Improving Transportability of a CBT Intervention for Anxiety in Youth with ASD: Results From a US-Canada Collaboration

Background: Psychiatric disorders frequently co-occur in youth with autism spectrum disorders (ASD) and markedly impede treatment progress (Levy et al., 2010). Anxiety disorders are among the most commonly co-occurring conditions (Leyfer et al., 2006; van Steensel et al., 2011). Cognitive-behavioral treatments (CBT) are well-established, evidenced-based treatments and have been used in youth with ASD with encouraging results (Olatunji et al., 2010; Reaven et al., 2012; Wood et al., 2009).   While it has been critically important to develop treatments for the co-occurring anxiety symptoms in children with ASD, it is equally important to facilitate the portability and sustainability of these treatments to real-world settings (Schoenwald & Hoagwood, 2001).  To bridge the gap between lab and community settings, introducing new treatments into real-world settings early in the process may inform intervention development, increase acceptability, and maximize success for clinical practice (Weisz et al., 2004).  Objectives: 1) To train mental health clinicians outside of our research program to deliver Facing Your Fears: Group Therapy for Managing Anxiety in Children with High-Functioning ASD (FYF: Reaven et al., 2011) to fidelity; 2) to examine youth treatment outcome; and 3) to obtain acceptability data from participants to inform the intervention. Methods: Clinicians (e.g., psychologists/psychologists-in-training) participated in a 2½ day training plus twice monthly phone consultation. Sixteen children ages 8-14 (and their parents) participated in the study and met the following inclusion criteria: 1) current clinical diagnosis of ASD, 2) exceeding criteria for ASD on both the ADOS and the SCQ, 3) presenting with clinically significant symptoms of anxiety on the Anxiety Disorders Interview Schedule – Parent Version (ADIS-P; Silverman & Albano, 1998), and 4) verbal IQ of 80 or higher. Four 14-week group cohorts for children and their families were conducted.  Multiple outcome measures were used, including the Clinical Global Impression-Improvement Scale (CGIS-I), derived from the ADIS-P, and the Screen for Child Anxiety Related Disorders (SCARED; Birmaher et al., 1999).  Results: Clinicians demonstrated significant improvements on CBT Knowledge Tests after attending training, t(9)=2.41, p=.02. Treatment fidelity ranged from 87-95% (M=92%) across all four cohorts. Significant decreases in parent-reported youth anxiety symptoms (SCARED) occurred following treatment, t(13)=4.16, p=.001. Further, 54% of the sample demonstrated a clinically meaningful improvement for the primary anxiety diagnosis post-intervention. Child, parent, and clinician participants completed session-by-session acceptability ratings for all four groups. FYF was viewed favorably across all participant groups (M=4.15, SD=.50; Likert ratings 1-5), although participants in the second group cohort yielded acceptability ratings that were significantly lower than the other three groups. Critiques from participants were incorporated into revisions of the FYF program.  Conclusions: Preliminary findings indicate that FYF may be successfully implemented by clinicians naïve to FYF.  Clinicians achieved excellent treatment fidelity and child participants demonstrated significant reductions in anxiety symptoms post-intervention. Furthermore, results indicated that FYF was acceptable to all participants. This study supports the initial effectiveness and potential transportability of FYF for treating the anxiety of children with ASD in real-world clinical settings. Limitations include small sample size and lack of a control group.