Training Clinicians to Deliver Group Cognitive Behavior Therapy to Manage Anxiety in Youth with High-Functioning ASD: Results of a Multi-Site Trial

Background:  Children with ASD are at high risk for developing anxiety disorders (van Steensel et al. 2011). Cognitive-behavioral treatments (CBT) such as the Facing Your Fears (FYF) group treatment (Reaven et al., 2011) have demonstrated strong efficacy in the reduction of anxiety for youth with high-functioning ASD (Reaven et al. 2012; Ung et al. 2014).  While it has been critically important to develop treatments for anxiety, it is equally important to facilitate the portability of these treatments to “real world” settings.  Common efforts to disseminate treatments in the community consist of distribution of manuals, only occasionally paired with brief trainings (Rounsaville et al. 2005).  A systematic comparison of clinician training methods for delivering CBT to children with ASD, tied to improved child outcomes, can provide guidelines for training real-world clinicians. 

Objectives:  (1) To identify an optimal training model to deliver FYF by comparing three instructional conditions: Manual (manual only), Workshop (two-day workshop) and Workshop Plus (workshop plus bi-weekly consultation); and (2) To examine the effectiveness of instructional method by assessing:  a) clinicians’ understanding of FYF (CBT Knowledge; Treatment Fidelity), and b) decreases in anxiety symptoms for youth participants (SCARED; ADIS-P).   

Methods:  A three group parallel design was used to randomize eight teams of three clinicians, to one of the three aforementioned conditions.  Four outpatient clinics across the US, serving youth with ASD, participated in the study.  Thirty-five clinicians delivered the 14-week FYF intervention across sites.  A well-characterized sample (e.g., ADOS-2; SCQ) of 94 children with ASD ages 8-14 (and their parents) were randomized to condition; 80 children completed treatment.  Fidelity and youth anxiety treatment outcome (SCARED; ADIS-P) was examined across all sites and conditions.  

Results:  Clinicians in both Workshop conditions significantly increased CBT knowledge post-workshop F (1,18)=19.81, p< .0001. Excellent treatment fidelity (absence/presence of core components) was obtained across all conditions (Manual – 89.9%; Workshop – 92.8%; and Workshop Plus – 93.2%), although Manual was significantly lower than would be expected by chance X(2)=11.94, p=.003.   Results of the intent-to-treat sample, yielded a significant interaction between time/condition in parent reported anxiety (SCARED) p=.04, with youth in both Workshop conditions demonstrating significant decreases in anxiety, and better than Manual.  There was also a significant effect for time for child reported anxiety (SCARED), but not for condition, p=.04.  Significant decreases in severity of Separation (p<.002), Specific (p<.0001), Generalized (p<.0001) and Social Anxiety Disorders (p<.0001), as derived from the ADIS-P, occurred for time.  There was also a significant effect for time/condition, as youth with Social Anxiety Disorder in the Workshopcondition, demonstrated significant improvements in symptoms relative to the other conditions p=.002.  

Conclusions:  Clinicians in all conditions delivered FYF with good adherence. Significant reductions in anxiety symptoms were apparent across conditions. While there may be an advantage to participating in the Workshop conditions, these results suggest that clinicians in Manual condition were able to read the Facing Your Fears manual, and achieve solid fidelity and youth outcome.  Implications for implementation of evidenced based programs will be discussed.