Implementing the Facing Your Fears Program in Clinical Settings: Balancing Treatment Fidelity and Model Adaptation

Background: Anxiety disorders frequently co-occur in youth with high-functioning autism spectrum disorders (ASD) (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 in well-controlled research settings with encouraging results (Reaven et al. 2012; Storch et al. 2013). However, little research exists on the implementation and dissemination of these treatments beyond research settings. Furthermore, little is known about the variables that enhance the ultimate adoption of new interventions to real-world settings. The balance between treatment fidelity and flexible adaptations of treatment models may be critical to understand as evidenced based interventions are disseminated into community settings (McHugh et al. 2009). Successful adoption of new interventions may be most likely to occur when clinicians implement interventions long after training has ended and strong treatment fidelity (without drift) is maintained (Beidas et al. 2011; Carroll, 2013).

Objectives: 1) to train mental health clinicians to deliver Facing Your Fears (FYF), a group CBT program for youth with ASD and anxiety; 2) examine the relationship between treatment fidelity and model adaptation in an effectiveness trial; and 3) to determine whether clinicians trained in FYF maintain high treatment fidelity more than two years post-training. 

Methods: Clinicians (e.g., psychologists/psychologists-in-training) participated in a 2 day training on the FYF intervention. A well-characterized sample of 16 children ages 8-14 (and their parents) participated in the study. Four 14-week group cohorts for children and their families were conducted. Treatment fidelity was examined and acceptability data obtained from all participants, which was incorporated into a revised version of FYF. Preliminary treatment outcome data was obtained for the 16 youth participants. In addition, treatment fidelity will also be examined in a FYF cohort conducted more than 2 years following the training workshop to assess drift.

Results: Excellent treatment fidelity was obtained following participation in the original study (87%-95%; M=92%). Acceptability data was collected across all cohorts and specific suggestions for changes in treatment delivery were incorporated into revisions of the FYF program to increase adoptability of program by clinical settings. Preliminary treatment outcome data indicated significant decreases in parent reported anxiety (SCARED), and 54% of the sample demonstrated clinically meaningful improvement for primary anxiety diagnoses. Long-term treatment fidelity will be examined for the cohort conducted 2 years post-training.

Conclusions: Results indicated that clinicians new to FYF demonstrated strong treatment fidelity post-training and consultation. Preliminary efficacy data demonstrates corresponding reductions in anxiety for youth participants. An examination of the relationship between treatment fidelity, model adaptations and long-term sustainability of FYF for new clinical settings will be discussed. Further, key characteristics of the FYF program will be presented on dimensions such as relative advantage, (perception that FYF is better than existing interventions) compatibility (the extent to which FYF is compatible with a new settings’ values and priorities) and complexity (perceived difficulty of the FYF to deliver) (Dingfelder & Mandell, 2011). Broader implications for dissemination of evidenced based programs will be explored.