A cluster randomized controlled trial comparing the effectiveness of two school-based interventions for autistic youth with anxiety.

BACKGROUND: Recent systematic reviews have indicated that cognitive behavioral therapy (CBT) is effective in reducing anxiety symptoms for autistic and non-autistic children. However, the vast majority of CBT research for autistic youth has been implemented within university settings and primarily by mental health providers. Schools hold great promise to equitably manage the mental health symptoms of autistic youth. Although preliminary research evaluating CBT within schools has been promising, CBT has not yet been compared to another readily available school mental health program. The goal of this protocol paper is to describe a multi-site study comparing two school-based interventions, Facing Your Fears-School Based (FYF-SB) and Zones of Regulation (ZOR) via a cluster randomized controlled type 1 hybrid effectiveness-implementation trial to determine which of the two interventions will best support autistic youth with anxiety in schools. METHODS: Up to 100 elementary and middle schools will be randomized into FYF-SB or ZOR. Once schools are randomized, a minimum of two interdisciplinary school providers at each school will be trained to deliver either FYF-SB or ZOR over the course of 12 weeks to groups of 2-5 autistic students ages 8-14 years. Over the course of two years, a total of 200 autistic students will receive either ZOR or FYF-SB. The primary outcome of this trial is child anxiety, as rated by masked evaluators and via caregiver- and student-report, which will be measured at baseline, post-treatment, and 6-month follow-up. Semi-structured interviews will also be conducted with a purposive sample of students, caregivers, and school providers to understand the acceptability, appropriateness, and feasibility of either ZOR or FYF-SB. Stakeholder engagement is a central component of this project via two stakeholder advisory boards that will directly inform and oversee the project. DISCUSSION: Results of this study will provide evidence about the relative impact of two school-based mental health interventions on outcomes reported as meaningful by caregivers and school providers. The additional focus on evaluating factors that support the implementation of FYF-SB and ZOR will allow future studies to test targeted implementation strategies that support mental health programming uptake and implementation within public schools. TRIAL REGISTRATION: This trial is registered with clinicaltrials.gov (NCT05863520).

Implementing school-based cognitive behavior therapy for anxiety in students with autism or suspected autism via a train-the-trainer approach: Results from a clustered randomized trial.

LAY ABSTRACT: Autistic youth frequently experience anxiety that can negatively affect them at home, with friends, and at school. Autistic youth have difficulty accessing mental health care, and this is particularly true for youth from traditionally underserved backgrounds. Providing mental health programs in schools may increase access to care for autistic youth with anxiety. The purpose of the study was to train interdisciplinary school providers to deliver school-based Facing Your Fears, a cognitive behavior therapy program for anxiety in autistic youth. Seventy-seven interdisciplinary school providers across 25 elementary/middle schools were trained by their colleagues and members of the research (train-the-trainer approach). Eighty-one students with autism or suspected autism, ages 8-14 years, were randomly assigned to either school-based Facing Your Fears or usual care. Students in school-based Facing Your Fears showed significant reductions in anxiety compared to students in usual care according to caregiver and student report. Other measures involved examining change in provider cognitive behavior therapy knowledge after training and determining how well interdisciplinary school providers were able to deliver school-based Facing Your Fears. Results indicated that interdisciplinary school providers showed significant improvements in cognitive behavior therapy knowledge after training. Interdisciplinary school providers were able to deliver most of school-based Facing Your Fears activities and with good quality. The positive outcomes in this study are encouraging. Training interdisciplinary school providers to deliver school-based Facing Your Fears may increase access to care for anxious autistic students. Future directions and limitations are discussed.

The Role of Maternal Anxiety in Treatment Response for Youth with ASD and Co-occurring Anxiety.

Anxiety disorders occur at higher rates in youth with ASD than in neurotypical youth. Although the efficacy of CBT for anxiety in children with ASD is widely supported, factors that influence treatment outcomes are not well understood. This study examined the role of maternal anxiety in treatment outcomes for youth with ASD. Youth with ASD and anxiety (ages 8 to 14), along with their mothers (n = 87), participated in a group CBT intervention. Results indicated that maternal anxiety did not improve over the course of treatment. However, findings suggest that high levels of maternal anxiety at pre-treatment predicted higher levels of youth anxiety post-treatment. Importantly, the relationship between parent anxiety and youth outcomes was moderated by child age. The findings of the present study may provide initial insight into the role that maternal anxiety plays in treatment outcomes for children with ASD and co-occurring anxiety, particularly when considering child age.

Effect of Co-occurring Psychiatric Disorders on Treatment of Children with Autism Spectrum Disorder and Anxiety.

Co-occurring psychiatric diagnoses are very common in individuals with ASD. Little is known about the effect that co-occurring psychiatric conditions may have on treatment response to CBT for children with ASD and anxiety. The present study examined the relationship between co-occurring psychiatric diagnoses and response to CBT for anxiety in ninety youth with ASD. Psychiatric complexity did not appear to differentially impact treatment response. A notable portion of youth with anxiety and externalizing disorders such as ADHD, no longer met criteria for those externalizing diagnoses following intervention. Results indicate that youth with ASD and anxiety present with complex psychiatric profiles and CBT for anxiety may positively affect co-occurring diagnoses. In addition, thorough and nuanced assessment of psychiatric symptoms in youth with ASD is needed to ensure the differentiation between diagnoses of anxiety and other co-occurring psychiatric symptoms.

Balancing Fidelity and Flexibility: Usual Care for Young Children With an Increased Likelihood of Having Autism Spectrum Disorder Within an Early Intervention System.

Naturalistic developmental behavioral interventions (NDBIs) are evidence-based interventions for young children with autism spectrum disorder. There has been growing interest in implementing manualized NDBIs within the early intervention (EI) system without a clear understanding of how these programs and the broader strategies encompassed within them are already used by EI providers. This study examined the use of manualized NDBI programs and broader NDBI strategies within an EI system and factors that impacted their use. Eighty-eight EI providers completed a measure of NDBI program and strategy use. Thirty-three providers participated in a supplemental focus group or interview. Overall, providers described using broader NDBI strategies and the need to adapt manualized NDBI programs. Provider-, intervention-, and organization-level factors impacted their use of NDBI programs and strategies.

From Clinic to Classroom: Two Case Studies of Youth With ASD and Anxiety From the School-Based Facing Your Fears Program.

Cognitive behavioral therapy (CBT) is considered best practice for treating anxiety in youth with autism spectrum disorder (ASD) in clinic settings. However, there is significant need to translate CBT into school settings. This paper presents two case illustrations of students who participated in the Facing Your Fears: School-Based program (FYF-SB), a manualized, group CBT intervention for anxiety in ASD, adapted for delivery in schools by interdisciplinary school providers. Students showed improvement in anxiety across multiple domains following intervention, according to clinical interview and parent- and self-report. These outcomes suggest that anxious youth with ASD can benefit from CBT delivered by interdisciplinary school providers. Importantly, decreases in anxiety symptoms were evident in domains that were not explicitly targeted during intervention. Overall, these case illustrations help frame areas of future research, including examining how treatment gains may generalize across anxiety domains as well as whether corresponding improvement in school functioning occurs.

Using evaluative frameworks to examine the implementation outcomes of a cognitive behavioral therapy program for autistic students with anxiety within public school settings.

LAY ABSTRACT: Cognitive behavioral therapy helps to treat anxiety symptoms in autistic youth, but it is difficult for families to access cognitive behavioral therapy in the community. Training school providers to deliver cognitive behavioral therapy may help autistic youth and their families to access these programs. Unfortunately, we do not know how cognitive behavioral therapy programs can be delivered by school providers and how these programs help the autistic students who access them. This study addressed this gap and was part of a larger study that looked at the effectiveness of Facing Your Fears-School-Based in 25 public schools. The study goals were to understand whether Facing Your Fears-School-Based helped students and the factors that made it easy or difficult to deliver Facing Your Fears-School-Based in schools. Thirty providers participated in interviews guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Participants shared information that fell into several major categories that included (1) delivering Facing Your Fears-School-Based to many different students; (2) the positive impact of Facing Your Fears-School-Based on students' school participation; and (3) plans to continue using Facing Your Fears-School-Based. School providers also shared that Facing Your Fears-School-Based was easy to use for non-mental health providers and reported adapting Facing Your Fears-School-Based to meet student needs. The results of this study suggest that Facing Your Fears-School-Based may help autistic students and highlight the importance of using mental health programs in schools that are flexible, able to be adapted, and that are able to be used by many different types of school providers.

Group Cognitive Behavioural Treatment for Anxiety in Autistic Adolescents with Intellectual Disability: A Pilot and Feasibility Study.

BACKGROUND: Adolescents with Autism Spectrum Disorder (ASD) and intellectual disability evidence significant anxiety. This study aimed to adapt a group cognitive behaviour therapies (CBT) programme designed for youth with ASD and anxiety to meet the cognitive, communication, and behavioural needs of adolescents with intellectual disability, and assess initial feasibility and efficacy of the intervention. METHODS: Structural, content and procedural adaptations were made to a 14-week family-focused CBT intervention. Twenty-three adolescents with ASD, intellectual disability and anxiety were included. Treatment acceptability along with adolescent anxiety symptoms was assessed via parent report measures. RESULTS: Of the 23 participants, 19 completed treatment and attended 94% of sessions. Parent acceptability was high. Significant reductions were noted on anxiety symptoms post-intervention. CONCLUSIONS: Results indicate that the CBT group was feasible and acceptable. Preliminary outcomes suggest that adolescent anxiety improved, although replication with a larger sample and comparison to a control group is needed.

Disparities in autism spectrum disorder diagnoses among 8-year-old children in Colorado: Who are we missing?

LAY ABSTRACT: Although autism can be reliably diagnosed as early as 2 years of age, many children are not diagnosed with autism until much later. We analyzed data to determine why many of the 8-year-old children who resided in Colorado and were identified as having autism through a review of their health and/or educational records did not have a documented clinical diagnosis of autism and were not eligible for special education services under an autism eligibility. We found that children who did not have a documented clinical diagnosis of autism and were not eligible for special education services under an autism eligibility were more likely to be female, aggressive, and argumentative. They had a poorer quality of information in their records and were less likely to have had a developmental regression, sleep problems, or an autism screener or diagnostic measure in their records. These results suggest that the symptoms characteristic of autism among this group of children may have been attributed to another disorder and that clinicians may be able to recognize autism more readily in children with more functional impairment and those who experience a developmental regression. We also discovered that differences in symptom presentations among children who had a documented clinical diagnosis of autism and/or were eligible for special education services under an autism eligibility were associated with different ages at autism diagnosis.

A Nexus Model of Restricted Interests in Autism Spectrum Disorder.

Restricted interests (RIs) in autism spectrum disorder (ASD) are clinically impairing interests of unusual focus or intensity. They are a subtype of restricted and repetitive behaviors which are one of two diagnostic criteria for the disorder. Despite the near ubiquity of RIs in ASD, the neural basis for their development is not well understood. However, recent cognitive neuroscience findings from nonclinical samples and from individuals with ASD shed light on neural mechanisms that may explain the emergence of RIs. We propose the nexus model of RIs in ASD, a novel conceptualization of this symptom domain that suggests that RIs may reflect a co-opting of brain systems that typically serve to integrate complex attention, memory, semantic, and social communication functions during development. The nexus model of RIs hypothesizes that when social communicative development is compromised, brain functions typically located within the lateral surface of cortex may expand into social processing brain systems and alter cortical representations of various cognitive functions during development. These changes, in turn, promote the development of RIs as an alternative process mediated by these brain networks. The nexus model of RIs makes testable predictions about reciprocal relations between the impaired development of social communication and the emergence of RIs in ASD and suggests novel avenues for treatment development.

Emotion regulation: A treatment target for autism spectrum disorder.

Individuals with autism spectrum disorder (ASD) tend to experience difficulties with emotion regulation (ER). Treatments designed to address ER difficulties in individuals with ASD are emerging. The authors review cognitive-behavioral therapy (CBT) and mindfulness-based treatments that have focused on ER difficulties in youth and young adults with ASD. In general, these treatments addressing ER skills have included awareness of emotions/psychoeducation about emotions, frustration tolerance, and ER skills, as well as practice and use of these skills during group therapy that sometimes includes caregivers. The results from these interventions are encouraging for individuals with high-functioning ASD because ER skills tend to improve following treatment. The inclusion of ER in other ASD treatments is discussed.

Examining the inclusion of diverse participants in cognitive behavior therapy research for youth with autism spectrum disorder and anxiety.

Results of randomized controlled trials have demonstrated significant reductions in anxiety symptoms following cognitive behavior therapy participation. Although promising, the extent to which previous research has included families from low socioeconomic status or racially/ethnically diverse backgrounds is unknown. Aims of this study are as follows: (1) What is the race, ethnicity, and educational attainment of youth with autism spectrum disorder and their families who have participated in research examining the efficacy of cognitive behavior therapy for anxiety? and (2) How do the demographics of these participants compare to that of the United States census? A total of 14 studies were reviewed that included 473 participants. Chi-square analyses indicated that there are significant differences between the race/ethnicity of youth with autism spectrum disorder participating in cognitive behavior therapy research for anxiety and that of youth in the United States. Standard residuals indicated significant overrepresentation of White youth and significant underrepresentation of Black and Latino youth in cognitive behavior therapy research (all p-values <0.001). Similarly, there were significant differences in the educational attainment of caregivers participating in cognitive behavior therapy research, with a significant underrepresentation of caregivers from low socioeconomic status backgrounds ( p < 0.001). These findings have implications for the development of cognitive behavior therapy interventions for youth with autism spectrum disorder and anxiety that are both rigorous and inclusive.

Exploring Relationships Between Negative Cognitions and Anxiety Symptoms in Youth With Autism Spectrum Disorder.

Although cognitions are central to the conceptualization and treatment of anxiety in typically developing (TD) youth, there is scant research investigating automatic thoughts and their relationship with anxiety in youth with autism spectrum disorder (ASD). We sought to examine the types of automatic thoughts experienced by youth with ASD and co-occurring anxiety as well as the predictive relationship of anxiety to different types of automatic thoughts in 97 children, ages 8-14 years. We also explored the relationship of automatic thoughts and intolerance of uncertainty. Consistent with prior data, there was a strong relationship between anxiety and automatic thoughts pertaining to social and physical threat. Anxiety and IU were independently associated with thoughts pertaining to personal failure which raises the hypothesis that personal failure may serve as a common pathway between anxiety, IU, and depression in ASD youth. These findings highlight the importance of assessing and treating negative cognitions in youth with ASD and anxiety.

Psychosocial interventions for internalizing disorders in youth and adults with ASD.

Internalizing disorders are common in individuals with ASD. Psychosocial interventions targeting these disorders in the ASD population have burgeoned in the last decade. Cognitive-behavioural therapy, modified for ASD, is the most frequently investigated model, although other interventions, including behaviour therapy, third-wave interventions, models targeting transdiagnostic constructs, and alternative interventions and treatment delivery methods are now emerging. This review provides a summary of the efficacy of these interventions in treating internalizing disorders in youth and adults with ASD. The barriers to accessing these treatments, which are experienced by many individuals with ASD and their families, as well as future research directions, are also discussed.

Training clinicians to deliver group CBT to manage anxiety in youth with ASD: Results of a multisite trial.

OBJECTIVE: Few guidelines are available regarding optimal training models for practitioners delivering cognitive-behavioral therapy (CBT) for anxiety in youth with autism spectrum disorder (ASD). The present study systematically compared 3 instructional conditions for delivering the Facing Your Fears program (FYF) to children with ASD and anxiety. METHOD: Thirty-four clinicians (Mage = 34 years; 94% women, 88% Caucasian) and an intent-to-treat sample of 91 children with ASD and anxiety (Mage = 11; 84% male 53% Caucasian) met eligibility criteria across 4 sites. A 3-group parallel design via a Latin square procedure was used to randomize 9 teams of clinicians to 1 of 3 training conditions: Manual, Workshop, Workshop-Plus. The effectiveness of instructional condition was assessed via implementation (CBT knowledge, treatment fidelity) and treatment outcomes (reductions in anxiety as measured by the Anxiety Disorders Interview Schedule-Parent (ADIS-P). RESULTS: Clinicians in both Workshop conditions significantly increased CBT knowledge postworkshop, F(1, 18) = 19.8, p < .001. Excellent treatment fidelity was obtained across conditions (above 89%), although clinicians in the Workshop conditions obtained significantly higher fidelity ratings and delivered FYF with greater quality than the Manual condition. Children with ASD demonstrated significant reductions in anxiety symptoms for three of the four anxiety diagnoses, with no differences noted across instructional condition. Rates of improvement were lower than those obtained in a previous controlled trial. CONCLUSIONS: Results suggest that although there may be some advantage to participating in a Workshop, clinicians in all conditions could deliver FYF with excellent fidelity and yield positive treatment outcomes. Lack of a no-treatment comparison group limits interpretation of findings. (PsycINFO Database Record

Priorities for Advancing Research on Youth with Autism Spectrum Disorder and Co-occurring Anxiety.

Research on anxiety disorders in youth with autism spectrum disorder (ASD) has burgeoned in the past two decades. Yet, critical gaps exist with respect to measuring and treating anxiety in this population. This study used the nominal group technique to identify the most important research priorities on co-occurring anxiety in ASD. An international group of researchers and clinicians with experience in ASD and anxiety participated in the process. Topics ranked as most important focused on understanding how ASD symptoms affect treatment response, implementing treatments in real world settings, developing methods to disentangle overlapping symptoms between anxiety and ASD, and developing objective measures to assess anxiety. Collectively, these priorities can lead to collaborative studies to accelerate research in the field.

The BUFFET Program: Development of a Cognitive Behavioral Treatment for Selective Eating in Youth with Autism Spectrum Disorder.

Selective eating (often referred to as "picky" eating) is common in individuals with autism spectrum disorder (ASD) across the lifespan. Behavioral interventions are widely used to treat selective eating; however, most of these programs are time intensive, have not been evaluated for use in outpatient settings, and do not typically include youth beyond early childhood. Despite the functional impact and risk for negative outcomes associated with selective eating, there are no empirically supported treatments available for older children, adolescents, or adults, either with or without ASD. To address this treatment gap, we developed BUFFET: the Building Up Food Flexibility and Exposure Treatment program. BUFFET is a 14-week, multi-family group cognitive behavioral treatment for selective eating in children (8-12 years) with ASD. In this paper, we will (1) discuss the theoretical conceptualization of BUFFET, (2) describe the treatment content and structure, (3) present feasibility data from the initial pilot trial, and (4) consider next steps in treatment development.

Feasibility, Acceptability and Preliminary Treatment Outcomes in a School-Based CBT Intervention Program for Adolescents with ASD and Anxiety in Singapore.

Adolescents with autism spectrum disorder (ASD) are at high risk for anxiety difficulties and disorders. Clinic-based cognitive behavioral therapy (CBT) is effective; however, few published school-based CBT programs for youth with ASD exist. In this study, the Facing Your Fears CBT protocol was adapted for delivery and piloted within a school setting by non-clinicians, with culturally appropriate adaptations. 44 13-15 aged youth with ASD from 22 mainstream schools in Singapore participated. Feasibility, acceptability and preliminary treatment outcomes were examined. Decreases in youth and parent reported anxiety symptoms were reported. Staff and parents found the program useful. Stakeholder support was important for implementation. Initial findings reflect the importance of carefully bridging research-to-practice for youth with ASD and anxiety.

Intolerance of Uncertainty Predicts Anxiety Outcomes Following CBT in Youth with ASD.

Modified cognitive-behavioral therapy (MCBT) has been demonstrated to reduce anxiety in youth with autism spectrum disorder (ASD). However, non-response rates are fairly high. Few studies have investigated factors associated with response. Intolerance of uncertainty (IU) is a treatment target for anxiety and worry in neurotypical populations and has been linked to anxiety and ASD. We sought to examine whether IU affects outcomes following MCBT in 43 children, ages 8-14 years, with ASD without intellectual disability. Consistent with prior data, there was a significant reduction in parent reported anxiety following MCBT. Higher levels of pre-intervention IU predicted higher anxiety and worry pre- and post-intervention. These findings suggest that targeting IU may improve outcomes following MCBT in youth with ASD and anxiety.