Addressing Access and Reach:

Implementation of a Group CBT

Intervention for Managing Anxiety in
Students with ASD in Urban Schools
Autism Cares
July 2019
Judy Reaven, Ph.D.
Professor of Psychiatry and Pediatrics
JFK Partners, University of Colorado
Anschutz Medical Campus
Judy.reaven@ucdenver.edu

Co-authors: Boles, R., Hayutin, L., Hepburn, S., Meyer, A.,

Morris, M., Pickard, K., Reyes, N.,Tanda,T., Walsh, C., &
Blakeley-Smith, A.
Conflict of Interest:
Royalties:
Facing Your Fears: Group Therapy for Managing Anxiety in
Children with High-Functioning Autism Spectrum Disorders
Paul Brookes Publishing Company
www.brookespublishing.com
http://facingfears.org

HRSA# : R41MC31075-01-00

Special Thanks:
Aubyn Stahmer, Ph.D. ; Professor of Clinical Psychiatry,
UC-Davis MIND Institute
Significance: Importance of Treating
Students with ASD and Anxiety
 Prevalence
◦ Anxiety symptoms are common in persons with ASD (Simonoff et al.
2008; Ung et al. 2014; Van Steensel et al. 2011)
 Impact
◦ Anxiety increases risk for academic, social, and emotional problems,
with marked financial cost (Rotheram-Fuller & MacMullen, 2011; van
Steensel et al. 2013)
 Potential to Treat
◦ Anxiety is treatable in general pediatric populations (Olatunji et al.
2010;Walkup et al. 2008)
◦ CBT extended to youth with ASD (McConachie et al. 2014; Reaven et al.
2012; Wood et al. 2009)
 Access to Treatment
• Schools are the ideal setting to intervene particularly for
underserved ethnic minority youth (Jaycox et al. 2010)
 Treatment of Choice
Cognitive-Behavioral
Strategies for Anxiety:
Core Components
Psychoeducation

Somatic
Management

Cognitive
Restructuring

Problem Solving

Graded Improvement rates exceed

Exposure
50% (Olantunji et al. 2010;
Relapse Reaven et al. 2012; Walkup
Prevention et al. 2008; Wood et al. 2009;
2015).
 FYF Treatment Program – Youth
with High-Functioning ASD and
Anxiety (ages 8-14)
 Total Duration of treatment: 14 weeks – 1 ½
hour per session

 Modality: varied; children alone, parents alone,

dyads and large group work

 First seven weeks: Define anxiety symptoms,

identify anxiety provoking situations, develop a set
of “tools” (somatic management, helpful thoughts,
emotion regulation, graded exposure)

 Second seven weeks: Identify goals and create

stimulus hierarchy, apply “tools” across settings, in-
vivo graded exposure, video activity to reinforce
core concepts

 Booster session: 4-6 weeks post-treatment

Facing Your Fears in the Clinic
 Case Study (Reaven & Hepburn, 2003)
 Initial group treatment study (Reaven et al. 2009)
◦ N=33; significant reductions in anxiety
 Randomized trial with independent evaluator
(Reaven et al., 2012)
◦ N=50; Psychiatrically complex; Post-TX - Fewer # of
Dx (including loss of GAD); 50% improvement
compared to 8.7% TAU – (effect size 1.03);
 Adolescent pilot (Reaven et al. 2012)
 N=24; significant reductions in anxiety and challenging
behavior; 46% of teen participants “much improved”
or “very much improved”
Bringing Evidence-Based Practice for
Youth with ASD and Anxiety to The
“Real World”
Specialist Clinic
Settings(Reaven et al. 2014;
Reaven et al. 2018)

Schools (Drmic, Aljunied, &

Reaven, 2017)

Rural communities (Hepburn et

al. 2016)
 Schools
Schools
Importance of
Working in Schools
 Students with ASD (or other social/communication
challenges) display marked anxiety/problem behavior in
school (Rotheram-Fuller & MacMullen, 2011).
 School professionals already experienced in working
with students with varied challenges
 Timing is right to build on pre-existing educational skill
set
 Evidence-based interventions frequently unavailable in
school settings
 Schools are the location of choice (Mychailyszyn et
al., 2011; Van Acker & Mayer, 2009).
 Real World Impact

 Trouble using the school bathroom (e.g., toilets

flushing, other kids, or germs)
 Fear of being late
 Avoids talking to new people/asking for help
 Trouble separating from parents to attend school
 Fear of making mistakes

SCHOOLS ARE IDEAL LOCATION

FOR INTERVENTION!
Substantial Disparities in Access
to Mental Health Services
Ethnic/Racial Disparities in CBT Research for Anxiety in
ASD (Pickard, Reyes, & Reaven, 2018)

 Reviewed 14 studies, 473 participants with ASD and anxiety in

the US
 Compared demographics of the participants with US Census
 Significantly more White participants/significantly fewer
Black/Latino youth than what US Census would suggest
 Highly educated sample – most caregivers with college degree
or above
 Implications
FYF in Colorado

Low income
Racially/ethnically
diverse
communities

Denver Public Schools

Littleton Public Schools
Cherry Creek School
District
 Primary Aims:
 Adapt FYF via iterative process with key
stakeholders to create a sustainable school-based
program
 Train cross-disciplinary school providers to deliver
FYF-SB to students with ASD and anxiety in public
schools and examine:
◦ Feasibility
◦ Acceptability
◦ Initial Effectiveness
 Approach
Facing Your Fears: School-Based Program in
Colorado

Advisory Board

Meet with parent focus Meet with professionals

groups focus groups
Advisory Board
Modify FYF-SB – training and
program

Meet with parent focus Meet with professionals

groups focus groups

Modifications: FYF-SB

Advisory Board

Training and Implementation of FYF-SB

Cherry Creek Littleton Public

Denver Public Schools
School District Schools
Focus Group: Parent Participants (n=23)
Age m= 42.62 (31-52 years)
Male (n=3, 13.04%)
Gender
Female (n=20, 87%)
Non-Hispanic (n=18, 78.26%)
Ethnicity Hispanic (n=3, 13.04%)
Did not report (n=2, 8.7%)
Caucasian (n=13, 56.52%)
Asian (n=2, 8.7%)
AA/B (n=3, 13.04%)
Race
>1 (n=2, 8.7%)
Other (n=1, 4.35%)
Did not report (n=2, 8.7%)
Some High School / HS diploma (n=5, 21.74%)
Some College (n=3, 13.04%)
Education
College graduate (n=10, 43.48%)
Masters degree (n=5, 21.74%)
PreK-2nd grade (n=5, 21.75%)
3rd grade – 5th grade (n=6, 26.1%)
Child’s grade Middle School (n=9, 39.1%)
High School (n=1, 4.35%)
Post HS (n=2, 8.7%)
Focus Group: Professional Participants (n=17)
Age m= 43.47 (31-70 Years)
Male (n=3, 17.65%)
Gender
Female (n=14, 82.35%)
Non-Hispanic (n=14, 82.35%)
Ethnicity Hispanic (n=1, 5.88%)
Did not report (n=2, 11.76%)
Caucasian (n=14, 82.35%)
AI/AN (n=1, 5.88%)
Race
AA/B (n=1, 5.88%)
Did not report (n=1, 5.88%)

GenEd (n=1, 5.88%)

SpEd (n=4, 23.53%)
Mental Health (n=6, 35.3%)
Professional Role OT (n=1, 5.88%)
SLP (n=1, 5.88%)
Admin (n=2, 11.76%)
Other (n=2, 11.76%)
 Focus group responses – professionals and
parents
Training
Who
 Involving multi-disciplinary teams is a good idea!
 Everyone in the school needs to know something
about the program - emphasize “buzzwords” of the
program
Content and support
 Need “buy-in” from school leadership
 Emphasize “growth mindset,” “grit,” and “resilience,”
as a way to get “buy-in”
Student Selection
Who
 Students could come from Gen Ed or SPED
What
 When describing anxiety, examples given about
challenging behaviors: refusals, defiant behavior,
and emotion regulation
 “fear has many different faces”
Challenges
 Teasing apart anxiety from anger/withdrawal
 Students don’t go to school due to school refusal
 Culture/bias makes it hard to identify students with
anxiety; over-identify challenging behavior rather
than anxiety, especially in students of color
Decisions
Training
Format
 12 hour face-to-face
 Practical, hands-on and interactive
Content
 Identifying anxiety; review of
intervention; logistics of school delivery
 Targets: Emotion regulation and
anxiety reduction
Student Selection
Who
 3rd – 8th grade students; SPED then
eventually Gen Ed. 3 schools per
district; minimum of 2 students/school.
 Social communication challenges
similar to ASD and inclusive of ASD
 Interfering anxiety symptoms (e.g., fear
of loud noises, change, making
mistakes, fear of participating in group
activities, avoiding assemblies, etc).
Focus Group Participants: Decisions
Parents/Professionals
Intervention Delivery Intervention Delivery
Timing Timing
 Consider after school for older students  30-40 minutes weekly
Parents throughout a semester (13
 Parents to be included throughout: a) weeks)
attending 3-4 evening meetings (and  During the school day
record?); b) written communication about Parents
lessons  3 parent meetings after
 “Sell it” to parents; learning new tools to school or in the evening
decrease anxiety, and strategies to cope  Weekly written
with anxiety related emotions communication about
program
 Parallel weekly written
communication for Gen Ed
Focus Group Participants: Decisions
Parents/Professionals
Measuring Success Measuring Success
 Pre-post measures of anxiety (student,  Several different
parent, teacher report) questionnaires:
 Teacher competence/satisfaction parents/teachers/student
 Functional behavior changes - # elopements  Absences, tardies,
due to anxiety, outbursts due to anxiety, expulsions, suspensions.
attendance, tardies, increased time spent on  Gift cards provided to
academics, completion of assignments, parents/school teams
evidence independently using strategies, completing measures.
progress on IEP-like objectives
 Fewer phone calls home about problem
behavior
 Fewer referrals to see social
worker/psychologist
 More time in classroom, less time being
pulled out
 Increase self-advocacy (student use the
terms and strategies from program)
Overview of Facing Your Fears –
School Based Program (FYF-SB)
Session 1 & 2 Session 3 -4 Sessions 5-7 Sessions 8-13
Welcome & Understanding My Managing My Mind; Three
Practice Facing Fears
Introduction Worry/Upset and Putting it All Parent
Calming My Body Together
Sessions
Getting to know
Introduction to Session 1:
Exposure: Facing
you/ice breaker Time Spent
Worrying/Upset
Active Minds & Fears Overview of
Helpful Thoughts FYF-SB
Creating exposure
Session 2:
Learning about
emotions
Externalizing
worries: Worry Plan to Get to
hierarchies/steps
to success
Introduce
bugs Green tools/strategi
es
Everybody worries Optional: Facing
and gets upset
Real Dangers vs. Your Fears Movie Session 3:
sometimes Identifying Goals Making
False Alarms
for Group Wrap-up and
review
How I react/feel Review &
student
when I worry
Measuring
worry/upset; Deep Sharing special Graduation progress
Breathing interests
 Core Components of FYF-SB
 Psychoeducation
◦ Increase emotion vocabulary
◦ Identify anxiety symptoms (enhance self-awareness)
◦ Identify physiological symptoms of
worry/anxiety/upset
◦ Compare “anxiety” vs “fun” time
◦ Emotion Regulation:
Calming the body/managing the mind
◦ Plan to Get to Green
Core Components of FYF-SB
Graded Exposure
◦ Identify anxiety/fears that interfere with
school functioning
◦ Develop a fear hierarchy (least anxiety-
provoking to most anxiety-provoking steps)
◦ Practice facing fears a little at a time to
manage/conquer the fear
Using Videos to Teach Exposure:
Facing Your Fear of Toilet Flushing

1. Student stands outside the bathroom

entrance and toilet flushes
2. Student stands closer to a stall and toilet
flushes
3. Student flushes the toilet himself.
4. Student stands close to a stall and several
toilets flush and a peer washes hands.
 FYF-SB Parent Components
 Provide psycho-education about anxiety
disorders; learn the basic tenets of CBT
 Aware of targets for graded exposure tasks
 Model brave behavior
 Encourage/reward brave behavior in their
children
 Encourage rewarding core concepts
 Discuss parental anxiety and parenting style
 Training and Implementation Phase
 Interdisciplinary school providers working
with students with ASD (12 hour training)
 Eleven schools across 3 districts
 34 school providers trained
Measures – School Providers
◦ CBT Knowledge
◦ Workshop Evaluations
◦ Evidence-Based Practice Attitude Scale (EBPAS;
Aarons, 2004)
◦ Organizational Readiness
 Consort Diagram
11 schools trained
in FYF-SB

10 schools
identified
students (n=31
students)
9 schools started
treatment (n=29
students)

8 schools 2 students
completed (1 school)
treatment 1 school did Did Not
(n=24 students) 1 student not complete Qualify
dropped from treatment
treatment (n=4
students)
 School Provider Characteristics (N = 34)

Interventionist M (SD) Range %

Age (years) 38.6 (9.5) 26-61
Years of experience 11.4 (8.0) 1-34
Gender (female) 97
Education

Bachelors 3
Some graduate / MS 61
Professional / PhD 36
Ethnicity (Non-Hispanic White) 96

Race (Caucasian) 94
Profession

Psychologist 26.5
Special Education teacher 26.5

Speech Pathologist 20.6

Social Worker 11.8
Occupational therapist 5.9

Counselor 5.9
Behavior Consultant 2.9
Preliminary Findings: Training
 CBT Knowledge
◦ Significant improvement in CBT knowledge:
Pre (M=15.8, SD=2.5) and post (M=17.5;
SD=1.8); t(32)=3.50, p<.001
 Training Evaluation (Likert 1-6)
◦ Met training objectives (M=5.6, 4.8-6.0)
◦ Satisfied with training activities (M=5.5, 4.6-
6.0)
◦ Knowledge and comfort with FYF (M=5.1,
4.0-6.0)
 Student Participants
 Inclusion Criteria
◦ Students with ASD or social/communication
challenges similar to ASD
◦ Elevations on the Social Responsiveness Scale
(SRS-2) (Constantino & Gruber, 2005)
◦ 2nd – 8th grade students
◦ Estimated IQ above 70
◦ Interfering anxiety symptoms
Primary Outcomes
 Anxiety
◦ SCARED-parent/child report (Birmaher et al.
1999)

◦ School Anxiety Scale (SAS); (Lyneham et al.

2008)

◦ Parent-Rating Anxiety Scale for ASD

(PRAS-ASD) (Scahill et al. 2018)
 Emotion Regulation
◦ Emotion Regulation Checklist (ERC) (Shields &
Cicchetti, 1997)
Student Participants (n=29)
Gender Male: n=21, 72.4%
Female: n=8, 27.6%

Age Mean=10.31 (1.83) yrs range=7-13 yrs

Ethnicity Hispanic or Latino: n=8, 27.6%
Non-Hispanic: n=21, 72.4%

Race (check all that apply) Asian: n=3, 11.1%

Black/African American: n=2, 6.8%
Caucasian: n=18, 66.7%
More than 1 race: n=6, 22.2%
Not reported: n=2, 3.4%

Consenting parent education Some high school/HS graduate: n=9, 31.0%

Some college/Associate degree: n=8, 27.5%
College graduate (BA, BS, etc): n=5, 17.2%
Some graduate training /terminal masters: n=3, 10.3%
Professional degree (lawyer, PhD, etc): n=4, 13.8%
 Linear Mixed Model Analyses (n=29)
Repeated Measure DF T-score Significance 95% Confidence Interval
(DV)

SCARED-P 20 2.66 .015 1.57 12.84

SCARED-C 26 2.11 .045 0.14 10.39

SAS-Tot 20 0.29 .772 -3.51 4.66

SAS-Gen Anxiety 18 0.40 .693 -1.85 2.72

SAS-Social Anxiety 22 0.14 .891 -2.14 2.45

PRAS-Total 20 1.74 .097 -0.96 10.70

PRAS-Total*(n=22) 17 2.14 .047 .107 12.87

I Want YOU to HELP me:
Barriers/Obstacles
General Procedures
 Collecting teacher (informant) data
 Collecting post data (parents/teachers)
 Parent attendance at face to face sessions
Train the Trainer
 School providers – time to train/provide
consultation with new providers
Sustainability
 Thoughts?
Next Steps
WRAP-UP:
Finish pilot year data
analysis

RAMP-UP
Train the trainer approach
for randomized trial Fall
2019-2020
n=30 schools; n=60
students
Real World Success

►Using bathrooms at school

►Walking into the classroom, even when late.
►Talking to new people; asking for help at a store
►Going to school and/or after school activities
►Turning in homework, making mistakes on tests
Thank You!!