverse student bodies. DPS is the
largest district of the three, with 93 elementary schools. The student population in DPS is
more than 56% Hispanic and 14% African American. CCSD has 42 elementary schools and LPS has
13 elementary schools; all three districts also have racially and ethnically diverse schools,
as well as low-income populations. All of the districts have large populations of students
with ASD. The districts have all expressed strong interest in this project, and have been
actively involved in Phase 1.

The results of this study will provide information about the feasibility and acceptability of
implementing a school-based cognitive behavioral intervention aimed at reducing the impact of
anxiety on school functioning for students with ASD. If this method of treatment delivery
proves to be feasible and potentially effective, it has the potential to improve access to
mental health support for youth who do not have ready access to specialists in the medical
community and for whom mental health supports are provided primarily in educational settings.

Successful completion of this study will result in a sustainable school based treatment
program to manage anxiety in students with ASD or other special learning needs. Successful
implementation and treatment outcomes will result in improved internal capacity of schools to
treat the significant and interfering anxious symptoms of underserved students with ASD or
other special learning needs. Reductions in interfering anxiety symptoms for high risk,
underserved students with ASD or other special learning needs, can lead to marked
improvements in school functioning. The results of this study will also help to identify
factors that may influence the implementation of FYF-SB (e.g., organizational constructs,
principal leadership), which may help determine critical next steps in implementation
research in school settings.

Inclusion Criteria:

1. Estimated Verbal intelligence quotient (IQ) of 80 or above as determined by the
Weschler Abbreviated Scales of Intelligence (WASI), or an equivalent measure
administered within the past three years; or presents with achievement scores in
school records that suggest average-low average-borderline intellectual functioning

2. Clinically significant anxiety symptoms as defined by significant elevations on either
the SCARED, or PRAS-ASD, according to either student, parent, or teacher report

3. Currently staffed into special education with an individualized education plan (IEP)
or 504 with one of the following eligibility categories: autism, other health
impairment, emotional disturbance, specific learning disabilities, multiple
disabilities or other speech/language impairment; OR currently identified as at risk
and in need of Response to Intervention (RTI) consultation and not yet found to be
eligible for special education services OR currently in the process of completing the
educational eligibility evaluation

4. Significant deficits in reciprocal social behavior as defined by a Total T Score on
the Social Responsive Scale Version 2 (SRS-2) of 60 or above

5. Lives with parent/guardian who can provide consent for participation.

Exclusion Criteria:

(1) Presentation of psychosis, severe aggressive behavior, or other severe clinical
symptoms that require more intensive treatment such as day treatment or hospitalization