Facing Your Fears in Schools: Implementing a CBT Program for Students With ASD or Other Special Learning Needs
Condition: Autism Spectrum Disorder
MeSH terms: Autism Spectrum Disorder
Study type: Interventional

Summary: 
      The overall goal of the project is to develop a feasible, effective and sustainable
      school-based program to manage anxiety in elementary and middle school students with Autism
      Spectrum Disorder (ASD) and other special learning needs. There are two phases to this
      Department of Health and Human Services/Health Resources and Services Administration-funded
      research. In the first phase, there will be engagement of community partners in the process
      of developing the adapted intervention for implementation in schools. The first phase is
      ongoing until approximately fall of 2018.

      This project is the second phase of this program of research and is focused on piloting and
      implementing the school-based intervention within 3 local school districts in a systematic
      and sustainable way - through a "train-the-trainer" model. Primary aims are:

        1. to prepare cross-disciplinary teams of School - Based Trainers to conduct three pilot
           student groups of Facing Your Fears - School Based (FYF-SB) within their own district,
           with the goal of later training others in their districts to deliver FYF-SB.

        2. at the start of the following academic year (2019-2020), within each of the three
           participating districts, 10 schools will be randomized to one of two conditions for the
           fall semester: a) FYF-SB or b) Usual Care; and assess implementation and treatment
           outcomes.
    

Detailed description: 
      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.
    

Intervention name(s): Facing Your Fears - School Based; Usual Care
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants receiving FYF-SB will receive cognitive-behavioral treatment (CBT), which is an evidence-based practice (EBP) for treating anxiety in typical youth, within their school setting.; Participants receiving usual care will experience no different therapies, strategies, or recommendations other than what would typically be administered within the school setting in the absence of the proposed study.
Other intervention name(s): Cognitive Behavioral Treatment
Allocation: Randomized
Intervention model: Crossover Assignment
Intervention model description: In the present study, we will use the measure entitled Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM; Glasgow, 2013) as a framework for planning and implementing FYF-SB in the school environment. The translation of research from controlled research settings to natural environments is often an exceptionally slow process, perhaps because of the emphasis on efficacy. A pragmatic framework such as RE-AIM can hasten the portability of evidenced based intervention to "real-world" practice by focusing on stakeholder feedback and environmental context, in conjunction with intervention development and content.
We plan to conduct a randomized controlled trial of the FYF-SB intervention across 30 schools within 3 districts. The intervention conditions occur for 1 semester within an academic year. Data will be collected in a pre-post design (before and after the condition of either Facing Your Fears - School Based or Usual Care).
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Special Learning Needs; Minority Groups