Autistic children and adolescents are often impacted by co-occurring anxiety. Cognitive Behavioral Therapy (CBT) can be an effective anxiety intervention for youth on the autism spectrum and there is growing evidence to support CBT interventions in school settings. However, less is known about student and caregiver satisfaction with school-based CBT interventions for anxiety among autistic youth. This secondary data analytic study examined student and caregiver satisfaction with Facing Your Fears in Schools (FYF-S), a manualized anxiety intervention for students on the autism spectrum or with related social and learning differences that is delivered in small groups by school providers. Post-intervention satisfaction with FYF-S was examined among 35 students (ages 8–14) with autism or suspected autism and their caregivers. Students and caregivers reported high satisfaction with the program. Caregiver, but not student, satisfaction was associated with lower post-treatment anxiety after controlling for baseline anxiety. Caregivers who completed more participation opportunities (i.e., attending a caregiver group session and/or watching a video) reported significantly higher satisfaction. These findings support the acceptability of FYF-S as a school-based intervention for students with autism or suspected autism and anxiety. Results also suggest that caregiver satisfaction is closely tied to student anxiety outcomes and highlight caregiver involvement as an important factor related to satisfaction with school-based mental health interventions.

The use of self-report to assess anxiety in adolescents with intellectual disability (ID) is notably underexplored. This study examined the impact of youth-level factors (i.e., age, verbal and cognitive ability, adaptive skills) on anxiety self-report completion and parent-youth agreement among 72 autistic adolescents with ID. We also examined if parent accommodation behaviors, such as reassurance or routine modification, served as predictors of parent-youth agreement of anxiety. Results showed that 83% of adolescents completed the self-report measure, with verbal, cognitive, and adaptive ability predicting completion. Parental accommodation predicted parent-youth agreement on physical anxiety symptoms, but not global anxiety symptoms. Youth-level factors did not significantly predict agreement. Results highlight the need for expanded assessment approaches for assessing anxiety in youth with ID.

Children with mental illness commonly live with caregivers who suffer from mental illness. Integrated mental-health-treatment approaches can provide more convenient and comprehensive care for families. This case report describes family-based treatment (FBT) for one parent/child dyad. The parent was a 37-year-old female with a history of anxiety and major depressive disorder and concern for symptoms of attention-deficit/hyperactivity disorder (ADHD). The child was an 8-year-old female with generalized anxiety disorder and concern for ADHD and behavioral problems. The parent received individual cognitive behavioral therapy (CBT) and parent management training. The child received CBT. Both also received medication management. The FBT team met regularly for coordinated treatment planning. Self-reported assessments via the Child Behavior Checklist showed meaningful improvement; anxiety decreased to nonclinical range week 12 and depression decreased to nonclinical range week 8. Clinician assessments showed improvement for both patients. Though more time intensive, FBT can yield significant improvement, particularly for children. Pragmatic approaches to treatment planning are important to minimize barriers to FBT.

Schools are a promising access point for youth with mental health concerns, but school-based mental health professionals (SPs) often need ongoing support to provide high-fidelity cognitive behavioral therapy (CBT). Adherence and competence, two critical elements of fidelity, were examined in a cluster-randomized implementation trial. We evaluated CBT adherence and then triangulated CBT adherence with end-of-study competence. We then evaluated the effects of two implementation supports, Coaching and (for slower-responding schools) Facilitation, on adherence and competence. By the end of the 43-week study period, 27.8% of SPs met adherence criteria. Adherent SPs scored higher on the competence measure, the CBT Competence Scale (t(116.2) = 3.71, p < .001). No significant difference in adherence was found among SPs at schools assigned to Coaching vs. not (Δ = 6.0%, p = .385), however SPs at schools randomized to Coaching scored significantly higher on two of the four competence subscales (Non-Behavioral and Behavioral skills). Among slower-responder schools, SPs at schools assigned to Facilitation were more likely to demonstrate adherence (Δ = 16.3%, p = .022), but there was no effect of Facilitation on competence. Approximately one quarter of SPs met adherence criteria in the trial; adequate delivery of exposure was a primary obstacle to reaching adherence. Facilitation may be especially suited to help SPs overcome barriers to delivery, whereas Coaching may be especially suited to help SPs improve CBT competence. Both are likely needed to build a mental health work force with the competence and ability to deliver EBPs in schools.

OBJECTIVE:Reassurance seeking, a behavior prominent in anxiety disorders and depression, is associated with poorer quality of interpersonal relationships and acts as a mechanism of stress generation. However, little research has elucidated momentary associations between state anxiety and reassurance seeking behaviors.METHOD:In a sample of 104 university-affiliated young adults, we sought to replicate cross-sectional associations of reassurance seeking with trait anxiety (Aim 1) and intolerance of uncertainty (Aim 2). We then used ecological momentary assessment (EMA) to evaluate concurrent fluctuations in daily anxiety and reassurance seeking across 14 consecutive days (Aim 3). Hierarchical multi-level models for intensive longitudinal data were used to evaluate the relationship between state anxiety and daily reassurance seeking.RESULTS:In baseline analyses, trait anxiety and intolerance of uncertainty were significantly associated with greater trait reassurance seeking, controlling for depression. Analyses of the EMA data showed that daily reassurance seeking behaviors fluctuated concurrently with daily anxiety during the 14 days, while controlling for trait anxiety and depression.CONCLUSION:Given evidence of concurrent fluctuations between state anxiety and reassurance seeking, the behavior should be considered as a potential target in treatment for anxiety disorders.

This pilot examines a self-distancing augmentation to exposure. Nine youth with anxiety (ages 11-17; 67% female) completed treatment. The study employed a brief (eight session) crossover ABA/BAB design. Exposure difficulty, engagement with exposure, and treatment acceptability were examined as primary outcome variables. Visual inspection of plots indicated that youth completed more difficult exposures during augmented exposure sessions [EXSD] than classic exposure sessions [EX] by therapist- and youth-report and that therapists reported higher youth engagement during EXSD than EX sessions. There were no significant differences between EXSD and EX on exposure difficulty or engagement by therapist- or youth-report. Treatment acceptability was high, although some youth reported that self-distancing was "awkward". Self-distancing may be associated with increased exposure engagement and willingness to complete more difficult exposures, which has been linked to treatment outcomes. Future research is needed to further demonstrate this link, and link self-distancing to outcomes directly.

Objective: To investigate prevalence and predictors of early depression response (EDR) in adolescents with substance use and depression receiving cognitive-behavioral therapy (CBT) for substance use and to test the efficacy of supplemental CBT targeting depression (CBT-D) for non-EDR adolescents in an adaptive treatment approach. Method: At 2 sites, 95 youths (ages 14-21, mean [SD] = 17.4 [1.8]) with alcohol or cannabis use and depressive symptoms received up to 12 sessions of CBT for substance use over 14 weeks. Assessments were at baseline and weeks 4, 9, and 14. The Children's Depression Rating Scale-Revised was the primary depression measure, with a reduction of 50% or more on this scale at week 4 defining EDR. The primary substance use outcomes of alcohol use, heavy alcohol use, and cannabis use frequency were assessed via interview report on the Alcohol Consumption Questionnaire and the Drug Checklist. Urinalysis provided a secondary measure of cannabis use. Non-EDR adolescents were randomly assigned to supplemental CBT-D or enhanced treatment as usual (ETAU). Results: Thirty-five adolescents (37%; 95% CI, 27%-47%) demonstrated EDR. Fewer days of cannabis use (odds ratio 0.977; 95% CI, 0.961-0.992) and absence of conduct disorder (odds ratio 0.149; 95% CI, 0.031-0.716) predicted EDR. Frequency of drinking (F-1,F-82 = 11.09, eta(2) = 0.119, p = .001), heavy drinking (F-1,F-82 = 19.91, eta(2) = 0.195, p < .0001), and cannabis use (F-1,F-220 = 35.01, eta(2) = 0.137, p <.001) decreased over time for EDR, CBT-D, and ETAU adolescents, with EDR adolescents evidencing earlier lower cannabis use (F-2,F-220 = 4.16, eta(2) = 0.036, p = .0169). Negative (clean) urine screens increased over time (F-1,F-219 = 5.10, eta(2) = 0.023, p = .0249). Comparison of CBT-D and ETAU indicated that depression significantly decreased over time in both groups (F-1,F-48 = 64.20, eta(2) = 0.572, p < .001), with no advantage for CBT-D. Conclusion: Approximately one-third of adolescents with substance use and depression attain EDR during substance use treatment. Less frequent cannabis use facilitates depression response. The relatively small sample may have precluded identification of additional EDR predictors. Clinical trial registration information: Treatment for Teens With Alcohol Abuse and Depression; https://clinicaltrials.gov/; NCT02227589.

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.

Background: A national shortage of mental health providers for youth exists in the United States. Implementation support for mental health services in schools, where students are most likely to access care, can help to fill these gaps. Coaching consists of in vivo modeling and support during service delivery and is effective in supporting the implementation of evidence-based practices (EBPs). This implementation report describes the recruitment and training of community providers to become coaches as a part of a modified train-the-trainer model of implementation support. Method: An EBP implementation program, Transforming Research into Action to Improve the Lives of Students (TRAILS), trained community providers in Michigan to increase knowledge of cognitive behavioral therapy (CBT) and position them as coaches in schools. The development of the coach network involved five stages prior to the initiation of a randomized controlled trial: (1) recruitment, (2) a one-day clinical training, (3) 12 weeks of individualized consultation, (4) evaluation, and (5) training in the coaching protocol. Results: A total of 347 individuals attended an initial training, and 187 were paired with a consultant. Eighty-six clinicians from 47 of Michigan's 83 counties successfully became coaches by completing all required elements of training. Coaches showed significant improvements in the use and knowledge of CBT across consultation. Conclusion: Statewide networks of trained mental health professionals can address gaps in mental healthcare for youth. This article demonstrates one strategy for strengthening and leveraging community expertise to support the implementation of EPBs in schools. Plain Language Summary Although youth face many barriers in accessing effective mental health care, schools are one setting where they can more easily receive treatment. Research shows that training and supports are needed for school mental health professionals to provide effective care. Coaching, which involves in vivo support for school mental health professionals, is one helpful strategy. We describe the process of recruiting and training community clinicians to become coaches. The Transforming Research into Action to Improve the Lives of Students (TRAILS) program successfully recruited and trained a network of 86 community clinicians to become coaches. Clinicians attended two day-long trainings and participated in 12 weeks of personalized consultation. Clients to whom these clinicians provided CBT showed significant symptom improvement. Clinicians also reported that they increased their knowledge and use of core CBT strategies, including psychoeducation, exposure, and behavioral activation. Community mental health professionals who are trained as coaches can address gaps in access to care for youth. We demonstrate one strategy for strengthening and leveraging clinicians’ knowledge of CBT to support the school-based implementation of CBT.

Cognitive behavioral therapy for youth with autism spectrum disorder and anxiety is effective, but disparities exist in accessing these programs. Training school providers to deliver cognitive behavioral therapy may help to address these disparities. However, little is known about how cognitive behavioral therapy programs are implemented by interdisciplinary school providers and the broader impact of these programs. This study aimed to address this gap and was part of a larger trial that examined the effectiveness of Facing Your Fears–School-Based across 25 public schools. Study aims were to understand the impact of Facing Your Fears–School-Based and factors that impacted implementation. Thirty providers participated in exit interviews guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Primary themes included (1) the fit of Facing Your Fears–School-Based for diverse students; (2) the effects of Facing Your Fears–School-Based on students’ school participation; and (3) planned Facing Your Fears–School-Based maintenance. Participants also highlighted the program’s accessibility for non-mental health providers and reported adapting Facing Your Fears–School-Based in response to student needs. Results suggest that Facing Your Fears–School-Based may have a broader impact on students and highlight the importance of task sharing to overcome mental health staff shortages within public schools. Programs that can be implemented flexibly are also critical given variability in school structures and student needs. 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.

School-aged youth have been significantly impacted by the COVID-19 pandemic. The effects of the pandemic will likely have long-standing effects on the well-being of youth, and access to mental health care is even more critical during this time. For the past 5 years, TRAILS (Transforming Research into Action to Improve the Lives of Students) has been working throughout the state to increase utilization of evidence-based mental health practices among K-12 school mental health professionals (SMHPs). By leveraging SMHPs who are widely accessible to students, TRAILS seeks to improve youth access to effective mental health care and reduce current mental health inequities. In March 2020, TRAILS responded to the COVID-19 pandemic by developing a group manual designed to be delivered virtually by SMHPs to help students develop effective coping skills to mitigate the impact of COVID-19. TRAILS focuses on promoting use of CBT and mindfulness, as these skills are ideally suited for school-based delivery, and thus the new manual, Coping with COVID-19 (CC-19), was grounded in these modalities. This article will describe the design, development, and deployment of the CC-19 program to address the mental health needs of students in the context of the pandemic. Early acceptability and penetration data will also be discussed.

Objective: This brief report reviews the literature on moderators of treatment for adolescent depression. Treatment moderators can help to guide the process of personalizing intervention to individual patient characteristics.Method: We conducted a systematic search in PsycInfo and PubMed. We also reviewed references of previous reviews and searched for moderator analyses conducted secondary to published efficacy studies.Results: We review 27 studies that address the following categories of moderators: demographics, severity indices, comorbidity, contextual factors, history of abuse or trauma, and cognition and coping. We found limited evidence that demographic, contextual, or cognitive variables consistently moderated treatment for adolescent depression. There was some indication of moderation by race/ethnicity, presence of some comorbid disorders, greater depression severity, and a history of trauma.Conclusion: Our review found inconsistent findings across studies, likely due to the strong impact of predictors relative to moderators and limited statistical power. More research using innovative statistical approaches is necessary before treatment tailoring can be an empirically-based process.

In the last two decades, evidence-based practices have become increasingly prioritized, and yet, adoption of evidence-based practices and principles is still limited. It is important then to characterize the contextual factors that facilitate or impede implementation and sustainment evidence-based practice. We conducted a needs assessment of diverse mental health providers (including clinical psychologists, social workers, and psychiatrists) to: (a) identify the most commonly perceived practical barriers to incorporating evidence-based practices into clinical care, (b) describe the most valuable features of existing resources that support evidence-based practice. and (c) offer suggestions for how those features can be leveraged to decrease challenges associated with integrating evidence-based principles into clinical practice. We present the results in this study of N = 476 clinical educators, practitioners, and trainees. Practicing in an evidence-based way was identified as a priority by most respondents and yet respondents noted time, cost, and access as barriers to training in, and ongoing engagement with, evidence-based practice. Assessing needs and desired resources helps create the roadmap toward sustainment of evidence-based care.

Depression is one of the most common psychiatric disorders of adolescence and is much more prevalent in adolescents than in younger children. Beginning around age 14, it is more prevalent in females than in males. Most of the evidence-based treatments for youth depression have addressed Major Depressive Disorder, although some studies have included milder forms of depression. Two psychological treatment approaches are considered well-established interventions for adolescent depression: cognitive behavior therapy and interpersonal psychotherapy, both attaining the level of well-established interventions. The authors outline that therapeutic alliance and psychoeducation are critical to effective depression treatment. The authors indicate that the effect size in meta-analytic studies for evidence-based treatments of adolescent depression is significant but of modest magnitude. They note that the generalizability of the efficacy of psychotherapy for depression with minority youths needs further investigation, although interpersonal therapy is considered well-established with Hispanic youth. The authors conclude there is a need for novel interventions that ameliorate adolescent depression more quickly and/or lead to greater protection from recurrent episodes.

Anxiety is one of the most common co-occurring diagnoses in youth with autism spectrum disorder (ASD). Cognitive behavior therapy (CBT) is an evidence-based treatment that has been tailored for youth with ASD and anxiety and has shown good efficacy in reducing youth anxiety immediately after treatment. One area that has not been widely studied is acceptability of CBT for anxiety in this population. Acceptability includes beliefs about the potential helpfulness and satisfaction with a given treatment and may be important in understanding treatment outcomes. This study focuses on parent, youth, and clinician acceptability of a well-researched CBT program, Facing Your Fears, for youth with ASD and anxiety. Data was collected as part of a larger multi-site study that compared three different instructional conditions for clinicians learning the intervention. Results indicated that parents rated acceptability as higher for the overall treatment compared to youth. Further, youth and parents rated exposure related sessions as more acceptable than psychoeducation, and higher exposure acceptability ratings were predictive of lower youth anxiety levels post-treatment. Clinicians who received ongoing consultation rated treatment acceptability lower than clinicians in the other training conditions. While some clinicians may be hesitant to implement exposure techniques with this population, findings suggest that it is the technique that parents and youth rated as the most acceptable. Results are discussed in terms of treatment and research implications for youth with ASD and their families.

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 (M-age = 34 years; 94% women, 88% Caucasian) and an intent-to-treat sample of 91 children with ASD and anxiety (M-age = 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.

With the increasing prevalence of adults with autism spectrum disorder (ASD), research examining the service experiences of this population is greatly needed. The current study investigated service use, unmet needs, and obstacles to service access for a large sample of adults with ASD. After accounting for various demographic factors known to impact service usage and needs, living situation was a significant predictor of service use, needs, and obstacles to services. Adults with ASD living with family reported less service use, higher unmet need, and more obstacles to accessing services. With more than half of this adult sample living with family, results have clear public policy implications to support the increasing population of adults with ASD living with aging caregivers.

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.

•We address whether anxiety predicts increased occurrence of dependent stressors.•In our review, physiological hyperarousal did not predict increased dependent stressors.•We propose a model that incorporates distal and proximal factors of stress generation.•As a distal factor, neuroticism was consistently associated with stress generation.•More longitudinal studies using contextual interviews will advance the literature.