Treatment Fidelity and Clinician Experience: Implementation of “Facing Your Fears” in Outpatient Settings

Background:  Clinician training and ability to implement a treatment program to fidelity are potential barriers to the transportability of evidenced based interventions (EBP) for youth with autism spectrum disorders (ASD) to outpatient clinics.  When youth present with both ASD and anxiety, clinician training issues are even more relevant.  Unfortunately, there are few clinicians with both ASD and anxiety experience.  In efforts to increase training of new clinicians, it is important to determine the background or experience required to implement an EBP to fidelity, (e.g., experience with ASD or experience with anxiety).   The role of clinician experience was examined in a study implementing one such EBP, Facing Your Fears (FYF; Reaven et al., 2011), a group cognitive behavior therapy for youth with ASD and anxiety, in outpatient settings.  

Objectives:  

(1) Examine whether clinician experience (i.e., years of ASD and/or anxiety experience) impacted fidelity ratings across three instructional conditions: Manual (manual only), Workshop (two-day workshop) and Workshop Plus (workshop plus bi-weekly consultation).

(2) Examine whether the quality of overall FYF delivery and the delivery of certain FYF components (i.e., psychoeducation, instruction on exposure, and implementation of exposure) varied across instructional conditions.

Methods:  A three group parallel design was used to randomize eight teams of three clinicians, to one of the three training conditions.  Four outpatient university clinics with 35 clinicians participated in delivering 24 groups of FYF across sites. Clinicians completed a questionnaire on treatment experience, reporting the number of years’ experience with anxiety and/or ASD. Treatment fidelity was evaluated by two clinicians who rated 100% of videotaped sessions across all sites and conditions.    Sessions were scored for absolute fidelity of all treatment components (absence/presence), quality of implementation (Likert scale, 1-5), and thoroughness of delivery of specified intervention components (i.e., Likert scale, 1-5).

Results:  

(1) Clinician Characteristics. There were no significant differences across conditions in the number of years’ experience clinicians had with ASD: F (2,31)=.053, p=.95. However, clinicians in the Manual condition had significantly more experience treating anxiety [F (2,31)=5.34, p=.95] . Greater ASD experience was associated with better fidelity (p = .039).(2) Quality of Treatment Delivery and Treatment Components:  Quality ratings for the delivery of FYF was significantly greater for the Workshop/Workshop Plus conditions than for the Manual condition: F (2, 1374)=50.55, p<0001.  There were no significant differences in the thoroughness by which clinicians implemented psychoeducational activities or instructional activities on exposure across conditions; however, Workshop Plus had significantly higher ratings of thorough implementation of in-vivo exposure activities, with the Manual condition faring significantly worse than chance (standardized residual 3.5 for fidelity=0).

Conclusions: Clinicians with greater ASD experience had significantly higher treatment fidelity ratings; however, clinicians across all three instructional conditions delivered FYF with good adherence. Clinicians in the Manual condition had significantly greater anxiety experience than clinicians in the Workshop conditions. Clinicians participating in the Workshop conditions provided significantly higher quality delivery of FYF and were more thorough in the implementation of all treatment components (including in-vivo exposure). These results will be discussed in light of child treatment outcome.