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A preliminary evaluation of a modified school-based facing your fears for students with autism spectrum… Kester, Karen R. 2019

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      A PRELIMINARY EVALUATION OF A MODIFIED SCHOOL-BASED FACING YOUR FEARS FOR STUDENTS WITH AUTISM SPECTRUM DISORDER AND ANXIETY by Karen R. Kester B.A., The University of Guelph, 1998 M.A., The University of British Columbia, 2001  A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY  in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Special Education) THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)    December 2019 © Karen R. Kester, 2019  ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled:  A preliminary evaluation of a modified school-based facing your fears for students with autism spectrum disorder and anxiety  submitted by Karen Kester  in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Special Education  Examining Committee: Joseph Lucyshyn, Special Education Supervisor  Deborah Butler, Human Development, Learning and Culture Supervisory Committee Member  Anthony Bailey, Psychiatry  University Examiner William Borgen, Counselling Psychology  University Examiner   Additional Supervisory Committee Members: Melanie McConnell, Psychiatry Supervisory Committee Member           iii Abstract  Anxiety is common in children with autism. Although there has been a steady increase in the empirical evidence demonstrating successful treatment of anxiety in children with ASD using Cognitive Behavioural Therapy (CBT), there is little research on implementing CBT in the school setting. With a high prevalence of anxiety among youth with ASD, researchers have identified implementing effective treatments in real-world settings as a top priority. Thus, this dissertation, consisting of two related studies, examined the adaptation for and delivery of the Facing Your Fears (FYF) program in the school setting. Using an integrated knowledge translation framework (iKT), knowledge user’s perspectives on the acceptability, feasibility, and sustainability of delivering FYF in a school setting were examined in Study 1. Qualitative data were collected through focus group discussions and analyzed using thematic analysis techniques. The insights provided by educators and parents regarding the strengths, barriers and practical considers for implementation of FYF in the school setting were used to inform provisions to FYF, resulting in a proposed modified school-based FYF intervention. In study 2, a quasi-experimental group design along with semi-structured interviews and focus groups were used to evaluate the effectiveness of educators implementing the modified school-based FYF to treat anxiety among students with ASD. Qualitative data were analysed using thematic analysis. Results are discussed in terms of skill acquisition, preliminary treatment outcomes, and social validity. Results indicated that with training and on-going feedback educators obtained a modest level of fidelity in implementing the intervention. Non-significant decreases in student anxiety symptoms across all informant ratings (students, parents and teachers) were observed. Social validity ratings across participants were high with the following themes emerging from the data: (a) outcomes; (b) program structure; (c) inclusion; and (d) recommendations. These results  iv provide a step forward in the promotion of anxiety treatment for children with ASD in school settings. Specifically, they offer a model for researchers to collaborate with key stakeholders in adapting interventions for use in schools, thereby, bridging the gap between research and practice. Importantly, they highlight educator’s capability in delivering empirically-supported treatments to address anxiety among students with ASD.                      v Lay Summary Students with Autism Spectrum Disorder are at a high risk for developing anxiety. However, treatment of anxiety in schools for students with autism is not common. Study 1 of this dissertation used teachers’ and parents’ views about Facing Your Fears (FYF), an intervention to treat anxiety, to create a modified version to delivery in schools. In Study 2 teachers learned to deliver the modified school-based FYF to treat anxiety among students with autism. Although teachers, parents, and students did not report decreased levels of anxiety on standardized measures, all participants (teachers, parents, and students) reported they enjoyed participating in the program and learned skills to help students cope with anxiety symptoms. These findings are important for moving research from clinically-controlled settings to real life settings, including schools.               vi Preface This dissertation is an original intellectual product of the author, K. Kester, who was responsible for all major areas of idea formation, recruitment of participants, data collection, data analysis, the production of this manuscript. Drs. Lucyshyn, McConnell, and Butler offered guidance and expertise during the formation of the research, data analysis and manuscript writing.   Prior to conducing the studies, approval was obtained by the UBC Behavioural Research Ethics Board (BREB) and the participating school districts. Study 1 (Chapter 2) was approved under Ethics Certificate H16-02836 “School-Based Facing Your Fears Anxiety Treatment for Children with Autism Spectrum Disorders: Educator and Parent Perspectives on Acceptability and Feasibility”. Study 2 (Chapters 3) was approved under Ethics Certificate H18-00967 “A Preliminary Evaluation of a Modified School-Based Facing Your Fears for Students with Autism Spectrum Disorder and Anxiety”.  A version of Chapter 2 has been published in Psychology in the Schools [Kester, K. & Lucyshyn, J. (2019). Co-creating a school-based facing your fears anxiety treatment for children with Autism Spectrum Disorder: A model for school psychology. Psychology in the Schools, 1-16. doi:10.1002/pits.22234]. I was the lead investigator, responsible for all major areas of concept formation, data collection and analysis, as well as manuscript composition. Dr. Lucyshyn was involved in the early stages of concept formation and contributed to manuscript edits.       vii Table of Contents  Abstract ........................................................................................................................................ iii Lay Summary ................................................................................................................................. v Preface ........................................................................................................................................... vi Table of Contents  ........................................................................................................................ vii List of Tables .................................................................................................................................. x List of Figures  .............................................................................................................................. xi List of Abbreviations ................................................................................................................... xii Acknowledgements .................................................................................................................... xiii Dedication  .................................................................................................................................... xv   Chapter 1: Introduction  ......................................................................................................................... 1   Anxiety in ASD ........................................................................................................................ 1   Cognitive Behaviour Therapy and ASD ................................................................................... 3   Facing Your Fears .................................................................................................................... 4  CBT for Anxiety in the School Setting .................................................................................... 5   Research to Practice Gap .......................................................................................................... 7  Statement of Problem and Research Questions  ..................................................................... 10  Chapter 2: Study One ................................................................................................................. 14     Method  ...................................................................................................................................... 14  Participants and Settings  ..................................................................................................... 15  Data Collection and Focus Group Procedures  .................................................................... 16  Qualitative Coding ............................................................................................................... 17     Results  ...................................................................................................................................... 18         Strengths of Facing Your Fears Program .............................................................................. 19         Barriers .................................................................................................................................. 22         Recommendations ................................................................................................................. 23  Team approach ................................................................................................................ 23  Intervention agent ............................................................................................................ 25  Effective communication ................................................................................................ 26  Procedural structure ......................................................................................................... 27  Cohort sessions ................................................................................................................ 28  Selection process ............................................................................................................. 28  Acceptability of the proposed modified intervention ...................................................... 29  Chapter 3: Study Two ................................................................................................................. 31  Research Questions ................................................................................................................... 31     Method ...................................................................................................................................... 33  Recruitment Procedures ....................................................................................................... 33  Participants ........................................................................................................................... 34 Educators ......................................................................................................................... 34 Students and parents ........................................................................................................ 35  Setting and Materials ........................................................................................................... 36          Measurement ............................................................................................................................. 37  viii       Demographic Information .................................................................................................... 37 Outcome Measures ............................................................................................................... 37 Research question 1: Examining educator skill acquisition and intervention  fidelity  ............................................................................................................................ 37 Assessment of CBT knowledge ............................................................................... 38 Intervention fidelity checklist ................................................................................... 38 Brief semi-structured interviews .............................................................................. 41 Research question 2: Examining student treatment outcomes ........................................ 41 ASC-ASD – Child Version ...................................................................................... 41 ASC-ASD – Parent Version ..................................................................................... 42 SAS-TR .................................................................................................................... 42 Worksheets with interviews ..................................................................................... 43 Research question 3: Assessing social validity ............................................................... 44 Social validity questionnaire .................................................................................... 44 Focus groups ............................................................................................................ 45  Research Design ................................................................................................................... 45  Procedures ............................................................................................................................ 47 Research Question 1: Examining Educator Skill Acquisition and Intervention  Fidelity ............................................................................................................................. 48 Educator training ...................................................................................................... 49 Research Question 2: Examining Student Treatment Outcomes .................................... 50 School-based FYF intervention ................................................................................ 50 Research Question 3: Assessing Social Validity ............................................................. 53  Data Analysis Procedures .................................................................................................... 53 Research Question 1: Examining Educator Skill Acquisition and Intervention  Fidelity ............................................................................................................................. 54 Research Question 2: Examining Student Treatment Outcomes .................................... 55 Research Question 3: Assessing Social Validity ............................................................. 56  Results  ................................................................................................................................. 57 Research Question 1: Examining Educator Skill Acquisition and Intervention  Fidelity ............................................................................................................................. 57 Assessment of CBT knowledge ............................................................................... 57 Intervention fidelity .................................................................................................. 58 Skill acquisition ........................................................................................................ 61 Helpful facilitating factors  .................................................................................. 63 Learning process .................................................................................................. 63 Challenges  .......................................................................................................... 64 Student behaviour ................................................................................................ 66 Personal expectations  ......................................................................................... 66 Research Question 2: Examining Student Treatment Outcomes .................................... 67 Changes in ratings .................................................................................................... 69 Tools ......................................................................................................................... 70  ix Research Question 3: Assessing Social Validity ............................................................. 70 Outcomes .................................................................................................................. 73 Program structure  .................................................................................................... 75 Inclusion ................................................................................................................... 77 Recommendations  ................................................................................................... 78       Chapter 4: Discussion  ................................................................................................................. 80         Study 1  .................................................................................................................................. 80          Study 2  .................................................................................................................................. 84 Skill acquisition and intervention fidelity .......................................................................... 84 Preliminary treatment outcomes ........................................................................................ 88 Social validity  ................................................................................................................... 91         Research and Clinical Implications ...................................................................................... 94         Limitations  ............................................................................................................................ 96         Future Directions  .................................................................................................................. 99         Conclusion ........................................................................................................................... 101  References ................................................................................................................................. 103  Appendices ................................................................................................................................. 118        Appendix A: Focus Group Consent Form for Study 1 ......................................................... 118        Appendix B: Parent-Child Invitation Letter for Study 2 ...................................................... 122        Appendix C: Fidelity Checklist Scoring Definitions: School-based Facing Your Fears ..... 124 Appendix D: Social Validity Questionnaire -Educator ........................................................ 126        Appendix E: Social Validity Questionnaire – Parent ........................................................... 128        Appendix F: Social Validity Questionnaire – Student  ........................................................ 130        Appendix G: School-based FYF Session Outline  ............................................................... 131    x List of Tables  Table 1. Themes, Subthemes and Frequency of Responses in Study 1 ................................... 19   Table 2.  Overview of Proposed Modified School-Based Facing Your Fears in Study 1 ........ 30  Table 3. Role and Number of Participant by Intervention Group in Study 2 ........................... 35  Table 4. Examples of Intervention Fidelity Checklist: Small Group Session 4 and  Session 7 in Study 2 ................................................................................................................. 39  Table 5. Timeline of Assessment Activities in Study 2 ........................................................... 48  Table 6. Median, Range, and Percentage Scores for CBT Knowledge in Study 2 .................. 58  Table 7. Themes, Core Ideas, and Counts of Occurrence in Study 2 ....................................... 62  Table 8. Individual Student Scores for the Three Anxiety Measures and Clinical  Significance in Study 2 ............................................................................................................. 68  Table 9. Mean, Range, and Grand Mean Scores for Social Validity Questionnaires in  Study 2 ...................................................................................................................................... 71  Table 10. Themes, Descriptions, and Core Ideas Identified in Study 2 ................................... 72     xi List of Figures Figure 1. Quasi-Experimental Group Design for Educator Outcomes in Study 2 ..................... 46  Figure 2. Quasi-Experimental group design for Student outcomes in Study 2 .......................... 46  Figure 3. Average Percentage of Facilitator Intervention Fidelity of Student Session Core Components in Study 2 ............................................. ................................................................ 59   Figure 4.  Average Percentage of Facilitator Intervention Fidelity of Parent Session Core Components in Study 2  ............................................................................................................. 60  Figure 5.  Average Percentage of Intervention Fidelity of Class Session Core Components for Group A in Study 2 ..................................................................................................................... 61    xii List of Abbreviations ASC-ASD   The Anxiety Scale for Children- Autism Spectrum Disorder ASD    Autism Spectrum Disorders CBT    Cognitive Behaviour Therapy EST    Empirically Supported Treatments FYF    Facing Your Fears iKT    Integrated Knowledge Translation                  xiii Acknowledgements  As I reflect on my journey through my doctoral studies, I am overwhelmed with feelings of gratitude, exhilaration, and a sense of achievement. A lot of amazing people were part of the process. I wish to express my appreciation for the extraordinary support and learning opportunities I received along the way.  First, I would like to thank my advisor, Dr. Joe Lucyshyn for your continued guidance as I hiked the mountain peaks. I am grateful for the many opportunities you have provided me throughout my academic career and your dedication to my success. Thank you for being such a strong model of kindness and humility. I am honoured you shared your wisdom with me. We have reached the summit!   I would also like to acknowledge my research committee members, Dr. Deborah Butler and Dr. Melanie McConnell for your insightful annotations, skillful guidance and diverse expertise. This dissertation is stronger because of your thoughtful contributions. A special thank you to Melanie, as well as Dr. Kristen McFee, for welcoming me to your team. You did more than share your knowledge of Facing Your Fears with me; you taught me the value of reflection and self-assessment, thereby, broadening my skills as a clinician and my character as a person.  I am incredibly grateful to the individuals who participated and made this study possible.  Thank you for your enthusiasm and giving your time so generously to participate. I hope this work will lead to further success of all students in schools.  Many thanks to my family and friends. To my parents, who at a young age taught me that I could do anything and be anyone. Your demonstration of loyalty, perseverance, and compassion are qualities I endeavour to emulate in every facet of my life. To my friends, you keep me strong and celebrate every small step with me.  I am not sure I would have made it  xiv through this journey without family dinner. A special thanks to the one in red, hiding behind the glass. To my husband Rob, for your support and encouragement when I needed it most. Above all, thank you for reminding me to laugh when the rocks are tumbling in my head.                      xv       Inspired by Anaïs, who as a little girl  showed me the potential this world has to offer,  I dedicate this work to the many children  who are brave in the face of their fears.    In her words: “You see, I lived my life in the darkness and cried, Nothing was perfect. My life was bedraggled and threadbare, Nothing was perfect. Till one day I arose from the darkness and saw, Though my life was not perfect, there was hope, There was hope!”         1 Chapter 1: Introduction Autism spectrum disorder (ASD) is an umbrella term used to define a continuum of developmental disorders characterized by deficits in social communication and interaction as well as repetitive and restricted behaviours (APA, 2013). Since its conception, anxiety has been an ancillary symptom in ASD. Current prevalence rates of comorbidity of anxiety disorders and ASD average between 40% and 50% for children with higher intellectual functioning and have been reported as high as 80% (Kerns & Kendall, 2012). Although the root of such high prevalence rates remains unclear, the impact of anxiety symptoms on this population and the development of efficacious treatment programs is gaining recognition among researchers and practitioners alike (Reaven, Blakeley-Smith & Hepburn, 2014). Anxiety in ASD Anxiety disorders are the most common concurrent mental health concern in children and youth with autism spectrum disorders (ASD: Vasa et al., 2014). Anxiety disorders are characterized by excessive worry in the absence of real danger and heightened psychological responses that precipitate avoidance to specific objects or situations (APA, 2013). Over the last decade, a substantial body of research has documented the prevalence (e.g., Leyfer et al. 2006; White, Oswald, Ollendick & Scahill, 2009), impact (e.g., Lopata & Thomeer, 2015; Rotheram-Fuller & MacMullen, 2011), conceptualization, and treatment of anxiety in children and youth with ASD (e.g., Reaven, Blakeley-Smith, Culhane-Shelburne, & Hepburn, 2012; Sofronoff, Attwood, & Hinton, 2005; Wood et al., 2015).  In a meta-analysis of 31 studies, results showed that nearly 40% of children and youth with ASD met criteria for at least one anxiety disorder (van Steensel, Bögels & Perrin, 2011); a rate that more than doubles the prevalence of anxiety among children without ASD (Paulus,  2 Ohmann, & Popow, 2016). The most commonly reported anxiety disorders among children with ASD are specific phobia (29.8%), obsessive compulsive disorder (17.4%) and social anxiety (16.6%). With the exception of a higher occurrence of obsessive compulsive disorder among the ASD population, this distribution, albeit with strikingly higher prevalence rates, parallels that of children without ASD (van Steensel et al., 2011). The manifestation of anxiety symptoms among children with ASD, however, can differ from their peers. Children with ASD exhibit anxiety through a wide variety of maladaptive behaviour, including aggression, disruptive behaviours, and poor social responsiveness (Lecavalier et al., 2014). This may present as verbal outbursts, tantrums, repetitive behaviours (vocal or physical), non-compliance or defiance, heightened senses, and/or elopement.  Taking into consideration the substantial overlap in characteristics of ASD and anxiety, it may be difficult to distinguish between the two disorders (Lydon, Healy, O’Callaghan, Mulhern, & Holloway, 2015). To this end, an ASD diagnosis frequently overshadows other mental health concerns, including anxiety. This can have significant ramifications when engaging in goal planning, such as developing Individualized Education Plans (IEP). As a result, students with ASD may not receive appropriate support and treatment to address their individual needs (Hebron & Humphrey, 2014). To fully address this concern, it is important to recognize how comorbid symptoms such as anxiety contribute to functional impairments that extend beyond the functional deficits of ASD alone and identify effective treatments. Cognitive Behavioural Therapy (CBT), with adaptations, has emerged as a promising effective approach to ameliorate anxiety symptoms among children with ASD.      3 Cognitive Behavioural Therapy and ASD Cognitive-behavioural therapy has become the primary psychotherapeutic intervention in treating mood and anxiety disorders among typically developing children (Olatunji, Cisler & Deacon, 2010). Based on a combination of basic behavioural and cognitive principles, CBT emphasizes the interconnection of thoughts, feelings and behaviour. The basic premise is that a change in one dimension leads to a change in the other dimensions. For instance, changing an individual’s thoughts or cognitive patterns leads to a change in his or her emotional state and behaviour. In the treatment of anxiety, a CBT model commonly consists of four main areas of intervention: psychoeducation, cognitive restructuring, relaxation techniques and graded exposure.  Of these four, it has been suggested that exposure is the most important component in reducing anxiety symptoms among children. Graded exposure requires a child to re-approach their feared situation in structured, incremental steps, in a safe setting using new thought patterns and calm breathing (Silverman, Pina, & Viswesvaran, 2008). This element of treatment may be even more crucial for children with ASD due to their difficulty in accurately communicating the emotions or feelings they experience (Attwood & Scarpa, 2013).  Building on the evidence demonstrating the efficacy of CBT in the treatment of anxiety in children without ASD (James, James, Cowdrey, Soler & Choke, 2015), modified CBT has become one of the primary interventions for the management of anxiety for children and youth with ASD (Fujii et al., 2013), with growing evidence supporting the effectiveness for this population (e.g., Reaven et al., 2012; Sofronoff et al., 2005; Storch et al., 2013; Wood et al., 2015). In a recently completed review (Kester & Lucyshyn, 2018), the evidence base for CBT in treating anxiety for children with ASD was evaluated using the Council for Exceptional Children Standards for Evidence-Based Practices in Special Education (CEC, 2014). Results of the  4 evaluation indicated that modified CBT interventions for children with ASD meet CEC criteria for an empirically-supported treatment.  While retaining the core components of CBT for anxiety, modifications have been incorporated to improve the accessibility of CBT to this population. Modifications used in the delivery of CBT with children with ASD often include the use of visual supports and concrete examples, participation of primary caregivers in the treatment process, adaptation of information to match a child’s cognitive abilities, incorporation of specific interests, and individualized reinforcement strategies (Moree & Davis, 2010). The Facing Your Fears program (Reaven, Blakeley-Smith, Nichols, & Hepburn, 2011) provides an illustrative example of a CBT intervention developed to treat anxiety among children with ASD.  Facing Your Fears Facing Your Fears (referred to as FYF) is an empirically supported CBT program designed specifically for children with ASD (Reaven et al., 2011). FYF is a family–focused group intervention with 14 weekly sessions of 1.5 hours duration and includes large-group components as well as child-only and parent-only break out groups to target session-by-session goals. The 14 weeks are divided into two treatment blocks: the first seven sessions offer psychosocial education about anxiety symptoms and basic CBT strategies, while the last seven weeks focus on implementation of specific tools through graded exposure practice.  In the first evaluation of FYF, a pilot study, in which 33 children with ASD and anxiety and their parents participated, showed a significant decrease in parent report of anxiety symptoms for children in the treatment group compared to a waitlist control group. (Reaven et al., 2009). Similar results were obtained in a randomized control trial with 47 child and parent pairs (Reaven et al., 2012). Participants who completed FYF demonstrated a reduction in anxiety  5 symptoms as well as endorsed fewer anxiety diagnoses compared to children in the treatment-as-usual group (TAU).  Subsequent studies of FYF have examined the application of the intervention in settings other than the clinical research setting. Effectiveness trials have investigated the delivery of FYF in: a home setting using a telehealth version (Hepburn, Blakeley-Smith, Wolff, & Reaven, 2016); a community clinical setting delivered by clinicians previously inexperienced in implementing CBT with youth with ASD and anxiety (Reaven et al., 2015); and a school setting implemented by educators (Drmic, Aljunied, & Reaven, 2017). In each study, results showed positive treatment outcomes for participating children and youth, with a significant reduction in anxiety symptoms reported post-intervention. Also, participants across the studies reported high satisfaction ratings of acceptability and feasibility of the intervention delivered in each community setting. Together, these findings reflect the potential for dissemination and implementation of FYF in community settings, including schools. CBT for Anxiety in the School Setting The school setting has been proposed as the preferred setting for addressing anxiety among children and youth by multiple authors (Allen, 2011; Drmic et al., 2017; Ludwig, Lyon, & Ryan, 2015; Mychailyszyn, 2015). Advantages put forth for treating anxiety in this context include: (a) providing an accessible location for students; (b) addressing problematic situations in real time; (c) reducing stigma; and (d) enhancing generalization. Furthermore, in addition to academic skills, educators are increasingly responsible for addressing the social and emotional needs of students, signaling a natural avenue for delivery of effective interventions to treat anxiety. Given the role school plays in the emotional development of children with ASD, there  6 are surprisingly few school-based interventions available to address anxiety in this context (Rotheram-Fuller & Hodas, 2015).  To date, the majority of studies that have examined ASD and anxiety in a school setting have focused on prevalence rates with little attention to treatment (Hebron & Humphrey, 2014). The research literature examining school-based CBT programs in the treatment of anxiety among children with ASD is limited to four recently published studies. Clarke, Hill and Charman (2017) investigated the effectiveness of delivering the Exploring Feelings program (Attwood, 2004) in a school setting. Using a quasi-experimental design, 28 youth ages 11-14 years old, across 6 schools participated. All the youth had a diagnosis of ASD and were identified by school staff as exhibiting heightened levels of anxiety. At posttreatment, participants in the treatment group demonstrated reduced levels of anxiety compared to the control group and engaged in fewer maladaptive coping strategies compared to pre-treatment and to youth in the control group. Likewise, Luxford, Hadwin, and Kovshoff (2017) used the Exploring Feelings program to evaluate the effectiveness of school-based CBT for youth with ASD by conducting a randomized control trial. Thirty-five youth with ASD and clinically significant symptoms of anxiety were randomly assigned to the CBT intervention delivered in a school setting or a wait-list control group. In this study, youth in the experimental group (compared to the waitlist group) showed greater reductions in anxiety symptoms, school anxiety, and social worry following participation in the CBT intervention. Drmic et al. (2017) conducted the first pilot study of an adapted version of FYF delivered in a school setting, in which school staff were trained to implement the intervention with youth with autism and anxiety. Forty-four youth participated in a group-based FYF delivered by school-based educators. Prior to implementation, adaptations were made to fit the school-setting and cultural context. These adaptations include: (a) reducing program length  7 and changing parent involvement to fit with school schedules; (b) emphasizing emotional regulation strategies and exposure practice pertinent to the school environment; and (c) modifying worksheets and videos to reflect the school setting and cultural aspects. Results evidenced a statistically significant reduction, with medium to large effect sizes (using Cohen’s classification for interpretation; see Cohen, 1988) in parent and youth reported anxiety symptoms postintervention. Results also showed improvements in school staffs’ knowledge of and confidence in applying CBT skills with youth with autism and anxiety following delivery of the program. Most recently, Ireri, White, and Mbwayo (2019) investigated the effectiveness of delivering the Multimodal Anxiety and Social Skills Intervention program (MASSI; White et al., 2010) in a school setting in Kenya. Using an experimental design, 40 students with a diagnosis of ASD ages 5-21 years old across 2 special education schools participated. Schools were randomly assigned to either treatment or control. Composition of student characteristics were similar across the two schools with schools located in different locations to prevent possible treatment contagion. At posttreatment, the intervention group demonstrated significant reductions in anxiety levels compared to the control group, as well as, improvements in ASD- related social impairments.   Research to Practice Gap Several researchers have argued in favor of additional research examining the transportability of CBT interventions to schools (Mychailyszyn et al., 2011; Ludwig et al., 2015), as well as expanding to diverse populations including individuals with ASD. Rotherham-Fuller and Hodas (2015) argued that it is paramount that schools offer modified CBT interventions to address anxiety for children with ASD. They emphasize that many anxiety-provoking conditions for children with ASD are relevant to the school setting and may indeed be primarily school- 8 based. Drmic et al. (2017) echoed the importance of school-based anxiety interventions for students with ASD, highlighting that school-based fears (such as making mistakes, talking in front of a group, and taking tests) can impede opportunities for students to fully participate in school activities.  A challenge shared by many empirically supported treatments is how to promote the adoption and utilization of interventions in school settings. Despite the formation of governmental organizations commissioned specifically to support the dissemination of educational research, such as the Institute of Education Sciences, few empirically supported treatments (EST) have been implemented and sustained by educators, indicating a poor translation of research to practice (Anderman, 2011). This lack of ESTs in school settings may be even more pronounced for children with ASD (Kasari & Smith, 2013). The provision of quality early intervention to children with ASD during the preschool years often is characterized by highly structured and tightly controlled clinical settings, making it challenging to transition children into neighborhood public schools which are more complex and not as highly structured throughout the school day. Known as the research to practice gap, a movement has been ignited in the field of psychology to narrow this gap (Chorpita & Daleiden, 2014). Among the barriers to adoption is the preponderance in the research literature of efficacy studies, which involve rigorous investigation of an intervention under ideal conditions. This is in contrast to the relatively low presence in the literature of effectiveness studies, which involve the investigation of interventions under real world conditions. Researchers across disciplines have noted this imbalance and efforts are being dedicated to effectiveness studies that investigate the implementation of an EST under real world conditions (Ghate, 2016). Within the field of  9 educational psychology, there is a growing interest in examining the process of translating research into clinical practice using implementation science (Forman et al., 2013). Defined as the study of methods and strategies to promote the adoption and integration of ESTs into practice settings (Eccles & Mittman, 2006), it has been argued that implementation science is essential to the successful integration of ESTs into the unique context of schools (Forman et al., 2013). Central to this process is an investigation of how to modify an intervention to fit the characteristics of a setting, such as schools, while maintaining core components of the intervention. One promising strategy in optimizing adoption of interventions, by making research more relevant to practitioners, is integrated knowledge translation (CIHR: Canadian Institute for Health Research, 2012).  Integrated knowledge translation (iKT) is defined by the Canadian Institutes of Health Research as a collaborative approach to research that simultaneously engages researchers and knowledge users in the exchange, synthesis and application of knowledge (CIHR, 2012). A key process of an iKT framework is collaboration at each stage in the research process (i.e., development of research questions, selection of methodology, data collection, interpretation of findings, approach to dissemination). Fundamentally, this framework involves a two-way interaction between researcher and knowledge user in developing, sharing and applying knowledge.   Traditionally, sharing of knowledge from researcher to practitioner has involved two distinct phases. The first phase centers around the development of an intervention followed by extensive testing of efficacy in controlled conditions. Next, when ‘sufficient’ evidence accrues, the intervention is transported to community settings where modifications are made to respond to contextual variables. This route to dissemination limits opportunities to integrate perspectives of  10 front-line practitioners and may threaten the fidelity of the intervention when applied in community contexts, as knowledge users report that they spontaneously modify interventions to suit their ecological setting (Stahmer et al., 2015). In contrast, iKT requires a reciprocal dialogue between researcher and knowledge users from the onset of research design. As a result, important contextual variables are actively incorporated during the intervention development phase, lending to greater acceptability and implementation fidelity in community contexts. Within an iKT framework, two pivotal mechanisms enhance the usefulness of research findings, which in turn, improves the uptake of an intervention in community settings (Gagliardi, Berta, Kothari, Boyko, & Urquhart, 2016). First, the on-going relationship between researcher and knowledge user builds a partnership based on trust and a shared vision, as well as provides early identification of possible discrepancies between perceived needs and actual needs, maximizing creation of relevant knowledge. Secondly, gaining an understanding of the perspectives of knowledge users allows researchers to more effectively develop interventions to match contextual circumstances (McGrath, Lingley-Pottie, Emberly, Thurston, and McLean, 2009). Together, these features serve to build the capacity of knowledge user and the sustainability of an intervention.  Statement of Problem and Research Questions Anxiety disorders and symptoms are recognized as one of the most common co-occurring conditions affecting children and youth with ASD (Vasa et al., 2014). According to The National Needs Assessment Survey conducted by the Canadian Autism Spectrum Disorders Alliance (Weiss, Whelan, McMorris, & Caroll, 2014), in the province of British Columbia 54% of caregivers of school aged children with ASD report concerns about anxiety. Despite the growing rate of children with ASD in need of mental health services, appropriate mental health treatment  11 is not readily available. It is estimated that a quarter of school-age children present with significant mental health concerns yet less than 30% of them receive any mental health care (Paulus et al., 2016). This deficiency of services becomes especially troublesome for children and youth with ASD, as their diagnosis often overshadows the need for mental health services, resulting in poorly directed interventions (Hebron & Humphrey, 2014).  The needs of anxious children are of concern as they are more likely to experience lower self-worth, difficulties adjusting to school, peer rejection, social isolation, increased teacher attention, academic difficulties, and school refusal (Lopata & Thomeer, 2015). Addressing anxiety symptoms may be especially important to educators as it affects the learning outcomes of students, including students with ASD. Anxiety symptoms are frequently associated with challenging behaviour, making it difficult for educators to teach the mandated curriculum set before them. Furthermore, since children exhibit a variety of school specific anxieties, such as taking tests, presenting in front of a class, and completing homework (Fujii et al., 2013), it is logical to presume that inclusion of educators as the intervention agent would increase the social validity for the use of CBT within schools. The significant number of children that have ASD and anxiety (van Steensel et al., 2011) coupled with the increasing pressure on schools to provide mental health services (Adelman & Taylor, 2006), highlights the urgency to align research and practice. Veritably, implementing anxiety interventions in real-world contexts has been identified as one of the top priorities for advancing research on co-occurring anxiety in youth with ASD (Vasa, Keefer, Reaven, South & White, 2018).   The nascent literature examining the effects of CBT to treat anxiety in children with ASD in a school setting although promising, is still in its infancy. Given the prevalence of anxiety  12 among this population and the debilitating impact anxiety has on school participation, it is imperative to identify evidence-based treatments that are acceptable and feasible to educators. The aim of this dissertation was to provide one intervention option to address this need. To this end, the specific objectives of this dissertation were to: (a) understand and describe key stakeholders’ perspectives on the feasibility, acceptability, and sustainability of Facing Your Fears (Reaven et al., 2011) in a school setting; (b) apply the knowledge gained from educators and parents to facilitate provisions for a school-based version of FYF; and (c) examine the effectiveness of the school-based FYF intervention delivered by educators in schools. These objectives were addressed across two studies. The focus and methods of each study are briefly described below. The first study (Chapter 2) used an integrated knowledge translation framework to evaluate the acceptability, feasibility, and sustainability of delivering FYF in schools. The perspectives of key stakeholders, specifically educators and parents of children with autism, were analyzed using thematic analysis techniques to identify the essential adaptations to FYF to support implementation in a school setting by educators. The insights provided by educators and parents guided the development of a modified FYF for implementation in a school setting (school-based FYF).  The second study (Chapter 3) examined the effectiveness of the co-created school-based FYF intervention delivered by educators in schools. A mixed methods research approach using an embedded design was employed to address three broad research questions: (a) examining educators skill acquisition in implementing the school-based FYF intervention; (b) examining effectiveness of the modified school-based FYF in ameliorating anxiety symptoms among students with autism; and (c) assessing the acceptability and feasibility of the intervention. An  13 embedded design involves the collection and analysis of quantitative data with a supplemental collection and analysis of qualitative data (Klassen et al., 2012). For this study, a quasi-experimental group design paired with brief semi-structured interviews were used to examine the first and second research questions. A questionnaire followed by focus groups were conducted to examine the third research question.    14 Chapter 2: Study One In this first study, I had two primary aims. First, I sought to understand key stakeholders’ perspectives on the acceptability, feasibility, and sustainability of Facing Your Fears (Reaven et al., 2011) in the school setting. Using an iKT framework, I engaged in discussions with educators and parents of children with autism and anxiety to obtain their perspectives on implementing FYF in schools. A second aim was to apply the knowledge gained from educators and parents to facilitate adaptations for a school-based version of FYF. Building on the view that schools have the potential to be prominent and accessible settings in delivering CBT interventions to children with ASD, the study aimed to identify essential adaptations to FYF to support implementation in a school setting by educators. In collaboration with knowledge users, a proposed school-based FYF was developed with the intention of examining effectiveness in a subsequent study (Study 2).  Method Ethics approval was sought and granted through the Behavioral Research Ethics Board (BREB) at the University of British Columbia and the administrative team of the school district where the study was conducted.  This qualitative study employed a thematic analysis approach using focus groups to examine knowledge users’ perspectives on the acceptability, feasibility and sustainability of a school-based FYF. Focus groups are well suited for iKT research, given that they offer a platform to capture in-depth information through a back-and-forth dialogue among participants. A “hallmark of focus groups is their explicit use of group interaction to produce data” (Morgan, 1997, p. 2) that can be used to develop, refine or evaluate existing interventions.   15 Participants and Settings Participants in the current study were key stakeholders from one public school district in the Vancouver area of British Columbia, Canada. There were two participant groups; one comprised of educators and a second comprised of parents of children with ASD and anxiety. The educator group consisted of three educators, all in the position of Learning Support Teacher (LST), from three different schools within the district. Two LSTs were in an elementary school (Kindergarten to Grade 7) and one was in a high school (Grade 7-Grade 12) at the time of the study. All were female. The number of years of work experience the educators had in the district ranged from 7 to 9 years. All educators had experience with and knowledge of ASD and some experience with the Facing your Fears program, with 2 of 3 educators implementing some aspect of the program. The educator focus group took place after school hours in the library of an elementary school within the school district.  The parent group consisted of two parents (both mothers) of a child with ASD and co-occurring anxiety symptoms or a formal diagnosis of anxiety. The children ranged in age from 10-12 years old. Demographic information such as age, occupation, and education was not collected for the parents. One child was diagnosed with Pervasive Developmental Disorder- Not Otherwise Specified (PDD-NOS) and Generalized Anxiety Disorder, and the other was diagnosed with ASD and demonstrated anxiety symptoms. Both children were fully integrated in a mainstream classroom in a public elementary school in their community. Both parents had previously participated in the program with their child in a clinic setting. The parent focus group took place at a time convenient to participants, in an office in a private clinic in the city shared by the school district.   16 Data Collection and Focus Group Procedures Both groups participated in two group discussions; a primary session and a follow-up session, scheduled six weeks apart. The sessions ranged from 60-75 minutes in duration. Discussions in the first sessions centered around two major components to align with the manualized FYF program; a psychoeducation component and an applied graded exposure component. Three guiding questions related to program strengths, barriers, and adaptations were used to guide the format of the focus group discussions, with each question discussed until saturation. In the follow-up sessions, emerging themes from the first sessions and a proposed modified FYF program based on participants’ perspectives was presented, followed by a facilitated discussion.   Written consent was obtained prior to participation (See Appendix A). Each participant was given the opportunity to ask questions about the process and the researcher reviewed the process of informed consent before beginning each focus group session. A minimum of two weeks prior to the initial focus group session, participants were given access to the Facilitators Guide to Facing Your Fears: Group Therapy for Managing Anxiety in Children with High-Functioning Autism Spectrum Disorders (Reaven et al., 2011) and a condensed overview of the program, highlighting key components of the original FYF program. Participants were asked to familiarize themselves with the material in preparation for the focus group discussion. Focus group discussions were facilitated by the primary researcher. Participants were informed that the information gathered would be used to modify the current FYF program in preparation for a quasi-experimental group study aimed at evaluating the effectiveness and acceptability of a school-based FYF. Upon completion of the second focus group session, participants were thanked and given a gift card of $50 from a place of their choice for participation.  17 Qualitative Coding Discussions from each focus group session were audiotaped and transcribed verbatim, and transcriptions were checked for accuracy against the audiotape. Focus group data were then analyzed using thematic analysis. This approach provides a vivid and detailed account of data yet allows flexibility for patterns and themes to form without a fixed hypothesis (Braun & Clarke, 2006). Given these elements, this research tool is ideally suited to understanding participants’ perceptions of the intervention in depth and allowed me to evaluate the fit of the intervention within the school context.  A coding scheme was developed through a combined deductive and inductive process. To begin, based on the guiding research questions, three broad categories were deductively identified; strengths, barriers and adaptations. Next, transcripts were inductively coded by key statements to identify repeating patterns as categories. These were used to develop a tracking sheet of code titles and definitions. Transcripts were then reread and codes were applied. When passages contained more than one theme, all relevant codes were applied. During the next stage of analysis, data were sorted and organized, and separate charts for educators and parents were created. A chart consists of a list of codes and their frequency of occurrence.  Subsequently, the relationship between codes was analyzed and collapsed into themes and sub-themes. Consideration was given to breadth (i.e., number of individuals mentioning a theme and frequency of occurrence) and vigour (i.e., strength of view as illustrated by amplifying words such as “super ___”, “really”, or “extremely”) in interpreting the data. Categories across groups were compared to identify similarities and differences between the educator group and parent group. The information provided by educators and parents was used to inform proposed adaptations to FYF for use in the school setting.   18 Finally, in accordance with an integrated KT framework, findings were shared with participants in a follow-up focus group and themes were validated for content using member checking (Goldblatt, Karnieli-Miller, & Neumann, 2011).  Specifically, a summary of themes and illustrative quotes were presented to participants and they were asked to comment on whether the results reflected their perspectives; they were also provided with an opportunity for further comments. A proposed modified intervention was then presented for knowledge users’ feedback. Focus group discussions concluded with eliciting participant’s view on pilot testing the proposed modified intervention in schools.  Results A thematic analysis approach (Braun & Clarke, 2006) was employed to investigate perceptions of fit of the FYF program within a school context. Six main themes were initially identified across the educator and parent data: (a) strengths of FYF; (b) barriers to transportability to school context; (c) importance of a team approach; (d) intervention agent; (e) effective communication; and (f) procedural structure of FYF. In the follow-up focus group sessions, two additional themes emerged: sequencing of cohort sessions and the selection process for eligibility. Themes were similar across the two groups, therefore, data were collapsed with differences highlighted where they existed. Representative quotes were provided throughout as descriptive examples of the data. Using a member check technique, participants across the two groups confirmed that the findings were congruent with their perspectives. This was supported by statements such as “yes, I would agree with that” and “this sounds really good”. A summary of the main findings is displayed in Table 1, along with corresponding frequencies of responses to describe patterns of the data.    19 Table 1  Themes, Subthemes, and Frequency of Responses  Theme Subtheme Frequency of responses Educator  Group   Parent Group Total      Strengths  Format Content  7 8 5 9 12 17      Barriers to transportability  School capacity Scheduling  Commitment  12 3 6 10 4 0 22 7 6      Team approach  Parent involvement Class involvement  Administrator support 6 4 4 7 3 2 13 7 6      Intervention agent  6 5 11      Communication   5 2 7       Procedural structure  Exposure practice Scheduling 4 3 2 1 6 4      Cohort sequencing   2 2 4      Selection process   3 0 3                Strengths of Facing Your Fears Program  All the participants agreed that offering a school-based anxiety intervention for children with ASD was needed and addressing anxiety was essential to foster learning in all areas for these children. Parents noted that much of the anxiety their child experiences stems from the school environment, while educators agreed that targeting anxiety at school would be helpful in addressing school specific anxieties. As previously noted, a majority of the participants had some previous experience with FYF in its original structure. As such, in identifying strengths of the  20 program, they integrated the description of the program as presented and their lived experiences with the program.   Strengths of the FYF program identified by participants were similar within groups (i.e., agreement among educators) and between groups (i.e., agreement among the educator group and the parent group). The most pronounced identified strength was the format of the intervention program. Both groups were drawn to the systematic structure of lessons and the combination of separate, dyadic and group-based activities. In describing the presentation of information, one educator stated “I like that it takes you through lessons and that it structures it for you so that you don’t have to reinvent constantly.” This statement was supported by a parent who commented, “I really liked the structure because we are not a very systematic family but …having some sort of planned practice was enough for us to keep the vocabulary and the awareness.” In terms of group structure, one parent commented positively on the organization of the group:  I just like the way the group is in that we meet as a group and then we separate, so we as parents get a little bit of separate time, and then we come together. I just really like that. I think it’s nice. Similarly, educators discussed the value of the structure, “I think the flow of the sessions is really meaningful; I can see how valuable that could be.”   Both educators and parents believed that the format of the intervention offers several benefits, including relationship development, generalization of skills and normalization of anxiety. First, participants shared how the collaborative nature of the intervention would contribute to rapport building and the development of a positive relationship between child and coach (parent or teacher), specifically during sessions that focus on exposure practice. As one educator described, “the relationship building piece around the coaches supporting the student, I  21 think that has been in our case, a very positive thing. There’s so much trust that has been built and, just time to connect.” Parents also noted the likelihood of a growing positive connection, as in the comment by one parent that, “you’re doing it with your child which I think is really powerful…it helps to build trust.” Generalization of skills also was viewed by participants as a likely benefit emerging from the format of the program. The step-by-step process of activities, such as cognitive restructuring and graded exposure, coupled with inclusion of home practice were seen as promoting generalization. For example, reflecting on her own child’s spontaneous use of helpful thoughts, one parent excitedly shared “that a little bit of magic just happened. I didn’t encourage it or anything; it just happened and it benefited both of my children.” A third perceived benefit consistently appearing throughout the parent data, and to a lesser degree the educator data, is how the format of FYF provides an opportunity to normalize anxiety. Participants remarked that the nature of the group creates an opportunity for individuals to witness and connect with others who are experiencing similar struggles with anxiety; both at a child and parent level. As one parent noted, “The fact that it is a community, it’s a group; it is a normalization of what’s going on.”   Another strength identified by all group members was the content of the program, consisting of information and tools. Parents commented on the value of having the background information to explain the content while educators focused on an understanding of the content despite not being clinically trained in cognitive behavioral therapy. Educators and parents shared common perspectives on the utility of tools incorporated in the FYF program.  Most notable were externalizing anxiety through participation in the worry bug activity, adopting helpful thoughts through cognitive restructuring, rating and tracking specific worries using a personalized stress-o-meter and Fear Tracker, as well as calming oneself through the use of progressive muscle  22 relaxation. During the process of developing the proposed school-based FYF, attention was given to preserving the core strengths identified by the participants.   Barriers Several prominent themes emerged across educators and parents related to barriers in implementing the FYF program in the school context. The most prominent barrier identified by all participants was school capacity. For educators, this primarily centered around staffing issues while for parents, staff training and effective support regarding anxiety were central. Underlining these concerns was a perceived lack of funding and resources, as well as scheduling and space problems. Other perceived barriers were the possibility that staff and/or parents’ commitment to the intervention might fade over time, and that members of the school’s administrative team may differ in regard to the value of the intervention, thus diminishing administrative support.  In describing insufficient staffing as a barrier to implementing FYF in schools, one educator summed up a substantial discussion: “The barrier is availability of staff … having the consistency in implementing the program ... the ratio of staff … we just keep coming back to there isn’t enough time.” In a similar view, parents discussed and empathized with the workload of teachers: “There is a lot of demand made on these people’s time and now this is another demand.”  Parents alone expressed concern that school staff may fail to recognize that anxiety is a root cause of the problematic behavior displayed by their children and advocated for a greater understanding by all school staff: “That’s where it really has to start with, I think, is for the adults to understand what’s really going on … I think that a lot of people still don’t believe that it is anxiety.”  Scheduling also was identified as a potential barrier by both educators and parents.  Both focus groups unanimously voiced concern about the ability of school staff to consistently run the  23 group sessions in light of many competing demands within the school day: “A barrier is just time because there is so much already packed into the school day.” In addition, the time of day, the frequency of the intervention, the duration of sessions, as well as the total number of sessions were highlighted as possible challenges for schools.   Educators, but not parents, reported fear of waning commitment to the program: “The commitment sometimes isn’t always there. At the start [parents and staff] are ‘this is a really good idea’ … my worry is that you get three sessions in and it kind of falls off.” This view was expressed by an educator who directly observed a reduction in commitment over time by colleagues implementing an intervention program focused on teaching social skills to students with ASD.  Recommendations  Enthusiasm for the transportability of the FYF program to the school setting was shared by educators and parents. Both groups believed a school-based FYF could be a feasible intervention for schools with some modifications. Several themes emerged during focus group discussions regarding recommendations in developing a school-based FYF, with considerable overlap between the two groups. These recommendations were organized into the following four themes: (a) team approach; (b) intervention agent; (c) effective communication; and (d) procedural structure. Team approach. Participants across focus groups concurred that a team approach was vital to the success of implementing school-based FYF.  Subthemes relevant to a team approach were inclusion of parents in the intervention, class involvement, and having strong and committed support from administrators.    24  Both educators and parents discussed the benefit of having parents involved in the program and agreed that maintaining this component is desirable. One educator noted “The hook that you got in this program is that you bring parents in for every session from the get-go to do the activities and all of that; that’s where I feel the value lies.” Parents also stated that it was important to be part of the intervention, expressing appreciation that “I also get to hear what [my child’s] hearing… instead of just sort of hearing about it after.”   Interestingly, both groups advocated for incorporating the class into the intervention, including teachers and classmates, by providing a class-wide component. An educator reflected, “I think it would actually be really cool to have a segment of it that is for the whole class.” This view was strongly supported by parents, who highlighted that a class-wide component would expose all students to the information and thus ‘it becomes a part of the culture of the classroom.” As described by one parent, “A big piece of the puzzle is just educating the other kids too, so they understand what the behavior is and it normalizes it a bit.” Participants also noted the prospective outcome of enhanced generalization of skills with class involvement.    In terms of administrator involvement, educators understandably were more cognizant of the importance of administrative support. They held that for FYF to be effective in the school environment, “it has to be a district approach” where support for the program (such as promotion of the program, training, and recruitment of staff and participants) originates at the district level and is filtered down to individual schools. Parents echoed the recommendation that offering FYF in schools may be best approached through a district program.   Given the recommendations provided for developing a team approach, the proposed program included maintaining ongoing parent participation through bi-weekly parent sessions. Also, three class-wide sessions were created and added to the proposed modified school-based  25 FYF. Drawing on participants’ perspectives, which identified the need to build understanding of anxiety among faculty within a school setting, it was proposed that class-wide sessions centre around psycho-education.  Intervention agent. In discussions of who may serve as the most effective intervention agent in delivering a school-based anxiety intervention for children with ASD, educators and parents differed slightly in their views. Parents made a case for including educational assistants (EA’s) as primary intervention agents. Their rationale rested on the view that it is important for EA’s to get the information and support in coaching students through anxiety provoking situations “cause they’re the ones with the kids all of the time”. In contrast, educators commented on the frequent absence of EAs, which can lead to limited consistency of implementation and gaps in the EA’s understanding of the intervention. They also expressed hesitation in regard to the skill level of EAs in implementing the program without extensive training and support. Instead, educators focused on learning support teachers (LST) and school counsellors as viable candidates to serve as main intervention agents. Both groups believed that classroom teachers should be included in the intervention, but to a lesser extent as they may be too overwhelmed by other responsibilities.  Through the member check in the follow-up focus groups, educators and parents emphasized the importance of incorporating professionals with mental health training, such as counselors, into the program. Educators held that it was critical to have a counsellor lead the parent group sessions. Parents also emphasized how helpful it can be to have guidance on mental health issues by a trained mental health professional. Drawing on her own experience, one parent highlighted that the parent group “in a way becomes a parent support group”; therefore, the training that counselors receive makes them best equipped to facilitate the parent group.   26 Common to both groups was the recognition that regardless of who may fill the role of intervention agent, the need for training is essential prior to implementing the program. For the participants, training involved the particulars of this specific intervention, but also included additional information about understanding anxiety among the ASD population. The importance of increasing knowledge about anxiety was more pronounced among parents’ perspectives.  Guided by the information provided by the participants, the proposed modified school-based FYF delineated roles that best matched the preexisting roles of school staff. Specifically, in the program, the following roles were proposed: a school-based Counsellor would serve as a facilitator, Learning Support Teachers and/or Educational Assistants would serve as coaches, and a school-based Psychologist would provide consultation to the team.    Effective communication. Participants from both groups reported the importance of active and effective communication among all participating members. Consistently highlighted was regular communication between school and families: “That connection with home and making sure that home is on the same page; we all know how valuable and integral being on the same page as home is.” Although definitive solutions were not presented for effective avenues of communication between schools and families, one option was presented by the educator group. To support communication of intervention progress, the possibility of using an on line platform, such as FreshGrade or Google classroom, was proposed.    Other partnerships identified and discussed included communication between closely involved team members and peripherally involved team members, such as between the FYF facilitator and classroom teacher; and across FYF team members. Based on a format used in a clinical setting, one parent talked about the value of planning sessions, in which FYF team members are given the opportunity to plan and practice before sessions and debrief after  27 sessions: “So there would have to be time again for that, for a school team to do [planning and debriefing sessions], I think, for it to be really effective.”  Procedural structure. Educators shared more insights into logistical adaptations to suit the school setting than parents. Parents, besides advocating for frequent exposure sessions (i.e., “three … per week”), focused on ensuring accountability of program implementation rather than what the program might look like logistically. To ensure accountability, one parent suggested that “you need a psychologist on the school part, on the school team to kind of oversee it all.” This view was reiterated by educators, who added that a school psychologist would provide “a good addition to bridge the gap” between the district as a whole and individually participating schools. Also, like their parent counterparts, educators viewed the frequency of exposure sessions as central to the impact of the program: We’re running this [exposure] once a week, I mean ideally, we [school] would be running it more than that to be, I think I would say, to actually gain some ground it would be great to be doing it more frequently.  The structure of graded exposures in a school-based intervention also was discussed by the educator group. Factors considered were the type of exposure targets and how to structure exposure sessions to maintain stakeholder involvement across school and home environments. The educators proposed a step-wise format, in which a step in a student’s fear hierarchy is first practiced at school. After the student “tried their exposure at school, [and] you have worked through it, building that growth”, then the same step is shared with home and “the family is working on generalizing it and doing it at home.”  A final subtheme under procedural structure identified as requiring modification was scheduling. Specifically, educators discussed finding an ideal timeframe to offer the program that  28 aligns with the school calendar, suggesting to “schedule for a time of year that you have the largest chunk of uninterrupted time.” Given this subtheme, logistical adaptions for the proposed modified school-based FYF included: using a step-wise exposure format that transcended school and home settings, and delivering the intervention over the span of 10 weeks to accommodate the school calendar.   Cohort sessions. A new theme emerging from follow-up focus group discussions was the sequencing of cohort sessions. Both groups voiced that cohort sessions should be sequenced deliberately. Educators suggested that parent sessions should occur prior to the student sessions: “I almost wonder if it would be helpful to have the parent lessons earlier in the week then [the] students’ [lesson].  The parents [then] are prepared to know what the students are coming home with.” Analogously, parents considered it important for the child sessions to precede the class sessions, providing students with ASD exposure to the information in a more structured and concrete manner before participating in the class lesson. One parent commented: I like how [the small group lesson] is a little bit of preloading, and then they [student with ASD] hear it again [in the class lesson] and everyone else hears it, including the teacher. Then [the next small group lesson] reinforces the information.  It is beautifully set up. Given these recommendations, the systematic organization of sessions would be as follows: (a) parent sessions, (b) students with ASD sessions, and (c) class-wide sessions.    Selection process. Another new theme identified in the follow-up data, appearing in the educator group data only, was the selection process for eligibility, including the logistics of the referral process. Specifically, educators posed questions about the process for identifying and referring students to receive the intervention. Questions raised included: What is the criteria for eligibility to be considered for the program; who is responsible for determining eligibility; when  29 would the referral process occur; what is the process of referral; and who is responsible and who needs to be involved in the referral? Such questions bring to light procedural challenges for school-based FYF. Group members also offered potential answers to these questions. In regard to eligibility, educators viewed FYF as a tier 3 intervention, at least within their district, and therefore, suggested that the referral process could follow a process similar to existing tier 3 interventions. They also recommended that the referral process have inclusion and exclusion criteria. Lastly, they agreed that it would be essential to have commitment from team members at the time of referral. Acceptability of the proposed modified intervention. At the end of the follow-up focus group, participants were presented with a multiple-choice question that asked if they would recommend pilot testing the proposed modified intervention in the school context (see Table 2 for an overview of the proposed modified FYF). Possible answers were “definitely yes”; “yes with reservations”; no opinion”; “no, but with revisions might be worth consideration”; and “definitely no”. All participants responded with “definitely yes”. Relevant to the acceptability of the proposed intervention, both groups noted that FYF complements self-regulation programs, such as Zones of Regulation® (Kuypers, 2011) and Mind UP® (The Hawn Foundation, 2011), currently being implemented in schools within this district. All participants expressed the view that the proposed FYF has the potential to extend this learning. As one educator described, “it breaks down that yellow zone, where you kind of get stuck”.   30 Table 2  Overview of Proposed Modified School-Based Facing Your Fears   Program Structure  ~ 10-week program with 1-hour, weekly sessions ~ 2-3 students in a group ~ 1 Facilitator (school-based Counsellor); 2-3 coaches (Learning Support Teacher and/or Educational Assistant) ~ school-based Psychologist in consultative role ~ district based program with a “host” school for sessions    Session Content  Week Small Group Parent Class 1 Welcome to Group ~ Getting to know you  ~ Learning about emotions ~ What makes me worry Introduction ~ Overview of program ~ Parent role  ~ Questions/Answers Understanding Worry ~ Understanding feelings ~ What makes me worry ~ False alarm/real danger 2 Understanding Worry ~ Time spent worrying ~ False alarm/real danger ~ What worry does to my body  ~ Relaxation Training   3 The Mind-Body Connection ~ Stress-o-meters and measuring anxiety  ~ Worried minds and helpful thoughts ~ Identify priority worries Understanding Facing Your Fears ~ Adaptive/excessive protection ~ Worried minds ~ Plan to get to green ~ Creating exposure hierarchies Calm Body-Calm Mind ~ Externalizing worry ~ Thoughts-feelings-actions ~ Calm body strategies ~ Calm mind strategies  4 Calm Body-Calm Mind ~ Learning facing fears ~ Plan to get to green   5 Steps to Success- Introduction to Exposure  ~ Creating exposure hierarchies ~ Learning facing fears Steps to Success ~ Fear hierarchies  6 Exposures and Making Movies  ~ Practicing facing fears ~ Making movies  Calm Body-Calm Mind ~ Plan to get to green ~ Learning to set goals 7 Exposures and Making Movies  ~ Practicing facing fears ~ Making movies Exposure Coaching ~ Review child progress ~ How to identify and target new worries   8 Exposures and Making Movies  ~ Practicing facing fears ~ Making movies   9 Exposures and Making Movies  ~ Practicing facing fears ~ Making movies Exposure Coaching  ~ Review child progress ~ Identify and target new worries  10 Graduation    31 Chapter 3: Study Two In the past decade, a small but growing body of research has documented the use of CBT interventions with children with ASD to ameliorate a broad span of anxiety symptoms. To date, at least ten systematic reviews have examined the evidence base for treatment of anxiety among children and youth with ASD using CBT as the primary treatment approach (e.g., Danial & Wood, 2013; Kreslins, Robertson, & Melville, 2015; Weston, Hodgekins, & Langdon, 2016; Wood, Klebanoff, Renno, Fujii & Danial, 2017). Collectively, conclusions from these reviews favour CBT as an effective intervention in reducing anxiety symptoms for children and youth with ASD when modifications are incorporated to address the specific needs of this population. In their review, Kester and Lucyshyn (2018) extracted information about school involvement in the input and delivery of CBT interventions. Overall, school involvement was extremely low to non-existent and warrants greater attention. A plausible explanation for this finding is that CBT is typically delivered by psychologists trained in this method of treatment, and they work largely in clinic settings, such as community-based health centres, hospitals and private clinics, rather than in school settings. Considering the high prevalence rate and significant impact anxiety has on the social and academic functioning among children with ASD (Rotheram-Fuller & Hodas, 2015), the need for effective interventions that are acceptable and feasible to educators is imperative. In Study 2, I examined one intervention option to address this need. Guided by previous research examining the effectiveness of a school-based FYF (Drmic et al., 2017) and input from key stakeholders (Kester & Lucyshyn, 2019), Study 2 addressed the following three research questions: 1. Examining educator skill acquisition and intervention fidelity  32 (a) Will there be a statistically significant improvement in educators’ CBT knowledge post-workshop when compared to pre-workshop assessment?  (b) Will improvements in educators’ CBT knowledge be maintained at follow-up?  (c) Will the training workshop and training feedback sessions be associated with a post-intervention average fidelity score of 80% or higher across educators implementing the modified school-based FYF program with students with ASD and anxiety?  (d) Will educators perceive the training workshop and training feedback sessions to be associated with their skill acquisition in implementing the FYF intervention.  2. Examining student treatment outcomes (a) Will participation in a modified school-based FYF intervention yield a statistically significant reduction in anxiety symptoms for elementary students with ASD post-intervention? (b) Will students’ reduction in anxiety symptoms be maintained at six-to-eight-week follow-up? (c) Will a reduction in anxiety symptoms for elementary students with ASD reflect a clinically meaningful change? 3. Assessing social validity (a) Do educators, parents/caregivers of children with ASD, and children with ASD who participate in the modified FYF intervention view the school-based intervention as socially valid?    33 Method  Ethics approval was sought and granted through the Behavioral Research Ethics Board (BREB) at the University of British Columbia and the administrative team of each of the two schools where the study was conducted.  Recruitment Procedures Two groups of participants were recruited for the current study: educators and students with at least one parent. The original intention was to include participants from Study 1 in Study 2; however, constraints within the school district of Study 1 required approaching alternate school districts and consequently new participants for Study 2. Participants were recruited through elementary schools across two municipalities within the Lower Mainland with assistance from administrators from Student Support Services. In the first step of the recruitment phases, all elementary schools within a public school district plus one independent school were sent an invitation to participate in the current study. Educators from two schools (one public school and one independent school) agreed to participate. Next, school staff from each of these schools identified potential student participants and the parents were invited to participate (See Appendix B). Families who responded to the recruitment letter were contacted by the researcher for introductory purposes, to confirm eligibility, discuss details of the study, and provide interested participants the opportunity to ask questions. For the purpose of this study, student’s anxiety levels at the recruitment stage were arbitrated by school staff without reference to clinical threshold criteria. This approach aligns with findings that show sub-clinical levels of anxiety can also have an adverse effect on an individual’s daily functioning (Weeks, Coplan, & Kingsbury. 2009). Written informed consent was obtained from all adult participants; assent also was obtained from students. Eligibility criteria for the two groups of participants are described below.   34 Educators, to be eligible for the study had to: (a) be employed in the position of counsellor, teacher, or Educational Assistant (EA) at the time of the study; and (b) agree to the time commitment required for the study (i.e., attend training workshop, all intervention sessions, and focus group). Student participants, to be eligible for the study, had to: (a) have a formal diagnosis of ASD; (b) have a chronological age between 8-13 years old; (c) demonstrate problematic levels of anxiety-related behaviours and symptoms, as identified by either teacher report or parent report; and (d) have an estimated verbal and total IQ score of 70 or above, determined by school staff through a review of school records. Students were excluded from participation if they: (a) were younger than 8 or older than 14 years old, (b) were receiving treatment elsewhere for anxiety at the time of the study, (c) presented with severe aggressive behaviour that would impede their ability to participate in a group format. Parents or primary caregivers, to be eligible for the study, had to: (a) agree to participate in parent sessions, and (b) speak English. Participants  Two groups of participants who met eligibility criteria were involved in the study: educators and student-parent pairs. There were two intervention groups; one group in a public elementary school (referred to as Group A) and one group in a K-12 independent school (referred to as Group B). Each group consisted of 3 educators, 2-3students with ASD and 3-4 parents.  Educators. A total of 6 educators (5 female and 1 male) participated in the study. Participants were of mixed ethnic heritage, including Caucasian, Asian, Indo and Latino. Experience working in a school setting ranged from less than 1 year to more than 10 years, with four participants having more than 10 years of experience. Three of the participants self- 35 identified as being Education Assistants; one self-identified as being a teacher; one self-identified as being an Integration Support Teacher (IST); and one self-identified as being a school counselor. Five of the educators held a university degree and one reported an “other” form of education. Overall, the educators were relatively inexperienced in implementing CBT therapies (range = 0 – 7 years); four educators (67%) reported no experience and all of the participants reported no experience with the Facing Your Fears program. Educator participants spread across two roles: Facilitators (n=2) and Coaches (n = 4). The role of the facilitators was to lead each school-based FYF session, including small group sessions, class-wide sessions and parent sessions. They also provided support to coaches in planning and implementing FYF strategies and exposures. The role of the coaches was to work directly with the student in implementing the school-based FYF strategies and exposures, including conducting between session exposures. The composition of the two intervention groups is displayed in Table 3.  Table 3  Role and Number of Participants by Intervention Group   Group A Group B  Facilitator  IST (n = 1)   Facilitator  Counsellor (n = 1)  Coaches EA (n = 2)  Coaches EA (n = 1)     Teacher (n = 1)  Family  Student (n = 2)  Family Student (n = 3)  Parent (n = 3)  Parent (n = 4) Note:  IST = Integration support teacher; EA =  Educational assistant.  Students and parents. A total of 5 students and their parents participated in the study.  The student participants included four males and one female. The age range for student participants was between 11-13 years of age (M = 12.2). Three students self-identified as Asian and two students self-identified as Caucasian. In addition to an ASD diagnosis, two students had  36 a diagnosis of attention deficit hyperactivity disorder and one student had a diagnosis of non-verbal learning disability and anxiety. One student was taking a prescribed anti-anxiety medication at the time of the study and had previously received treatment for anxiety.  Parent participants consisted of four mothers and three fathers (including two mother-father dyads in which both parents participated). Three families were married and two families were legally separated at the time of the study. Of the parent participants, two held a high school diploma, three held a college/technical diploma, and two held a graduate degree. Family incomes ranged considerably with one family falling within a yearly income bracket between $30,000-50,000, one between $50-70,000, and three over $70,000. The role of parents was to apply CBT strategies with their child in the home setting and conduct graded exposures at home. Setting and Materials The modified school-based FYF program was delivered in two schools within neighbouring districts in an urban area of British Columbia, Canada. The training sessions for educators took place at each respective school (i.e., training for Group A was delivered at a public elementary school and training for Group B was delivered at an independent school).    Only educators participating in the study were present during the training sessions. All small group and parent sessions were conducted at school during school hours. Class sessions occurred in the regular classroom of each participating student with ASD. All focus group sessions occurred at each respective school.    Materials for the school-based FYF intervention included the original FYF facilitator manual and parent and child workbooks with modifications. Additional worksheets were created specifically for the school setting, as well as modification of graphics and activities. New written material was created for the class-wide sessions. The modified facilitator guide and parent and  37 child workbooks were provided by the researcher. Instructional materials, such as stress-o-meters, calming kits, and visual supports also were provided by the researcher. Measurement This section provides a description of the different measures, scales and data which were collected from the participants.  Demographic information. Demographic information was gathered for each participant. Educators were asked to complete a brief questionnaire to collect demographic and clinical characteristic information at the onset of the study. Data collected included: gender, years of teaching experience, years with the school district, role with the school district, and experience working with students with ASD. Parents completed a separate questionnaire, also at the onset of the study. They were asked to provide demographic information related to themselves and their child participating in the study, such as the student’s age, gender, family constellation, parent education, and income.  Outcome Measures Three sets of dependent variables were measured in this study: (a) those related to educator’s knowledge of CBT principles and fidelity of implementation of the modified school-based Facing Your Fears (FYF) program; (b) those related to anxiety symptoms of children with ASD; and (c) those related to the social validity (i.e., acceptability and feasibility) of the modified school-based FYF program. Organized by the study’s three broad research questions, a description of each dependent variable is provided below.  Research question 1 – Examining educator skill acquisition and intervention fidelity. Measures of educator’s skill acquisition included three components: (a) CBT knowledge (i.e., degree to which educators are familiar with CBT principles), (b) implementation fidelity  38 (i.e., degree to which educators deliver the intervention as intended), and (c) educators’ perceptions of skills.  Assessment of CBT knowledge. Educators completed a 20-item multiple-choice test at three assessment periods of the study: (a) prior to the training workshop, (b) following the training workshop, and (c) at the end of the 10-week school-based FYF intervention. Three similar but not identical versions of the assessment were used. The questionnaires used in this study are based on those developed by Reaven et al. (2015), who evaluated training of clinicians in a community setting to implement Facing Your Fears.  Intervention fidelity checklist. An implementation fidelity measure was used to assess the degree to which facilitators implemented the school-based FYF intervention as intended. The measure had two parts: (a) a measure of facilitator’s fidelity of implementation of core components of the school-based FYF intervention; and (b) a measure of facilitator’s overall competence in the delivery of the intervention.   Intervention fidelity was defined as the extent to which facilitators implemented the core components of the school-based FYF program as intended. Given that each session contained both a common and varied set of core components, intervention fidelity was measured on a session-by-session basis using a checklist of components for each session. An example of the intervention fidelity checklist for a psychoeducation session and for a graded exposure session (i.e., Session 4 and Session 7 of Small Group, respectively) is presented in Table 4. Items were scored on a 3-point scale, with a score of “0” indicating the key component was not present in the session; “1” indicating partial adherence to intervention components; and “2” representing full implementation of the intervention component. An average score for treatment fidelity was  39 generated by dividing the sum of item ratings by the total possible points, multiplied by 100. Scores equal to or exceeding 80% indicate acceptable intervention fidelity.   In addition to the intervention fidelity checklist of core components, a rating of competence was assigned at the end of each session. The competence rating encompassed five skills: (a) comprehension, (b) group participation, (c) language, (d) time management, and (e) behaviour management (see Appendix C for definitions). Each of the five skills were rated on a 3-point Table 4  Examples of Intervention Fidelity Checklist: Small Group Session 4 and Session 7 Activity Adherence Measure  0 1 2 9  Not  Present  Partial Implementation Full Implementation Not Applicable   Session 4 Homework review: Active minds/helpful thoughts worksheet     Deep breathing     View instructional video – Facing Your Fear of dogs.     Start and stop the tape- review strategies and steps tosSuccess.      Fear Tracker     Introduction to Exposure (Facing Your Fear of snakes)     Plan to get to green strategies      Share time: green tools        Session 7 Homework review: Opportunities for facing fears     Deep breathing     Fear Tracker     Practice Facing Fears       How Did I Do? worksheet     Make a movie: complete scripts and make one movie     Deep breathing        40 scale (i.e., a score of “0” indicating poor quality of the skill; “1” representing adequate quality of the skill; and “2” representing excellent quality of the skill). An average score for competence was generated by dividing the sum of item ratings by the total possible points, multiplied by 100. Scores equal to or exceeding 80% indicate acceptable levels of competence. It should be noted that the assessment of intervention fidelity and competence focused on educators serving in the facilitator role. Intervention fidelity and competence were not gathered for educators serving in the role of a coach.  I video recorded each student session and parent session using a HD video camera. The video camera was placed in a fixed position at the back of the room, with the lens set on a wide-angle in view of all participating students or parents and the facilitator. Following each session, recordings were transferred to an encrypted USB. Next, I observed each recorded session on a computer monitor in a secure office at UBC, and coded facilitator intervention fidelity and competence data using a paper version of a checklist. Class sessions were not video recorded; therefore, I coded intervention fidelity and competence data immediately following each class session using the same paper version of the checklist.  Inter-observer agreement procedures. A second observer, familiar with CBT concepts, was trained to observe and record videotaped occurrences of facilitator intervention fidelity and facilitator competence. A random sample of video recordings was used for interobserver agreement (IOA) training. The second observer was provided with a fidelity checklist containing operational definitions and a scoring protocol. The researcher and second observer independently scored the data and then compared results. Training was provided until at least 90% accuracy across two consecutive trials was achieved. IOA sessions were randomly selected from all student and parent intervention sessions. Class intervention sessions were not included in IOA  41 sessions, as consent for video recording was not sought, therefore video recording did not occur. IOA sessions were held on a total of 20% of student and parent intervention sessions, balanced across the two intervention groups. Only data recorded by the researcher was used for data analysis.  Percentage of total agreement for facilitator intervention fidelity and facilitator competence was calculated by dividing the number of agreements by the total number of agreements and disagreements, multiplied by 100. The average IOA for facilitator intervention fidelity was 86%, with a range of 75% to 100%. The average IOA for facilitator competence was 89%, with a range of 75% to 100%.   Brief semi-structured interviews. Following each school-based FYF session, brief semi-structured interviews were conducted with each facilitator. Example questions include, “How do you think the last session went?”, “What worked/was helpful”, What didn’t work?”, “What will you do differently next time?”. All interviews were audiotaped and transcribed.    Research question 2 –Examining student treatment outcomes. Three summative measures were used to examine changes in anxiety levels of the student participants from multiple informants. All measures were administered at pre-intervention, post-intervention, and follow-up. Brief semi-structured interviews with student participants were used throughout the intervention period to triangulate findings.  The Anxiety Scale for Children- Autism Spectrum Disorder (ASC-ASD – Child Version). Children self-reported their feelings of anxiety using the ASC-ASD-C (Rodgers et al., 2016). This 24-item anxiety questionnaire asks the child to rate the frequency with which they experience each symptom based on a 4-point scale (0=never, 1= sometimes, 2= often, 3=always). The measure provides a total score for anxiety (scores ranging from 0 - 72), with scores 20 or  42 higher indicating presence of significant levels of anxiety. It includes four sub-scales: Separation Anxiety (SA), Uncertainty (U), Performance Anxiety (PA) and Anxious Arousal (AA). In this study, I used the total anxiety score. Adapted from the Revised Children’s Anxiety and Depression Scale (RCADS: Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000), a validated measure of anxiety with children without ASD, the ASC-ASD was designed specifically for use with young people between 8-16 years of age with ASD. In a scale development study, Rodgers et al. (2016) reported good psychometric properties of the ASC-ASD. Cronbach alpha coefficients were high for total scores on the child version (a = .94), as well as on the subscales (a = .85-.88) with excellent test-reliability (r = .82). In the current sample, the ASC-ASD was observed to have high internal consistency across time points, as determined by a Cronbach’s alpha of .92 at pre-treatment, .96 at post-treatment. The Anxiety Scale for Children- Autism Spectrum Disorder (ASC-ASD – Parent Version). Parents completed the ASC-ASD-P, a 24-item parent-report version of the ASC-ASD. Like the child version, parents rated frequency of anxiety symptoms on a 4-point scale ranging from ‘never’ (score of 0) to ‘always’ (score of 3). A total score is generated by summing four subscale scores yielding a maximum score of 72. Similar to the child version, I used a total anxiety score. Rodgers et al. (2016) demonstrated good psychometric properties for the parent-report scale, including excellent internal consistency for the total (a = .94) and subscale scores (a = .87 – .91) and good test-retest reliability (r = .84). Similar values were obtained for the present sample (a = .92 at pre-treatment and a =.93 at post-treatment). School Anxiety Scale- Teacher Report (SAS-TR). The SAS-TR (Lyneham, Street, Abbott & Rapee, 2008) is a 16-item teacher-report questionnaire designed to assess anxiety-related behaviours of children ages 5 to 12 years old observable in a school setting. Classroom  43 teachers for each participating student rated the frequency of behaviours (e.g., “the child is afraid of making mistakes”) on a 4-point scale ranging from ‘never’ (score of 0) to ‘always’ (score or 3). Teachers informants were aware the student was participating in an intervention to target anxiety; therefore, they were not independent raters blind to the intervention. Scores from two subscales (reflecting social anxiety and generalised anxiety) are calculated to obtain a total score for anxiety (maximum score = 48), with scores above 17 indicating heightened levels of anxiety. The total anxiety score was used in this study. The SAS-TR demonstrates acceptable psychometric properties in children without ASD, including strong internal consistency (a > .90) and a discriminant validity of > 68% in distinguishing children with and without clinical levels of anxiety (Lyneham et al., 2008). In a sample of children with ASD, good reliability (a > .70) has been demonstrated (Luxford et al., 2017). For the current sample, the SAS-TR showed high internal consistency with Cronbach’s alphas of .94 at pre-treatment and post-treatment.  Worksheets with interviews. Beginning in session 3 and continuing weekly during small group sessions, students and their coach completed the Fear Tracker worksheet. The Fear Tracker worksheet is designed to monitor intensity of five identified fears. Based on child SUDs (subjective units of distress), students and their coach independently rated the same student-identified fears using an 8-point scale (with 1 meaning ‘not much of a worry’ and 8 meaning the ‘biggest worry’). Beginning in session 6 and continuing weekly during small group sessions, students completed the Facing Fears: How Did I Do? worksheet. The worksheet is designed to self-evaluate proficiency in managing a fear during graded exposure practice using a 5-point pictorial scale. A single open-ended question asked students to identify what they might do differently in the next graded exposure.   44 For the purpose of this study, the ordinal data gained from the two worksheets was collected but not analyzed. Instead, the purpose of the worksheets was to guide conversation with students and their coach. Using a semi-structured interview format, I probed their perceptions of change in anxiety symptoms and clinical importance. Example questions include, “What does this rating mean to you?”, “Do you notice a change in your ratings?”, “What felt good/went well?”.  Descriptive field notes were taken.  Research question 3 - Assessing social validity. Social validity of the school-based FYF intervention was assessed using a mixed methods approach.  Social validity questionnaire. Social validity questionnaires were administered once at the completion of the intervention. Developed for the purpose of this study, the questionnaires were designed to gather information on participants’ perspectives on the utility of and their satisfaction with the school-based FYF intervention. Three similar, but not identical, versions were used to collect data from three stakeholder groups: educators, parents, and students (see Appendices C, D and E). The number of items on the three social validity questionnaires varied from 13 on the student version to 22 on the educator version, with 3 open-ended questions on the parent and educator versions only.  Participants rated their satisfaction with overall quality of the intervention, logistics of the program, communication between members, ease of implementation, content relevance, and utility of individual intervention components (e.g., activities). Questions were rated on a 5-point scale ranging from either “not helpful” to “extremely helpful/useful” or from “strongly disagree” to “strongly agree”, depending on the focus of the question (i.e., utility or satisfaction). Students used a pictorial scale that matched these rating categories. Faces with a gradient of expressions were ordered in a sequence from very sad (equivalent to “not helpful”) to very happy (equivalent to “extremely helpful”). An  45 average social validity score was calculated for each evaluation and used as a summative rating of social validity.  Focus groups. Two focus groups, an educator group and a parent group, for each intervention group (i.e., Group A and Group B) was conducted within 3 weeks following the intervention. Discussions from each session were audiotaped and transcribed.  Research Design The current study used a mixed methods research approach using an embedded design to examine implementation of a modified Facing Your Fears program in a school setting. Mixed methods research integrates quantitative and qualitative methods to develop a deeper understanding of research questions, with growing utilization in implementation research (Palinkas et al., 2011). An embedded design involves the collection and analysis of quantitative data with a supplemental collection and analysis of qualitative data (Klassen et al., 2012). Methodological triangulation was used to assess the convergence, complementarity or divergence of quantitative and qualitative data. It was anticipated that methodological triangulation would capture a deeper and wider understanding of the findings derived from each research question. I employed a quasi-experimental group design to examine the three research questions. This was paired with brief semi-structured interviews throughout the intervention and focus groups following the intervention to allow for a more in-depth analysis of participants’ perspectives regarding implementation of the intervention in a school setting. All educators (n = 6) participated in a 2-hour training session prior to the FYF intervention. Educators were part of Group A or Group B dependent on their affiliation with the participating student. Figure 1 summarizes the research design that was used to answer my research question regarding educators’ acquisition of CBT knowledge.   46    (Assessment I)  Post-intervention (Assessment II) Follow-up (Assessment III)  Group A Group B O O X X O O O O Note: O = observation, X = training workshop Figure 1. Quasi-experimental group design for educator outcomes Students with ASD and anxiety (n = 5) participated in two intervention groups (Group A and Group B) based on their school affiliation. Selection of students was purposeful, with attempts made to match students by age, cognitive level and interests to maximize students’ engagement in the group-based intervention. This approach is akin to a purposeful homogenous sampling strategy often used in implementation research (Palinkas et al., 2015). The importance of matching students also was identified as a critical factor by key stakeholders in the integrated knowledge translation study I conducted as a precursor to this study (Study One). The original intention was to run Group A and Group B simultaneously. However, due to delays in recruitment, the intervention was implemented at different points in time over a single school year. Figure 2 summarizes the research design that was used to answer my research question regarding student outcomes, with different starting points for assessment.    Pre-intervention (Assessment I)  Post-intervention (Assessment II) Follow-up (Assessment III)  Group A O X O O Group B  O X O O Note: O = observation, X = intervention (Facing Your Fears program)  Figure 2. Quasi-experimental group design for student outcomes   47 Following the intervention, I conducted separate focus groups with educators and parents at each school site, for a total of four focus groups. Focus group session ranged in duration from 30-45 minutes. Open-ended questions were used to obtain participants’ perceptions of acceptability and feasibility of the school-based intervention. Discussion centred around: (a) the structure and process of the intervention; (b) what was helpful or not helpful about the program, factors that are critical for success in a school setting; and (c) clinical significance of outcomes. Probing statements (i.e., “tell me more about that”) were used as necessary to clarify or expand participant’s responses.  Procedures Research procedures included preintervention assessment, intervention, postintervention assessment, and follow-up assessment, as well as brief semi-structured interviews throughout the intervention period. Assessment periods varied, dependent on the particular research question. Table 5 displays the timeline of assessment periods across the three research questions, followed by a more in-depth description of the research procedures. The reader should note that follow-up data for Group B was not collected due to the end of the school year. The final intervention session occurred in the last week of school before the summer holiday. It is my intention to collect follow-up data in the upcoming school year; however, this information is not available for the current analysis.        48 Table 5  Timeline of Assessment Activities   Time                Activity Research Question Week 1 TE1 Pre-intervention CBT knowledge Training Workshop  TE2 Post-workshop CBT knowledge   1 Week 2  TS1 Pre-intervention  • ASC-ASD-C • ASC-ASD-P • SAS-TR  2 Weeks 3-13 Intervention  • 10 weeks intervention  • training feedback sessions • brief interviews  2 1 1 & 2 Week 14 TS2 Post-intervention  • ASC-ASD-C • ASC-ASD-P • SAS-TR TE3 Follow-up CBT knowledge  Social Validity Questionnaires  2    1 3 Weeks 15-17 Focus Groups  3 Week 19 TS3 Follow-up   2 Note: TE1, TE2, TE3= Educator Assessment Periods 1, 2 and 3; TS1, TS2, TS3= Student Assessment Periods 1, 2, and 3.   Research Question 1: Examining educator skill acquisition and intervention fidelity. The study began with educator training. Data were collected at three assessment points: TE1, TE2, TE3. The training included a training workshop (delivered over two 1-hour sessions), followed by training feedback sessions with each facilitator coinciding with weekly FYF sessions (i.e., 10 group sessions, 5 parent sessions, and 3 class sessions). Direct measurement of pre-intervention CBT knowledge (TE1) was collected prior to the workshop. Assessment of CBT knowledge was repeated at the end of the workshop (TE2) and again at the end of the FYF  49 intervention (TE3). Fidelity data were collected following each FYF session to reflect session specific content.    Educator training. A Behavioural Skills Training (BST) approach was used to train educator participants in implementing the modified school-based FYF intervention. BST is a training method that incorporates instruction, modeling, behavioural rehearsal, and direct feedback, with empirical evidence to support effective transfer of skills using this method (Gianoumis, Seiverling, & Sturmey, 2012).   Training began with a 2-hour training workshop, presented in two 1-hour sessions for the educator participants (i.e., facilitators and coaches). The workshop was presented a total of two times during the study, one at each participating school site. Consistent with a BST approach, the workshop consisted of a combination of didactic presentations, examples, role-play activities, and feedback. The workshop was presented by the researcher. First, I provided some basic information about cognitive-behavioural therapy with an emphasis on treating anxiety among individuals with ASD. Educators were given a brief description of core components of CBT and modifications to CBT for working with children with ASD incorporated in the FYF intervention program. Following this introduction, I presented a session-by-session review of the school-based FYF. Examples and demonstrations were used to model key concepts and activities. Next, educators engaged in short role-play activities to practice the CBT and graded exposure strategies. The researcher provided verbal feedback to support educators’ acquisition of skills, including positive comments to reinforce skills performed correctly and informative feedback to provide clarification on skills requiring further practice.    Following the workshop, educator participants implemented the school-based FYF. Educators facilitated the FYF sessions and I was present for all sessions to provide coaching as  50 necessary. In-person consultation with the facilitators was provided following each session. Each feedback session followed a consistent format: (a) question-and-answer period regarding the prior session; (b) feedback regarding adherence to objectives and activities of the previous session, including praise, missing elements and suggestions for delivery; and (c) planning for the up-coming session. In addition, a brief semi-structured interview was embedded in the feedback sessions to gain facilitators’ perspectives on skill acquisition in implementing the FYF intervention. Feedback sessions varied from 15-30 minutes in duration.  Research Question 2: Examining Student Treatment Outcomes  There were three periods of assessment for the student participant groups: TS1, TS2, TS3. Pre-intervention assessment (TS1) for the student group was collected after consent was obtained from both parent and child; TS2 was conducted after the 10-week CBT intervention ended; and TS3 was conducted 6-to-8 weeks after intervention had ended for Group A and is planned to be conducted 3 months after intervention for Group B.  I also collected student self-report data on their perceptions of anxiety levels and clinical importance using two worksheets: (a) the Fear Tracker worksheet, and (b) the Facing Fears: How Did I Do? worksheet, beginning in week 4 and week 6, respectively. Students and their coach were interviewed using a brief semi-structured protocol during the two activities, providing supplementary narrative data.  School-based FYF intervention. The CBT intervention used in this study is a modified version of the original manualized Facing Your Fears program developed by Reaven and her colleagues (Reaven et al., 2011). The school-based version of the FYF program was developed in collaboration with a small group of key stakeholders using an integrated knowledge translation framework. In a qualitative study (Study One), I conducted focus groups with educators and parents from a district in the Lower Mainland (Kester & Lucyshyn, 2018). Their perspectives on  51 the acceptability, feasibility and sustainability of a school-based FYF were used to design the modified version that was used in this study. Consistent with the original FYF program (Reaven et al., 2011), the core components of a cognitive-behaviour approach for the treatment of anxiety were maintained. These include: (a) psychoeducation around a general understanding of anxiety; (b) development of coping strategies including somatic management, cognitive restructuring, and problem-solving; and (c) graded exposure. While school-based FYF maintained the core objectives, concepts and strategies to reduce and mange anxiety symptoms in children, several modifications were incorporated to reflect the school setting. Similar to Drmic et al. (2017), specific modifications included: (a) dividing students and parents into two distinct groups; (b) spending more time distinguishing between “real fears” and “false alarms”; and (c) reducing the number of sessions. Unlike Drmic et al., the school-based FYF used in this study retained the video project.  Students spent time creating and filming their own Facing Your Fears videos in order to facilitate the generalization of core concepts. Unique modifications also were incorporated into the present version. Specifically, class-wide sessions were added and an exposure checklist for parents was developed and used. The sessions were guided by a facilitator’s manual and individual workbooks for students, parents, and class. Materials from the original FYF program were used with some new written materials, worksheets and graphics added. Examples of changes to activities and worksheets include: (a) modifications to the tracking sheet to document exposure practice; (b) the addition of a brain science activity, additional worksheets to identify the connection between thoughts, feelings, and behaviours; and (c) a greater emphasis on practicing strategies to manage body’s reaction to anxiety.  52 The school-based FYF is a 10-week intervention program with three group components: small group, class group, and parent group. See Appendix F for an outline of schedule, key concepts and activities. Small group. The small group sessions are designed for 2-4 children with ASD, with a total of 10 sessions, each 1-hour in duration. Similar to the original FYF program, the school-based FYF is divided into two sections: (a) psychoeducation, and (b) planned exposure to anxiety-provoking situations. The first five sessions (weeks 1-5) offer psychosocial education, providing an introduction to anxiety symptoms and basic CBT strategies. Students with ASD learn: (a) about emotions, (b) how to identify anxiety, (c) how to externalize anxiety, (d) about the connection between the body’s reaction and thoughts (i.e., the mind-body connection), and (e) how to cope with their anxiety using CBT strategies. The second half of the program (weeks 6-10) focuses on implementing specific tools through exposure practice. Students, with the support of their coach, develop a fear hierarchy on which they break down a fear or anxiety-provoking situation into small steps and list the steps from least to most anxiety provoking. Next, students practice facing their fear (with their coach) and managing their anxiety through role plays and/or in vivo exposure. Generalization is promoted through making movies, where students are provided an opportunity to model graded exposure for facing a fear in their own Facing Your Fears video.  Parent group. The parent sessions are designed for parents or primary caregivers of the child with ASD, with a total of 5 sessions, each 1-hour in duration. Parent sessions are conducted every second week (weeks 1, 3, 5, 7, 9). Coordinating with the small group session schedule, the parent group begins (i.e., the first two sessions) with psycho-education. Parents are provided with: (a) an overview of the school-based FYF program; (b) information about the interaction  53 between parental anxiety, parenting behaviours (e.g., adaptive and excessive protection) and the maintenance of anxiety symptoms; and (c) how to help their child recognize and regulate anxiety symptoms. The next three sessions are dedicated to coaching parents in creating an exposure hierarchy and supporting their child in participating in planned exposures at home.   Class group. The class group sessions are designed for classmates (including the child with ASD), with a total of 3 sessions, each 45 minutes in duration. Class sessions are conducted in weeks 1, 3, and 6 of the 10-week program. With a focus on psycho-education, class group sessions provide an opportunity for peers and the classroom teacher to learn and develop useful strategies to address stress and anxiety. Core concepts shared with the class include: (a) identifying anxiety, (b) understanding anxiety (e.g., brain science), (c) externalizing anxiety, and (d) learning strategies to cope with anxiety. The student with ASD is present during the class discussion, allowing an introduction (or preloading) of information for the student with ASD prior to the small group sessions.    Research Question 3: Assessing Social Validity  Assessment of social validity occurred following the intervention. Study participants completed social validity questionnaires 1 week after intervention had ended. Focus groups were conducted within 3 weeks after intervention had ended.  Data Analysis Procedures It was anticipated that due to the small sample size, the quantitative data would not conform to a normal distribution, a requirement for the use of parametric statistics; therefore, non-parametric tests were used to analyze the quantitative data. The non-parametric Friedman Test was used to determine statistically significant changes within subjects across three assessment points (TE1, TE2, TE3). The non-parametric Wilcoxon Signed-Rank Test was used to  54 determine statistically significant changes within subjects across two assessment periods. The statistical analysis was performed using RStudio (R Core Team, 2014; RStudio Team, 2015). Supplementary qualitative data were analysed using thematic analysis techniques to gain a richer understanding of findings. Following the guidelines outlined by Braun and Clarke (2006), analysis of data included: (a) reading the text multiple times, (b) generating initial codes, (c) sorting data by themes, (d) generating a thematic map, (e) defining and naming themes, and (f) reporting results. My analysis plan is presented below, organized by my three research questions.  Research Question 1: Examining Educator Skill Acquisition and Intervention Fidelity The effectiveness of the training for educators and their subsequent ability to implement the school-based FYF intervention was assessed in three ways. First, educators’ (facilitators and coaches) knowledge of CBT was compared across the three assessment periods (i.e., before and after the training workshop, and post intervention) using the non-parametric Friedman Test. If the results of the Friedman Test showed a statistically significant difference in CBT knowledge scores, post-hoc tests to identify the location of the change was conducted. A post hoc analysis using the Nemenyi test was performed on all possible pairs of assessment periods (i.e., Assessment TE1 and TE2; Assessment TE1and TE3; and Assessment TE2 and TE3). The use of post hoc multiple comparison procedures has been recommended to minimize the occurrence of false positives (Type I errors) due to multiple comparisons across assessment periods (Miller, 1981). I also calculated within subject effect sizes (ES). The calculation of ES allows for evaluation of the magnitude of change in CBT knowledge. Effect sizes were calculated using standardized mean differences.  Second, educators’ (facilitators only) fidelity of implementation was assessed by examining the data within and across facilitators. Analysis included examining percentage data  55 for each facilitator for each group condition (i.e., small group session scores, class group session scores, parent group session scores and total session scores). I also examined summary percentage data across facilitators, session-by-session for each group condition. Implementation of the intervention was originally planned to include three cohort sessions. That is, the intention was for two facilitators to each deliver all sessions (student, parent, and class) of the intervention to one group. However, due to scheduling demands and class composition, class sessions were not possible for Group B. Furthermore, the facilitator for Group B reported apprehension in her skills to sufficiently plan for and deliver the content to parents, prompting me to take the lead facilitator role for half of the parent sessions.  Finally, qualitative data collected through brief semi-structured interviews with educators (facilitators only) were analyzed using the six-stage thematic analysis process developed by Braun and Clarke (2006). As described above, this process involves: (a) reading the text multiple times, (b) generating initial codes, (c) sorting data by themes, (d) generating a thematic map, (e) defining and naming themes, and (f) reporting results. Analysis involved identifying, comparing and contrasting patterns and themes across multiple debrief discussions; first with-in data for each facilitator, then across facilitator data.  Research Question 2: Examining Student Treatment Outcomes The non-parametric Wilcoxon Signed-Rank Test was used to measure change in students’ anxiety level between two assessment periods: pre-intervention and post-intervention. In addition to testing for statistical significance, I calculated within subject effect sizes (ES) which allows for evaluation of the magnitude of change in anxiety levels. Effect sizes were given as a median of the within-subject differences over time. First, I calculated the subject-specific difference by finding the different between TS1 and TS2 for each student. Next, I calculated the  56 median of those differences over the entire sample. To examine clinical significance, I followed Jacobson and Truax’s (1991) procedure for computing statistical significance of the magnitude of each student’s change in anxiety levels. Using reliable change indices (RCI), scores greater than ±1.96 were considered clinically meaningful. An identical approach was used to analyze the data collected for each anxiety measures (i.e., ASC-ASD-P, ASC-ASD-C, SAS), from three groups of informants; parents, students and teachers.   Supplementary qualitative data collected from students and educators were analyzed using thematic analysis to assess patterns and themes related to students’ weekly self-evaluation of changes in anxiety levels and clinical importance.  Research Question 3: Assessing Social Validity A combination of quantitative and qualitative analysis was used to examine social validity of the school-based FYF; that is, participants’ perspectives on the acceptability and feasibility of the intervention.  First, quantitative data from educators, parents and students were analyzed using descriptive statistics. For each evaluation, an average score across the total number of items was calculated and used as a summative rating of social validity. Descriptive statistics (mean, standard deviation, range, and grand mean) for educators, parents and students were calculated.   Next, qualitative data collected through focus groups with educators and parents were analyzed using an inductive thematic analysis approach, as described by Braun and Clarke (2006). Analysis involved identifying, comparing and contrasting patterns and themes within and across groups; first within each group data (i.e., four focus groups), then across group roles data  57 (i.e., educators and parents). Lastly, themes across groups were compared to identify similarities and differences between the educator group and parent group. Results This research was conducted using a quasi-experimental design and took place in a real-world setting, i.e., school setting. Many variables could not be tightly controlled, including number of participants, delivering all intervention components and timing of intervention to allow for follow-up data. Nevertheless, careful analysis allowed for a variety of interesting findings. The results are presented below, organized by my three research questions.  Research Question 1: Examining Educator Skill Acquisition and Intervention Fidelity Assessment of CBT knowledge. Educators demonstrated improvements in CBT knowledge following participation in the training workshop and intervention period compared to pre-workshop CBT knowledge. Results of the Friedman Test showed a statistically significant change in educators’ CBT knowledge across pre-training (Assessment TE1; M = 53% correct, SD = 18%), post-training (Assessment TE2, M = 68% correct, SD = 12%), and follow-up (Assessment TE3, M = 75% correct; SD = 10%), χ² = 9.65, p = .008. Post-hoc tests of all possible pairs of assessment periods (i.e., Assessment TE1and TE2; Assessment TE1 and TE3; and Assessment TE2 and TE3) showed that a statistically significant improvement occurred between Assessment TE1 and TE3 (p = .007); that is, between pre-training and follow-up assessments. The effect size for the treatment effect between TE1 and TE3 was 0.65. Although educators demonstrated improvements in assessment of CBT knowledge after attending the training, there was no significant difference between pre-training and post-training scores (p = .19). There was, however, an effect size of 0.43. Table 6 summarizes the median, range (composite raw score 0-20), and percentage scores for educator’s acquisition of CBT knowledge.   58 Table 6  Median, Range, and Percentage Scores for CBT Knowledge  Pre-training    Post-training  Follow-up  Mdn (SD) R %  Mdn (SD) R %  Mdn R % Group A 11 9-11 55  14 13-15 70  14 12-16 70 Group B 9 6-16 52  14 9-14 65  16 16-18 80 Total 10 6-16 53  14 9-15 68  14 12-18 75 Note. Mdn = Median; R = Range; %= Percentage. Numbers are displayed in raw scores.  Intervention fidelity. Educator’s fidelity of implementation was calculated based on the percentage of core components that the facilitators implemented across the 10-week intervention period. Implementation fidelity percentages ranged from 33% to 94% across all session groups and facilitators (M = 79% for student sessions; M = 66% for parent sessions). Figure 3 shows the average percentage of core components that Group A and Group B facilitators implemented during student sessions. Variability in adherence to intervention components was observed across the first few student sessions for both facilitators. There was an overall upward trend across intervention sessions, with a stabilization of level and trend across the last four sessions (average fidelity of 88%). Looking at individual facilitators, the Group A facilitator evidenced an overall fidelity of 82%, and the Group B facilitator evidenced an overall fidelity of 77% for student sessions.   59  Figure 3. Average percentage of facilitator intervention fidelity of student session core  components.    Figure 4 shows the average percentage of core components for parent sessions by facilitator. In comparison to student sessions, a greater variability between facilitator intervention fidelity was observed for parent sessions. The Group A facilitator showed low variability across sessions with a slight overall upward trend from session 1 to session 5 and an overall fidelity of 80%. In contrast, the Group B facilitator showed high variability for parent sessions with an 01020304050607080901001 2 3 4 5 6 7 8 9 10Average Percentage of Intervention FidelitySessionsGroup AGroup B 60 average of 51% fidelity for parent sessions.    Figure 4. Average percentage of facilitator intervention fidelity of parent session core  components.  Due to low classroom teacher participation at one site and complex needs of classmates at the other site, implementation of class sessions was restricted. Only a total of 5 (out of a possible 12) were delivered, all at one school site (Group A). Group B was situated in an independent school that offers specialized education for students with a variety of developmental disabilities. Given that class sessions of the school-based FYF were designed to provide universal instruction (Tier 1) for typically developing peers, following a discussion with school staff, it was agreed that the format of class session content poorly aligned with the abilities of that target students’ classmates. For this reason, the Group B facilitator (i.e., classroom teacher) declined to conduct the class sessions with her students. The average percentage of core components for class sessions delivered by the facilitator of Group A are shown in Figure 5. Three sessions were delivered to classmates of one student with ASD (Class One) and two sessions were delivered to classmates of a second student with ASD (Class Two). Group A facilitator’s average intervention 01020304050607080901001 2 3 4 5Average Percentage of Intervention FidelitySessionsGroup AGroup B 61 fidelity for the class sessions delivered was 84% (5 sessions). The limited data available for class sessions reduced the ability to evaluate graphical information using visual inspection techniques.  Figure 5. Average percentage of facilitator intervention fidelity of class session core  components for Group A.  Data regarding facilitator’s competency were also collected for each session. Competency ratings included: comprehension, group participation, language, time management and behaviour management. Average competency ratings were similar across facilitators for student sessions (M = 81% for Group A and M = 86% for Group B) and parent sessions (M = 93% for Group A and M = 90% for Group B). Average competency ratings for class sessions (Group A) was 76%.   Skill acquisition. Following each school-based FYF session, a brief semi-structured interview was conducted with educators (facilitators only) to gain information regarding their perspective about facilitating factors to skill acquisition and barriers to the implementation of the school-based FYF program. Five main themes emerged across the two facilitators. The themes and core ideas (or subthemes), with counts of how many instances of each core idea, are listed in 01020304050607080901001 2 3Average Percentage of Intervention FidelitySessionsClass OneClass Two 62 Table 7. To ensure confirmability of the findings, I engaged in the member checking process (Goldblatt, Karnieli-Miller, & Neumann, 2011). First, I transcribed the recording of each interview, then I hand coded the data to identify the themes and codes that emerged. Next, I summarized the results, sent a copy to participants, and asked them to read the final themes to check for accuracy. Three questions were posed: does this match your experience; do you want to change anything; do you want to add anything? Both facilitators provided written feedback indicating the findings were an accurate reflection of their own experience. Thus, the member check supported the credibility of my analysis.  Table 7   Themes, Core Ideas, and Counts of Occurrence Theme  Core Ideas Counts of occurrence F1 F2 Total Helpful Facilitating Factors  Knowledge 9 11 20 Consistency  4 5 9 Learner Needs 6 8 14 Parent Involvement  3 4 7      Learning Process Planning 5 3 8 Coaching 3 3 6 Adaptions   4 6 10      Challenges Behaviour  21 8 29 New Role  3 6 9 Student Learning Style 1 5 6 Competing Demands 3 10 13 Staffing 3 3 5      Student Behaviour  Low Engagement  6 3 9 Reluctance 5 3 8 Mood 5 2 7      Personal Expectations  11 12 23      Note. Values are counts of occurrence across multiple de-briefing sessions.    63 Helpful facilitating factors. Both facilitators reported a range of factors that were helpful in skill acquisition in implementing the school-based FYF intervention. The materials, concepts, and resources they described to be helpful in delivering the intervention are grouped into four core ideas. Knowledge was the most commonly reported facilitating factor, being mentioned 20 times across the two facilitators. Throughout the intervention, they expressed the benefits of having input from others, whether it be related to: (a) the intervention itself, “always good to have you [referring to myself, the researcher] there, with your expertise and guiding and coaching”; (b) the student’s learner profile, “having teacher in the room was very good – she knows the kids”; or (c) the development of their own knowledge, “the more I practice, I know more of the answers”. Consistency also was noted as a contributing factor to successful implementation, including repetition and predictability. As one facilitator commented, “I guess because we have had so many sessions that run in similar way, it has become more of a routine for them and myself now”. A third core idea relates to learner needs and the time dedicated to discussing and providing supports to meet these needs, including modifying vocabulary, pairing props with concepts (i.e., pinwheel for deep breathing), setting up the environment to reduce distractions, and using individualized visuals. A final facilitating factor identified by the educators was parent involvement. They shared that having the opportunity to receive input from parents was helpful in making sessions successful. As one facilitator highlighted, “Mom’s information – I think it was a very big thing for us in understanding him a little bit better”.  Learning process. This theme relates to specific references the educators shared regarding what they learned during the process. Three core ideas were identified based on their experience: planning for upcoming sessions, coaching skills, and ability to make meaningful adaptations. Both facilitators expressed the belief that spending time preparing for upcoming  64 sessions supported their learning as well as enriched the students learning, such as “thinking how we make those steps; what components we can play with to make it a little harder but not too hard”, as well as “think through some helpful thoughts in advance so I am prepared”. As the weeks of intervention passed, the facilitators noted a shift in their confidence and their ability to coach students in facing their fears. As described by one facilitator, “Now that I know, I know how to coach it a little bit better”. This was echoed by the second facilitator who said, “I think now I am starting to understand this is going to be a process”. Both facilitators reflected on their growth in making modifications, which they believed enriched the learning experience of the students. Modifications included providing concrete examples, changing the environment to reduce distractions, and modeling exposure steps, such as “concretely show[ing] him rather than describ[ing] to him [an exposure step] …”. While facilitators’ feedback on the implementation of school-based FYF was primarily positive, they did identify barriers or challenges to implementing the program in the school setting that may have hindered their acquisition of skills. Categorized under the main theme of challenges, five core ideas emerged: behaviour, new role, student learning style, competing demands, and staffing. An additional theme, student behaviour, was identified. This theme was correlated with the challenges theme (i.e., double-coding across themes). These themes are discussed below. Challenges. Facilitators reported a variety of challenges that surfaced during the intervention period, which made delivering the intervention difficult. Most notably, student behaviour was identified as a factor in interrupting the flow of sessions. This was particularly evident for one facilitator where it was the most dominant theme across sessions. This facilitator but not the other, also expressed that parent behaviour and EA behaviour reduced session success  65 due to incomplete homework assignments, forgetting about sessions, parents leaving their workbook at home, and coach’s response to conflict. For example, the facilitator noted that “the EA gets stuck with her – becomes a little bit of a battle”. A re-occurring concern expressed predominately in the early sessions by both facilitators was the novelty of the role. Both facilitators stated that the lack of experience or familiarity with the program made it challenging to work through the activities. For example, they disclosed that “it was a little bit challenging because it is a new thing” and “I have never done it before either, so I didn’t really know how we were going to work through it myself”. Likewise, they highlighted how the lack of familiarity influenced their confidence in delivering the sessions, as in the comment, “I don’t feel comfortable enough because I am not really aware with the program”. One facilitator, more than the other, described learner profiles as a barrier to successful implementation of the school-based FYF intervention. For example, she explained that the students’ different learning styles, including attention style and mastery of vocabulary, made it challenging to present the material: “different attention styles; it is really hard to deal with different kinds of attention and thoughts. One student wants to rush through and another needs time to process the information”. Another challenge the facilitators frequently faced was competing demands and responsibilities. They reported their numerous responsibilities made it difficult to sufficiently prepare for sessions or interrupted sessions. As stated by one facilitator, “I don’t have the time and my time is rushing through in preparing myself for the session” and echoed by the other, “I didn’t even have a second to look over the material”. To a lesser degree, staffing was identified as barrier. This included staff being late, absent or disinterested, illustrated by the comment, “it would help if the teacher bought in a little bit”.  66 Student behaviour. This theme relates to concerns educators shared related to student attitude, emotion or engagement. Across the course of the intervention, three core ideas were identified: low student engagement, student reluctance, and mood. Both facilitators identified times of low student engagement. One facilitator commented that a student was often distracted and difficult to keep engaged in the activities: “he is in his own world and trying to bring him back to paying attention [is difficult]”. The other facilitator experienced a similar challenge, sharing that it was difficult “trying to get their full attention when we are to discuss something”. One facilitator more than the other dealt with students’ resistance or reluctance to participate in activities. She described that the “student was resistant because she does NOT want to face her fears. She says she is NEVER going to do it!”. Both facilitators noted that occasionally a student’s emotional state stemming from events occurring outside of the intervention affected their ability to participate in session activities. For instance, a facilitator described how one student “was having a little bit of stress about something completely different, of what was going on in his classroom” and as a result, was unable to complete a worksheet. She also noted that another student “came in already angry at her EA” which interfered with her ability to participate in the graded exposure practice. It is worthwhile to note a substantial amount of time was dedicated to discussing and planning strategies to address student problem behaviours during feedback sessions with both facilitators. This included, removing distracting items from the learning area, increasing delivery of positive reinforcement (verbal praise and points for a tangible prize), incorporating more opportunities for choice, and incorporating special interests (i.e., character specific stickers).    Personal expectations. In addition to skill acquisition, facilitators reflected on their role and how their own emotions, confidence, or personal expectations influenced their experience in  67 delivering the intervention. Each facilitator reflected on their vision of running sessions, including how the students learn the material and a desire to do well. As one facilitator stated: “I was a little anxious to make sure that they knew exactly [the body reaction] right now”. The other facilitator shared, “some of my frustration is my own anxiety for wanting to see it go a certain way”. Both discussed how their outlook changed over the course of the intervention. As an illustration, a facilitator proclaimed, “I think that I need to look at little successes, there have been little shifts here or there”. As previously noted, a recurring thought shared by the facilitators, particularly in the first few sessions, was “learning how to deal with this new situation”. Both expressed that with practice their confidence would grow: “I am sure with experience it is going to be better” and “I think that now that I have gone through it once, I think it will run more smoothly”.  Research Question 2: Examining Student Treatment Outcomes The non-parametric Wilcoxon Signed-Rank Test was used to examine changes in anxiety levels of student participants from multiple informants; teachers, parents, and self-report. No significant changes were found for anxiety scores across informants from pre-intervention to post-intervention. Considering follow-up data was obtained from only 2 (of a possible 5) students, these data were not used in the final analyses. Outcomes are reported in raw composite scores (0-72). For student-reported anxiety, results of the Wilcoxon Test did not show a statistically significant difference in anxiety scores from pre-intervention (Assessment TS1; Mdn =18) to post-intervention (Assessment TS2, Mdn = 8), p = .22. Results of the Wilcoxon Test did not show a statistically significant difference in anxiety scores on parent report from pre-intervention (Assessment TS1; Mdn = 22) to post-intervention (Assessment TS2, Mdn = 27), p = .50. Likewise, the Wilcoxon Test did not show a statistically significant difference in anxiety  68 scores on teacher report from pre-intervention (Assessment TS1; Mdn = 31) to post-intervention (Assessment TS2, Mdn = 23), p = .20. In addition to testing for statistical significance, I calculated within subject effect sizes (ES) which allows for evaluation of the magnitude of change in anxiety levels. For student-reported outcomes, these effect sizes ranged from 5 to 21, with a median of 7. Similarly, for parent-reported outcomes, effect sizes ranged from 1 to 8 with a median of 5, and teacher-reported effects ranged of 0 to 8 with a median of 5.   Table 8 shows individual student scores for the three anxiety measures along with reliable change indices (RCI). Notably, several of the students had low levels of anxiety at pre-treatment (i.e., scores below 20 on the ASC-ASD and below 17 on the SAS). The reliable change index is used to determine whether a change in an individual’s score is statistically significant based on the measurement’s test-retest reliability. It provides information regarding whether the observed effect can be easily attributed to measurement error (Jacobson & Truax, 1991). Following standard conventions, scores greater than ±1.96 were considered clinically meaningful. Table 8  Individual Student Scores for the Three Anxiety Measures and Clinical Significance   ASC-ASD (C)  RCI (C)  ASC-ASD (P)  RCI (P)  SAS  RCI (T) Child I II    I II    I II   1 24 8  2.85*  22 27  -0.98  33 28  1.59 2 9 4  0.89  14 22  -1.57  12 16  -1.27 3 35 14  3.74*  36 30  1.18  8 8  0.00  4 8 1  1.25  37 36  0.20  31 23  2.54* 5 18 32  -2.49*  16 22  -1.18  32 26  1.90 Note: ASC-ASD (C) = child-reported anxiety measure, ASC-ASD (P) = parent-report anxiety measure, SAS = teacher-reported anxiety measure *absolute value of RCI > 1.96   69 Within participant score changes show that the majority of students (n=4) self-rated lower anxiety scores at post-intervention than at pre-intervention, with two students demonstrating a clinically significant decrease in anxiety scores. One student reported higher rates of anxiety scores post-intervention compared to pre-intervention, and this increase was clinically significant. Teachers also were more likely to report lower anxiety scores at post-intervention than at pre-intervention, with one student meeting the criteria for clinical change. This would suggest that while student levels of anxiety as reported by teachers were lower at post-intervention this was not at a clinically significant level of change for many of the students. Parents, on the hand, demonstrated a different trend, with three parents reporting higher levels of student anxiety at post-treatment compared to pre-treatment.   Qualitative data were also gathered to assess changes in anxiety levels and clinical importance. Using two self-evaluation worksheets (Fear Tracker and Facing Fears: How Did I Do?) to guide discussions, weekly brief interviews were held with students. Field notes were taken of student comments and non-verbal cues exhibited by students. Overall, student-reported ratings of their individual treatment target (e.g., bees, stuck in traffic, making mistakes, germs) showed changes from week 3 to week 10, decreasing by at least 2 points (on a scale of 1 to 8).  Student experiences revealed two main themes: (a) changes in ratings, and (b) tools.  Changes in ratings. As the weeks of intervention progressed, all the students noted a change in their individual ratings. During the initial brief interviews (e.g., week 4 and 5), many of the students commented that their ratings “is the same” or “it has not changed”. One student adamantly responded “eight, eight, eight! They are all eight and will always be eight!” By week 7, all the students identified some change in their ratings, including the student who expressed her ratings would never change. During week 7, she shared while smiling that two of her ratings  70 “went down to a seven”. Another student, during week 7, shared that his ratings “have changed a lot. I used to have bad thoughts, now I have good thoughts”.  A few of the students struggled with expressing the meaning of the change in their ratings. They identified that the numbers were different; however, discussions were limited to what their numbers represented, such as “an 8 means I am very afraid of bees” or number values, such as “it was at an 8 and now it is a 6”. Others articulated that the decrease in their numbers made them feel proud and happy. As one student expressed, “it is a good thing” and another, “see my numbers went down, my stress is going down. I feel proud of that”.  Tools. This theme reflects the strategies students employed to help manage their anxiety. The students described some of the strategies they used during graded exposure practice and the usefulness of the strategies. One student talked about how using helpful thoughts changed his feelings about his fears. Several students reflected that using fidget toys helped in managing strong emotions. As described by one student, “the bubble timer is really calming”. All of the students generated ideas of strategies they would consider using when facing a fear, including naming specific calming tools and ways to change exposure steps to address their specific fears.  Research Question 3: Assessing Social Validity Acceptability of the modified school-based FYF program was high across the two groups (M = 4.2). Table 9 summarizes the mean, standard deviation, range and grand mean of social validity ratings for educators, parents and students. Social validity ratings were highest among parents (M = 4.6, SD = 0.3) and educators who facilitated the intervention (M = 4.6, SD = 0.2). The average mean ratings of social validity were higher for students in Group B (M = 4.2, SD = 0.9) compared to students in Group A (M = 3.3, SD = 0.8).    71 Table 9 Mean, Range, and Grand Mean Scores for Social Validity Questionnaires  Educators  Parents  Students    M (SD) R  M (SD) R  M (SD) R  GM Group A 4.4(0.4) 4.0-4.7  4.2 (0.2) 4.1-4.3  3.3(0.8) 2.7-4.2  4.1 Group B 4.0(0.6) 3.3-4.4  4.8 (0.1) 4.7-4.9  4.2(0.9) 3.2-4.8  4.3 Total 4.2(0.5) 3.3-4.7  4.6 (0.3) 4.1-4.9  3.8(0.9) 2.7-4.8  4.2 Note. M = Mean; SD = Standard Deviation; R = Range; GM = Grand Mean With the exception of one student, all of the participants across groups (educators, parents and students) stated that they enjoyed participating in the school-based FYF group and would recommend this program to other parents or would like to participate in school-based FYF again. Educators and parents also were given the opportunity to provide written comments to describe their experience of the program. Responses were positive for all participants. For example, educators commented: “the calming exercises were helpful and great to learn”; “I liked that the tools were easy to implement”; “I found it easy to understand and fun”; and “the kids had plenty of opportunity to apply what they learned.” Parents commented: “this has been a very positive experience”; “I like the group setting where other parents get to share situations which could be similar to my child”; “my favourite part is that I can be involved”; and “I learnt practical solutions and strategies”.  Following the intervention, additional reports of social validity were collected through focus groups with educators and parents. Specifically, participants were asked about the structure and process of the intervention, what was helpful or not helpful about the program, factors that they perceived as critical for success in a school setting, and clinical significance of outcomes. Themes, along with illustrative quotes from the participants, are described below.   72 Themes were similar across the educator groups and parent groups; therefore, data were collapsed in presenting these findings. Themes were validated for content by a peer-debriefing method (Bloomberg & Volpe, 2012). First, I transcribed discussions from each focus group and data were coded by looking for key statements. All transcripts were coded before cross-group analysis was completed. The key statements were then sorted into broad categories, identifying initial broad themes. Next, one member of my research committee examined the themes to check for their accuracy. Validation of themes involved examining a total of 20% of the raw data across the four focus groups and applying the theme definitions, as well as reviewing all sorted key statements. In an iterative process, codes were discussed and subsequently initial themes were refined, resulting in the four themes, along with core ideas, outlined in Table 10. Creswell and Miller (2000) describe these procedures as methods for increasing the validity and credibility of the results.  Table 10   Themes, Descriptions, and Core Ideas Identified  Theme Description  Outcomes  Relates to knowledge, understanding and use of program components  • Tools and skills  • Self-awareness  • Self-efficacy    Program Structure  Relates to the format of the program   • Parent involvement   • Group structure  • Quantity of information  • Time allocation   • Competing demands   Inclusion      Relates to merits of the program for a wide of individuals   Recommendations  Relates to essential factors and suggestions put forth by participants for implementation in a school setting  • Resources  73  • Parent involvement  • Joint sessions  • Include classmates  Outcomes. Participants from all groups identified that participating in the school-based FYF provided a variety of positive outcomes. Most notably, comments across educators and parents highlighted gains in knowledge, understanding and use of tools and skills. Educator participants identified specific strategies they had learned and found helpful in supporting their students with autism cope with anxiety. For instance, one educator shared, “the helpful tools, so the breathing exercise with the ball is really working for my student”. Another educator agreed and added, “the peaks and valley breathing, we thought that was a good visual, rather than just breathe in, breathe out kind of thing”. Other educators identified learning how to generate and apply helpful thoughts (a cognitive restructuring strategy). As described by an educator,  …the helpful thoughts was the biggest thing. Just practicing being creative with this negative, this stressful situation – how I can neutralize it to be non-stressful – think of helpful thoughts. It is working. Educators from both groups also discussed the benefits of learning how to break fears down into steps for graded exposure practice. As commented by an educator, “I liked the step-by-step. It was easy for me to understand so it was easy for me to make sure that my student understood it as well”.  Similar to the educator group, parents identified specific strategies that they learned, felt able to apply and found helpful in supporting their child cope with anxiety. Specifically, they identified using a step-by-step approach, helping their child understand false alarms, learning new ways to practice deep breathing, and rating fears using the stress-o-meter. One parent shared, “the stress-o-meter is great because it gives the kids, as well as myself, a visual where  74 they are at. I think that helps them a lot”. Parents also reflected on learning how to address anxiety. As an example, one parent commented, “Oh, there is something we can do to help fight over fear and anxiety, I didn’t know that. I now know. That’s good”. Both educators and parents also reflected on gains in students’ knowledge about and use of strategies. For example, an educator commented there is a “change in the student’s deep breathing; he is doing much better” and another described, “they are thinking more helpful thoughts or they are coming up with helpful thoughts”. Several parents shared how their children are using the tools at home and in the community. One parent shared how her son manages his anxiety using calming tools when they are stuck in traffic. Another parent described a change in her daughter’s cooperation to engage in calming tools: “she is more cooperative now, will do the balloon breathing”. Other parents, however, identified that application of tools and skills did not generalize across contexts. For example, one mother explained that her child did not always share with her the supporting materials: “she won’t tell me where the stress-o-meter is.” Another parent identified her child’s reluctance to use tools across context, telling his parents that “you cannot use it, only teachers can use it”.  In discussing their experience in participating in the intervention, two distinct but interrelated core ideas emerged throughout educator and parent reflections: self-awareness and self-efficacy. They spoke of growth in knowledge and confidence for all participating members; students, parents, and educators. Herein, self-awareness refers to knowledge of one’s own emotions and self-efficacy refers to confidence in skills. Examples of both self-awareness and self-efficacy were discussed for students. For instance, in describing self-awareness, one educator described a student’s ability to express body reactions when anxious: “he is more aware of verbalizing it, what exactly is happening to him”. Educators also described students’ growing  75 sense of self-efficacy: “he is getting more awareness that he can overcome the fear”. Parents primarily highlighted their child’s self-awareness of emotions. For example, one parent shared her excitement about her son’s ability to identify and communicate his emotions. Another parent told a story about using the stress-o-meter with her child and her child’s ability to communication “going towards yellow”.   Illustrations of growth in self-efficacy were identified for parent participants. Specifically, educators noted an increase in parent’s ability to recognize and respond to their child’s anxiety: “Mom is becoming more knowledgeable about how she is coaching and then gives her child a break if she realizes that her child has had too much”. Overall, parents conveyed that they learned skills and confidence to help their children cope with their anxiety, and what they learned will be helpful in the future. As described by one parent, “dealing with their fears and anxieties is always challenging. I think this program made it easier to deal with those situations”.   Educators also reflected on their own self-efficacy, albeit to a lesser extent. It should be noted, however, that these subthemes were evident among facilitators during brief interview sessions following each intervention session, as denoted by comments regarding their ability to coach students in facing their fear, such as “learning how to amend to suitable steps in facing fears” and “I know how to coach it a little bit better”.  Program structure. This theme relates to the overall form of the program and components that participants identified as either helpful or a challenge that influenced their perception of satisfaction with the intervention. In terms of components that contributed to satisfaction, educators identified parent participation as a key component. An educator in the role of facilitator also identified the feedback sessions as enjoyable, noting, “I like the feedback  76 sessions”. Meanwhile, parents highlighted the importance of the group setting for both their children and their own experience. Specifically, they identified the benefit of the program being offered in the school setting. As described by one parent, “the program in the school setting and with peers allows them to see that they are not the only ones that have these fears. That’s incredibly useful” adding, “[my child] has really enjoyed it too. Today in the car on the way here he said, ‘today is my last group’. He was disappointed about it”.  In relation to parents’ experience, parents across the two groups expressed gratitude for the opportunity to be part of the school-based FYF group and described the prominence of their involvement in parent sessions as important, including the importance of meeting in person to support their own learning. Along the same lines, several parents commented on the benefits of meeting as a group with other parents as it provided an opportunity to connect with others. One parent commented, “I think for us, as parents, being in a group setting as well helps a lot because we are all facing the same issues”. Another parent added, “I learned a lot from you guys [referring to the other parents]; we have same experiences, I didn’t realize that”. Educators also noted relationships building among the parents: “I know two parents were talking about [group] and making plans to connect over summer”. In response to the question what they liked most about their experience, one parent identified learning alongside her child: “mostly hearing the feedback what my child is learning. That helped me to go ‘oh this is how she thinks then this is the approach I am going to take’”.  Participants also identified factors of the program that inhibited their satisfaction. Specifically, the quantity of the information presented, the time allocated to learning the material, and competing demands were identified by both educators and parents. The interconnection of these three factors is captured by one parent’s comment, “there is too little  77 time. There is so much information that we absorbed. I felt like you get overwhelmed, but you want to sit there and digest it”.  In addition, participants described how competing demands interfered with their engagement. One educator summarized this experience: “I struggled a little to be present every session. I had to say ‘no’ [to other tasks] or I couldn’t see some kids, this stress me a little bit” For parents this was reflected in the following comments: “home practice was challenging to complete. I didn’t really spend a lot of time with my child because I was quite busy with my work”; and “I need to start reading more but then other information keeps coming up, you are running a family”.  Inclusion. Educators and parents across all groups consistently commented on the practical importance of the intervention. In the words of one participant, “I feel this is an incredibly worthy program” and in another, “I really think the program is very useful”. Importantly, their comments suggested how the benefits of the program extended beyond the participating students. For example, an educator commented, “it was really applicable. A lot of it was really applicable to day-to-day life. I like that”. This was echoed by another parent: “it is helpful just even in our own lives, when you caught yourself having thoughts like that, to go hmmm, wait a second that wasn’t a very helpful thought, just in our own lives”. Furthermore, participants identified that a broader population of students would benefit from the program. Educators from one of the groups engaged in a lengthy discussion around planning how to incorporate the program into their regular curriculum while an educator from the second group discussed her plans for continued use of the strategies with all the students she supports. Also, both educator groups discussed how to extend training to their fellow teachers and educational assistants and offer the program to a wider population of students. For example, one educator stated, “I can think of so many kids that could benefit from this that are not autistic”. Parents also  78 expressed how the program could benefit other students. This is captured by one parent’s comment, “I have already been sharing this with other parents because it can apply to everybody”.  Recommendations. Educators provided their views on factors that they perceived as critical for success in a school setting. Among the factors mentioned, availability of resources was considered the most critical across all educator participants. They reflected on how they enjoyed the program, however, they suggested allocating resources (such as time, staff, and training assistance) to sustain offering the program in schools. As summarized by an educator who was discussing the importance of offering the program, she stated it “depends on resources”. The other educator group summarized a similar conversation with, “it would be worthy to have a teacher and EA’s running these kinds of programs, but resources are needed to make it happen”. Related to resources, was having sufficient time. An educator noted that it was important, “to make sure we covered everything we needed to” because “I felt there was not time to stop and reflect”. Parent involvement also was identified as critical to successful implementation of school-based FYF. As stated by one educator and agreed by the others, “unless you have that home-school connection, I think this would be hard to work”.   Parent participants highlighted some of the challenges they faced during the intervention and the importance of addressing these challenges to increase feasibility of delivering the intervention in a school setting. Specifically, parents identified generalization as a concern. As already mentioned, a parent stated:  one thing is generalization, those things I mentioned, he uses here but not allowed to use at home…even the meter. But the problem is child won’t allow me to do that… he say  79 “no, no that is for school, put it away please. You cannot use it, only teachers can use it. You are not allowed”. That is the problem, it is a barrier.   Parents suggested it would be helpful to have a joint session with their children and this may address the challenge of generalization, in particular the use of strategies across environments. Interestingly, having a joint session also was mentioned by an educator at the other school site, as she believed this would enhance participation as a team. Parents in one group also suggested that it would be valuable to include classmates in the intervention. Although, the proposed intervention included class-wide sessions, it was not possible to deliver these class sessions at this school site due to the complex needs of the student population. Parents suggested peer coaching as another avenue for inclusion of peers.      80 Chapter 4: Discussion  The current investigation into the feasibility and effectiveness of a school-based FYF was conducted in a school setting with elementary-aged students. The primary goals of the dissertation were twofold, reflected in two complementary studies. The first goal (Study 1) was to identify the necessary adaptations to FYF for implementation in a school setting, in regard to the feasibility, acceptability and sustainability of a school-based FYF. The second goal (Study 2) was to evaluate the effectiveness of educators implementing the adapted school-based FYF in reducing child anxiety.   The two studies within this dissertation contribute to the research literature by providing an investigation of the effectiveness of educators delivering a modified school-based FYF to treat anxiety symptoms among students with ASD. Chapter 4 includes: (a) a discussion of the findings of the two studies, (b) the research and clinical implications of the results as well as the limitations of each study, and finally (c) recommendations for future directions. Study 1  Study 1 provides a qualitative understanding of educator and parent perspectives on how Facing Your Fears may be implemented in a school setting to address anxiety in children with ASD. A key finding of the study was that members of both knowledge user groups expressed the view that providing intervention to manage anxiety for children with ASD is a worthy intervention target for schools. While it was expected that parents would view treatment of anxiety in schools as important, given their abiding interest in their own child’s needs, the strongest endorsement came from the educators. This finding is encouraging in light of claims that educators often prioritize academic goals over social-emotional goals (Locke et al., 2015).  81 Also encouraging is the support educators and parents expressed for pilot implementation of the proposed modified intervention in schools.  Several other findings from Study 1 may guide successful implementation of FYF in schools to address anxiety for students with ASD. Educator and parent perspectives on suitable intervention agents indicated the importance of a team approach. Educating and involving multiple agents at school, including individuals who may not be directly implementing the intervention, was viewed as crucial to the effectiveness and sustainability of the intervention. Inclusion of mental health professionals, such as school-based counsellors and psychologists, was emphasized by both groups. This is in line with recommendations by the authors of the original FYF, who acknowledged that although professionals from a variety of fields may successfully implement the intervention, due to the psychiatric complexity of children with ASD, consultation with mental health providers is crucial (Reaven et al., 2011). Parents, and with some reservation educators, suggested that EAs could be an effective intervention agent and valuable addition to the team considering schools’ reliance on paraprofessionals in supporting students with ASD. Educators, however, cautioned that this group of paraprofessionals would require substantial training to fulfill this role. This finding is not surprising in the light of research that indicates the majority of paraprofessionals lack the training necessary to deliver effective support to children with ASD (Stahmer et al., 2015). Knowledge users noted that for EA’s to acquire the skills necessary to assist in treating anxiety in students with ASD, in-depth training would need to be provided. This view is consistent with research that shows that Behavioral Skills Training (BST), a training method that incorporates instruction, modeling, behavioral rehearsal, and direct feedback, is effective in teaching educators and parents to implement ESTs with fidelity (Gianoumis et al., 2012).   82  Qualitative findings also showed that educators and parents agreed that parent involvement in a school-based anxiety intervention is essential. The importance of parental involvement in the treatment of childhood anxiety is well founded and consistently recommended for the ASD population (Moree & Davis, 2010). Active parental participation has been shown to affect both the magnitude of change in children’s level of anxiety and their ability to generalize the use of strategies to self-regulate their anxiety. In a randomized control trial of CBT conducted by Sofronoff et al. (2005), 71 children (aged 10-12 years) diagnosed with Asperger Syndrome and anxiety were assigned to one of three groups: Intervention 1 (child only group), Intervention 2 (child and parent group), or a waitlist control group. The two intervention groups participated in the same 6-week, clinic-based CBT program. Parents in Intervention 1 were provided with information about their child’s participation in group and home practice assignments while parents in Intervention 2 received training and coaching in the use of strategies. Quantitative and qualitative data demonstrated several significant differences between the two groups, with the combined child and parent group reporting a greater reduction of anxiety symptoms and increased competence among parents in supporting their child to use CBT strategies.   Educators and parents also provided important suggestions regarding the process of implementing FYF at school to ensure success. Of highest priority was inclusion of classmates by offering a class-wide component. Integrating strategies into the regular classroom may be less stigmatizing for students with ASD. Furthermore, educators noted that participation could provide the opportunity to develop empathy, compassion and patience among peers. It also was noted that many typically developing peers may experience some degree of anxiety and thus would benefit from the psychoeducation lessons in FYF. To date, no published studies have  83 examined the effects of an anxiety intervention delivered simultaneously to both students with ASD and students without ASD. There is, however, a large body of research on universal prevention programs delivered in schools that have yielded improvements in emotional, behavioral, social and academic functioning for students without ASD (Allen, 2011).   Educators and parents also offered specific recommendations regarding how to structure the school-based FYF program. These included: (a) ensuring the FYF was a district-based program; (b) sequencing cohort sessions; (c) including parent coaching strategies to complement graded exposures conducted at school; and (d) emphasizing emotional self-regulation through active rehearsal. Practical considerations for planning and implementing FYF at school also were provided. For example, knowledge users suggested that session duration and program length be adjusted to suit school scheduling. Specifically, it was recommended that individual sessions be reduced from 90 minutes to 60 minutes and the original 14 weeks be converted into 10 weeks. Other suggested revisions included changing vocabulary and modifying graphics to be more reflective of the concepts that visual supports are designed to illustrate. Last, knowledge users supported maintaining the systematic approach of FYF presented in the manual, yet suggested it be infused with a modular approach that allows flexibility and individualization to match students’ needs and skills. The benefits of allowing individualization while adhering to overall fidelity is commonly reported in studies examining interventions designed to support the social needs of children with ASD (Kasair & Smith, 2013). Furthermore, using a modular approach to intervention protocols has also been identified as one means to promote the adoption of ESTs in school settings, thereby addressing the research-to-practice gap. (Chorpita & Daleiden, 2014).     84 Study 2  Study 2 employed a quasi-experimental group design along with brief interviews and focus groups to assess the feasibility of educators implementing a modified school-based FYF to treat anxiety symptoms among students with ASD. To this end, this effectiveness study investigated the following research questions: (a) did the training sessions increase educator’s knowledge and use of CBT concepts and strategies; (b) did educators deliver the intervention with fidelity; (c) did participation in the school-based FYF reduce anxiety symptoms of participating students with ASD; and (d) did educators, parents, and students view the school-based FYF as socially valid; that is, acceptable and feasible?   Skill acquisition and intervention fidelity. Results of Study 2 offer initial support for the delivery of a modified school-based FYF in a school setting with educators as the intervention agent. Similar to previous effectiveness studies of the FYF program (Reaven et al., 2015; Drmic et al., 2017), this study employed a training workshop to train educators in the school-based FYF program. In addition, weekly feedback sessions with facilitators were conducted using behavioural skills training (BST) to review session-by-session activities. Educators demonstrated modest, non-significant gains in knowledge of CBT concepts and strategies following the training workshop and significant gains in CBT knowledge after conducting one course of the school-based FYF intervention. This finding differs from the previous studies mentioned, in that the training workshop alone was not sufficient in generating statistically significant improvement in CBT knowledge. Effect sizes (ES) interpreted using conventional standards, however, were moderate for both pre-training workshop to post-training workshop and pre-training workshop to follow-up, with a more robust ES at follow-up. In interpreting these results, the importance of using a variety of teaching strategies to train  85 educators in implementing new interventions is highlighted. Specifically, the utility of incorporating on-going feedback into training is supported, aligning with previous research that has shown that on-going feedback is effective in teaching parents and educators skills to work with individuals with autism in school and community settings (Ward-Horner & Sturmey, 2012; Shayne & Miltenberger, 2013). Joyce and Showers (2002) discussed the efficacy of various training components to support teachers in their acquisition and transfer of new knowledge and skills into their practice. They highlighted the importance of coaching and practice techniques to increase the transfer effect of training into the classroom. Similarly, the results of this study provide evidence that in vivo coaching facilitated learning among educators, as demonstrated by higher scores of CBT knowledge and increased competency at follow-up. Furthermore, a stabilization of variability across time points (i.e., high variability at pre- and post-training workshop and low variability at follow-up) suggests that skill acquisition among educators was enhanced with opportunities to practice applying their new knowledge, which was particularly evident for educators in Group B. This finding is consistent with the Professional Development (PD) literature that argues that the design and delivery of professional development affects skill acquisition among educators. In particular, the PD literature highlights the role of practice and feedback in building educators’ skills (Rutherford, Long, & Farkas, 2017).  In terms of implementation fidelity, one facilitator but not the other reached the minimum standard for acceptable treatment (80%) across cohorts. Both facilitators reached a higher level of adherence to protocol for the student sessions (82% and 77% for Group A and B, respectively) compared to the parent sessions (80% and 51% for Group A and B, respectively). As reported by the facilitators themselves, the difference in adherence across the cohort groups was primarily due to time constraints and, by extension, confidence in knowledge. During the weekly brief  86 interviews, the facilitator of Group B shared that time constraints decreased her ability to sufficiently plan and practice for both cohort sessions (student and parent). She expressed that the parent sessions are, “a higher level of discussion and I don’t feel comfortable enough” to run the sessions. As a result, I became the primary leader for many of the activities in the parent sessions, leading to a lower fidelity rating for this facilitator. Consideration also may be given to the process of teaching adults versus teaching students. Requiring a different skill set, it is possible that the facilitators, teachers of children and youth, did not possess a foundation of knowledge and skill in how to teach adults. Reflections provided by the facilitators on conducting parent sessions highlight an important factor in training educators to deliver the school-based FYF program. Specifically, training should involve addressing andragogy, or how to work effectively with adult learners (Knowles, Holton, & Swanson, 2005).    Disappointingly, implementation of class sessions of the school-based FYF was incomplete, with only 5 of a possible 12 sessions delivered. The barriers to conducting class-wide sessions speaks to the challenges faced when introducing new interventions in real-world settings. Although educators identified the benefits of the class-wide sessions, multiple factors contributed to unsuccessful implementation. The challenges experienced in this study echo previously identified factors inhibiting intervention implementation in schools. Specifically, limited administrative support, time constraints, teacher buy-in, and a poor fit of intervention components to the setting (Forman et al., 2013; Mychailyszyn, 2015). Given the prevalence of anxiety among children without ASD (James et al., 2015) and children with ASD (Kerns & Kendall, 2012), the school-based FYF program has potential to offer a valuable intervention for students without ASD at tier 1 (class-wide sessions) in addition to students with ASD at tier 3 (student sessions). However, the barriers to conducting in-class sessions will need to be  87 addressed before this potential can be realized in a school-based version of FYF. To address these barriers, one avenue to examine is identifying and incorporating champions into the implementation process. Conceptualized as individuals within a system who actively advocate for and facilitate change, champions may be vital to the adoption and adaptation of new interventions in school settings (Avant & Lindsey, 2016).    Both facilitators described how the novelty of the approach and related CBT skills limited their confidence in delivering the program at the onset of the intervention. According to Owens et al. (2014) a critical component for successful implementation of new interventions requires participation in meaningful professional development. Implementation fidelity for student sessions was observed to gradually increase over the course of the 10-week intervention, with a slight dip at Session 6 with the introduction of planned graded exposure practice. This increase reflects each facilitator’s growth in skills and confidence in their knowledge and skill application, suggesting that BST was effective at training the educators to deliver the school-based FYF intervention. Towards the end of the intervention, facilitators from both groups required lower levels of support and delivered the student sessions with high levels of fidelity. Both facilitators achieved an average of 88% adherence across the last four student sessions. Also, both facilitators reported that their confidence grew with more opportunities to deliver the intervention, and their ability to deliver school-based FYF according to protocol was greater. This is in line with the body of research examining the relationship between educators’ sense of efficacy and their effectiveness in implementing programs (Rutherford et al., 2017).  The importance of implementation fidelity is well documented, given that it is integral to understanding the efficacy of an intervention (Wainer & Ingersoll, 2013) However, the challenge of implementing treatment to a high level of fidelity in complex settings (e.g., ≥ 80%) such as  88 schools has led some to question the extent to which a high level of treatment fidelity is necessary for positive treatment outcomes (Reaven et al., 2015). It may be valuable, as we move treatments from controlled research conditions to natural environments, to examine the level of treatment fidelity that may be required to achieve positive and meaningful results. Additionally, in their investigation of school counsellors implementing an anxiety treatment, Masia-Warner et al. (2016) found that student outcomes were comparable when the intervention was delivered by either specialized psychologists or school counsellors, despite psychologists’ demonstrating higher competence in their delivery. This finding suggests that more research is needed to understand the relationship between treatment fidelity and treatment effect as we move forward with dissemination efforts.  Preliminary treatment outcomes. Another aim of Study 2 was to examine the effectiveness of a school-based FYF in the treatment of anxiety symptoms for students with ASD. The quantitative findings of Study 2 did not show a statistically significant decrease in anxiety for the student participants post-intervention at the level of self-report, parent report, and teacher report. These finding may be explained in part by the brief duration of treatment (e.g., 10 weeks), the program structure which involves targeting one fear at a time, as well as limited between-session exposure practice. As previously mentioned, exposure practice is considered the most important component of a CBT model in reducing anxiety symptoms among children. There is some evidence that shows that the amount of exposure practice affects the success of CBT intervention programs with children without ASD (Peris et al., 2017). Better outcomes were associated with increased time between sessions spent challenging fears. Although, this study included an informal check-in regarding between-session exposure practice, in-depth information was not gathered. Given this, future researchers and practitioners should conduct more rigorous  89 evaluations of between-session exposure practices, and ensure that a sufficient number of exposure practices are conducted in the school or home.  The non-significant finding in treatment outcomes may also be explained by student’s pre-intervention anxiety levels. Specifically, total scores at pretreatment were already below clinical levels of anxiety for half of the students identified by the school to take part in the intervention. These findings also may be explained by the study’s small sample size. With only five children as participants, the study had very low power to detect statistically significant effects. Significant results would only be evident if the effects were extremely large.   Efficacy of treatments in the field of psychology also has been evaluated using clinical significance, defined as “the extent to which therapy moves someone outside the range of the dysfunctional population or within the range of the functional population.” (Jacobson and Truax, 1991, p.12). Given the nature of this study, individual difference in anxiety scores for students was evaluated using a Reliable Change Index. The scores obtained suggest that overall the students who participated in the school-based FYF did not make sufficient changes in their scores to suggest a clinical level of change. It has been argued that the criteria (>1.96) set forth in evaluating clinical significance may be inappropriate for assessing treatment effects for some clinical contexts, including individuals with dual diagnosis disorders (Wise, 2004). Instead a continuum of confidence levels has been proposed in interpreting RCI scores to provide a more informative indicator of outcomes. Specifically, Wise (2004) recommended applying a gradation of 1.96, 1.28, and .84, corresponding to 95%, 90%, and 80% confidence levels or recovered, remitted, and improved, respectively. Using this classification of clinical significance, the majority of students met criteria for improved at the self-report (n = 4) and teacher-report (n = 3) level. In applying this alternative classification criteria, there still remains the finding that three  90 of the students showed increased levels of anxiety post-intervention as reported by parents. One possible explanation is that participating in the intervention and learning about anxiety may have increased parents’ awareness.   Although findings showed a non-significant decrease in student anxiety levels, parents and educators, and to a lesser extent, students, reported that they felt better equipped to manage anxiety symptoms following participating in school-based FYF. As Kazdin (1999) stated “clinically significant change can occur when there is a large change in symptoms, a medium change in symptoms, and no change in symptoms” (p. 332). This perspective shared by participants is also relevant in light of recent conceptualization that treatment gains for this population may be better understood from an inhibitory learning approach instead of the conventional habituation learning model (Reaven & Willar, 2017). In this sense, the evaluation of progress and success shifts from a focus on fear reduction to fear tolerance. During the exposure process, individuals learn a new safety schema that competes with an existing fear schema when faced with an anxiety provoking condition. From the lens of an inhibitory learning approach, success is defined by an individual’s ability to face the fear, thereby accepting negative emotional states, rather than fear reduction over time (Abramowitz, 2013).  In considering clinically meaningful change, qualitative data can allow for additional understanding. Data gathered from the brief interviews with students during intervention sessions provided the opportunity to examine patterns of change in self-reported anxiety ratings for specific treatment targets (i.e., Fear Tracker targets). Over the course of the intervention, all of the students reported a decrease in Fear Tracker ratings, with at least a 2-point difference (on an 8-point scale). In conjunction with the reported decrease is the students’ awareness of the bravery displayed when facing fears. Understanding the behavioural challenges presented by this  91 group of students is pertinent to interpreting the magnitude of this finding. In this light, a meaningful change may be illustrated by one student’s transformation from resistance to participating in discussions and practice of facing fears to openly sharing with the whole group the decrease in her Fear Tracker ratings and her self-proclaimed success in practicing a step in her fear hierarchy. It also may be illustrated by another student who talked about facing his fear the previous weekend while on a trip with his family, specifically how brave he felt.  Social validity. The qualitative and quantitative data converged to indicate that participants perceived the school-based FYF to be socially valid. Participants from all groups rated social validity high, with an overall average of 4.2 on a 5-point scale. These results indicate that educators, parents and students viewed the goals, procedures, and outcomes of the school-based FYF program as acceptable and feasible. In particular, adult participants (educators and parents) across the two school sites had very high social validity ratings, which suggests that the intervention may be acceptable at other school sites with parent involvement. Qualitative findings identified a number of factors that may have contributed to the social validity of the intervention. Educators and parents agreed that the strategies were easy to learn and implement in a variety of settings. Strategies, in particular calming tools, learned in sessions were implemented in other settings including the classroom, home and community for some participating members. This made the intervention and its components practical for these participants. The direct involvement of front-line school staff promotes the generalization and maintenance of the skills learned (Luxford et al., 2016). Educators also identified how the goals and procedures of school-based FYF aligned with their current curriculum and discussed offering the program to a wider range of students, as well as ways to encourage students to use skills across the school day. Participating educators and parents supported infusing the  92 psychoeducation components of school-based FYF into the classroom and showing students how the skills can be used daily to assist with commonly occurring feelings of anxiety. This finding speaks to creating an inclusive learning environment.   Another important detail provided by the participants in understanding their experience is parent involvement. Educators found it valuable to receive information from parents, which allowed them to consider the challenges a student was having in the home context and the possible impact this had on a student’s behaviour at school. Parents found it valuable to learn concepts and strategies to support their child in managing their anxiety symptoms. Parents also found it valuable to connect with other parents with similar experiences and expressed gratitude for being included in the process. This finding is consistent with previous research that highlights the benefits of a group format in supporting parents of children with ASD (Reaven & Willar, 2017). Together, this suggests that parent involvement was closely linked to participants’ perceptions of the intervention’s validity. The inclusion of parents in the treatment of anxiety among individuals with ASD has been recommend (Moree & Davis, 2010) and was also identified by key stakeholders in Study 1 as essential to the success of school-based FYF. The inclusion of parents in Study 2 and the study’s findings support the benefits of parent involvement in addressing anxiety among children with ASD. Based on these findings, some suggestions for effectively including parents in the intervention include using a collaborative approach to enhance the family-school relationship, creating opportunities for face-to-face interaction between parents and teachers, and providing parents with easy to implement strategies to practice outside the school setting.  These findings echo the long-held understanding that family-school collaboration serves an important role in the promotion of academic, social and emotional development of children  93 (Christenson & Sheridan, 2001). Research has shown that the involvement of parents working in partnership with educators is associated with positive student outcomes (Cox, 2005). For example, in their evaluation of a school-based CBT intervention, Ruocco, Gordon, and McLean (2016) employed a collaborative effort between school psychologists and parents in the treatment of anxiety among typically developing students aged 5-7 years. In addition to showing significant reductions in anxiety, parents reported positive perceptions about the intervention delivered in the school setting. Family-school collaboration also is highly valued among parents of students with ASD. In an effort to address communication between home and school, Goldman, Sanderson, Lloyd, and Barton (2019) evaluated the effectiveness of home-school notes for students with ASD who exhibit off-task behaviour at school. Central to the intervention was reinforcement delivered at home contingent on teacher reports of on-task behaviour at school. Although results showed mixed treatment effects, participants reported improved family-school partnership and communication. Likewise, in a qualitative study examining the transition and adjustment of students with ASD to an inclusive setting, emergent themes highlighted the benefits of family-school collaboration. Specifically, partnership between parents and educators was perceived to contribute to improved student academic performance, a smooth transition process, and better social adjustment for students (Josilowski & Morris, 2019). Educators and parents stated that the intervention produced many positive changes for the students and described personal benefits. Among the most prominent of these changes was an increase in student’s engagement and use of strategies to manage their anxiety symptoms. Parents in particular described the social significance of these changes. Specifically, they articulated an increased ability to support their child when faced with an anxiety-provoking situation which led to greater participation in and enjoyment of community outings for the whole  94 family. Furthermore, the majority of participants expressed observable improvements in students’ behaviour (i.e., increased willingness to participate and greater engagement in activities and tasks) both at school and at home. Parents also described an improvement in their child’s ability to communicate their emotional state, allowing the parent to respond more effectively in the moment. Both educators and parents reported an improvement in their relationship with the children. In addition, participants described personal benefits, including recognizing their own anxiety and ways to apply the skills learned to everyday issues and concerns.  While the general perception of the intervention was overwhelmingly positive, participants provided some suggestions for future improvement. Among the most salient during follow-up discussions was consideration of factors to promote generalization. Both educators and parents recommended providing opportunities for greater involvement of parents. Specifically, they suggested including joint sessions with parents and students, which they believed would support and promote generalization across environments. Likewise, participants endorsed integrating program components into class lessons, making the concepts and strategies available to all students. As well, they proposed creating more opportunities for the inclusion of peers, such as integrating peer coaching into the program.   Research and Clinical Implications In Study 1 focus groups were conducted to understand knowledge users’ perspectives on the strengths and barriers of Facing Your Fears, as well as practical considerations for implementation in the school setting. Taken together, the insights provided by knowledge users informed the design of a proposed modified FYF intervention. The findings are offered as a starting point in considering how to modify FYF for implementation in a school setting. It provides one example of how integrating knowledge users’ perspectives into the research process  95 can enhance the feasibility and acceptability of an intervention, which in turn may increase the sustainability of the intervention in educational settings.  In Study 2 a quasi-experimental group design was employed using the results of the iKT study as an independent variable to examine the effectiveness of educators implementing the modified school-based FYF intervention in schools. Despite the large number of school-aged children with ASD exhibiting anxiety symptoms and the vital role educators play in promoting prosocial behaviours for this population, few studies have involved educators in the process (Kester & Lucyshyn, 2018). Consistent with dissemination research in the child mental health field, the treatment outcomes found in the present study are not as robust as findings reported in efficacy studies conducted in controlled research settings (Weisz, Ugueto, Cheron, & Herren, 2013). Nonetheless, the findings provide a valuable contribution to the literature in three important ways. First, Study 2 is among the first to evaluate educators delivering a CBT program to treat anxiety for students with ASD in the school setting. Results of this study showed that educators may be viable intervention agents and able to deliver the program with a degree of fidelity. Second, the results shed light on knowledge users’ perspectives on facilitating factors for the uptake and implementation of intervention components, as well as effective training practices for educators. Finally, it builds on transportability efforts dedicated to examining the effectiveness of CBT programs delivered in the school setting (Drmic et al., 2017; Mychailyszyn, 2015). In alignment with the argument that effective dissemination of empirically-supported treatments requires effectiveness studies (Chorpita & Daleiden, 2014), Study 2 offers an initial contribution toward bridging the gap between research and practice in the treatment of anxiety for students with autism in school settings.   96 It is worthwhile to reiterate that due to unforeseen factors, it was not possible to maintain continuity of participants from Study 1 to Study 2. Within an iKT approach, ideally there is sustained partnership between researchers and knowledge users, in which the intervention is built and refined over time (i.e., build the intervention with educators and then test with the same educators in a reiterative cycle). Thus, while the results of this iKT study may provide a starting point for the development of a viable school-based FYF program, its sustainability likely would be stronger if the intervention development process was conducted in a more reiterative fashion. Although the use of quasi-experimental and experimental group designs may preclude the enrolment of the same educators and families, due to the need to establish pre-intervention conditions, continuity could be established by conducting subsequent studies in the same schools or school districts with the same administrators.  In a related point, the recruitment process experienced in these studies, in particular Study 2, highlight the challenges of conducting research in real world settings, such as schools. In order for this intervention to be implemented, multiple levels of agreement needed to be obtained (i.e., district-level administrators, school-level administrators, front-line educators, as well as parents and students). As experienced in this study at any given point in the recruitment process, one group of prospective participants may decide not to participate thus requiring the recruitment process to begin anew with another school. This challenge highlights a potential barrier for the conduct of future research on the school-based FYF program, but also in regard to its adoption within a school district.  Limitations During the recruitment phase, I encountered several challenges across participant groups. Specifically, obstacles I faced in recruiting participants included: (a) administrators’ reluctance to release staff to conduct the intervention groups; (b) educators’ apprehension of their skills to  97 simultaneously transcend mental health (anxiety) and special education (autism) needs; (c) parents’ availability to attend parent sessions; and (d) identification of a sufficient number of students of similar characteristics (i.e., cognitive level and age) within a single school site to formulate a group.  As a result, an overarching limitation of this dissertation was the small sample size. Although effort was made at the outset to recruit more participants, both Study 1 and Study 2 had small samples, which significantly limits the generalization of study findings. A small sample also limited the type of analyses that were performed; therefore, caution should be applied in interpreting results from statistical analyses. It is unclear whether the finding of non-significance in changes in anxiety levels is due to the absence of treatment effects or because the study was underpowered. Additional school-based studies using randomized experimental designs with larger sample sizes will allow for a better understanding of the effectiveness of the intervention in treating anxiety among students with ASD. Future studies that use an experimental design may also consider calculating an effect size based on standardized mean gain (SMG). As Mychailyszyn (2017) describes, SMG effect size provides information about differences in scores for treatment compared to control groups across time.   Another limitation of both studies was the potential threat of participant desirability bias.  All participants across the two studies had an invested interest in the treatment and favourable outcomes. As such, it is possible that the high social validity ratings were influenced by a desirability effect. It is recognized that the threat of socially desirable responding is common in survey research (McKibben & Silvia, 2016). The presence of qualitative data may have assisted in mitigating against this potential bias. Both studies also had unique limitations. A limitation of Study 1 was the sample characteristics. Despite an effort to recruit educators with varying roles (i.e., School Counsellors,  98 Classroom Teachers, Learning Support Teachers, and Educational Assistants), the educators who enrolled in the study shared a common role: Learning Support Teacher. Representing three different schools, this group was in a position to provide valuable insight into the needs of children with ASD, given that their role involved planning and consulting with teachers and parents on teaching strategies, as well as providing supplementary teaching to students who require additional support. Limiting the educator focus group to one role, however, precluded gaining insights into the perspectives of other relevant roles at school. Similarly, participants for Study 1 were drawn from a single school district. Some features of this district may affect the perceptions of knowledge users, such as district endorsed policies and programs that support self-regulation skills, the school district’s small size in comparison to surrounding districts, and the relative affluence and high level of education of parents. Also, all the participants were female, therefore, a male perspective was not captured, including the perspectives of fathers. Inclusion of father’s perspectives may be important in future research, as it has been identified that there is a gender difference in parental attitude in raising a child with ASD (Ozturk, Riccadonna, & Venuti).  A limitation for Study 2 was the absence of follow-up data for student anxiety measures. Unfortunately, it was not possible to collect follow-up data for Group B, as the ending of the intervention period coincided with the end of the school year. Follow-up data on student anxiety measures would have provided valuable information regarding the efficacy of the intervention. It should be noted that it is my intention to collect follow-up data for Group B and complete the proposed analyses. Similarly, the class wide sessions of the program were not implemented for Group B. Although it is possible to consider these sessions as optional, as they primarily provide review, the sessions are a part of the intervention package that was not delivered. Participants  99 themselves identified the value of the goals in the class session, specifically the inclusion of classmates in discussions to support normalization and generalization. Another limitation of Study 2 was the absence of interobserver agreement measurement for facilitator intervention fidelity and facilitator competence during class-wide sessions. Thus, the reliability of these data may be called into question.  Another limitation of Study 2 was the screening process that was used to identify student participants. School staff recommended students based on their interactions with the student and subjective measures of anxiety. The assessment of anxiety symptoms using a standardized measure was determined once a group was formed. In other words, students were included in the study regardless of anxiety levels pre-treatment. As previously noted, half of the students had low levels of anxiety pre-intervention, as determined by ASC-ASD scores. The inclusion of student with low levels of anxiety prior to intervention may have contributed to the non-significant results found in the study. Future researchers may consider using a more robust screening process that involves assessing pre-intervention scores on standardized anxiety measures.  Future Directions The results and limitations presented in this dissertation suggest three directions for future research. First, the iKT approach used in Study 1 may serve as a model for future research on adapting effective interventions for widespread dissemination. Additional studies using an iKT approach could further bridge the gap between research and practice, empowering knowledge users to apply the findings from research into their practice. Second, more effectiveness studies in the school setting are needed. Future research should continue to use a mixed methods approach to investigate the effectiveness of school-based anxiety treatments for  100 students with ASD. The inclusion of qualitative data in addition to the quantitative data gathered in Study 2 led to a better understanding of the factors that helped or hindered the implementation of the intervention, and identified coping strategies adopted by participants to modulate feelings of anxiety. Additional effectiveness studies will further advance our understanding of the feasibility of school-based FYF, contributing to the overall implementation of empirically supported interventions in schools. Future effectiveness studies also should consider collaborating with teachers to develop facilitative adaptations during the implementation process that may be necessary to enhance the contextual fit and effectiveness of the intervention. Facilitative adaptations refer to modifications that can be made to an intervention without compromising the core components of the intervention that are essential for its effectiveness (Chambers & Norton, 2016). In Study 2, the teacher responsible for Group B declined to implement the class-wide sessions because of the discrepancy between the way in which the sessions were designed and the characteristics of the students in her class (i.e., students with developmental disabilities). If I had collaborated with the teacher to adapt the classwide-sessions to better match her students’ abilities, it is possible that the teacher would have conducted the sessions and overall results would have been improved.  Finally, future research should explore a “train the trainer” model as a method of teaching school staff across a number of different schools within and across districts. As part of this investigation, researchers will need to examine who is best suited to provide this training. In the studies presented here, participants identified the importance of trainers having a deep knowledge of the intervention. Indeed, although the participants perceived the school-based FYF as feasible and acceptable, it is important to note that the training was provided by a researcher outside the school. With this in mind, future studies will want to consider the training and expertise of individuals within the school setting.  101 Further research is needed to examine who (e.g., school psychologist, learning support teachers, counsellors) should provide training in the school-based FYF intervention and how this should be accomplished (e.g., specialist trainer, workshops, on-going consultation). Training educators who are employed by school districts to train other educators to implement the school-based FYF would further increase the feasibility and affordability of this intervention. Consideration should also be given to including supervision, in the form of in vivo coaching and performance feedback, as a component of the training process.  Conclusion The two studies in this dissertation represent a small yet valuable contribution towards bridging the research-to-practice gap. Specifically, they address transportability of an anxiety treatment program for children with ASD to the school setting. Given the number of school factors that potentially contribute to or maintain anxiety symptoms (e.g., peer interactions, academic demands, disruptions in routines, overwhelming sensory stimuli), implementing the modified FYF intervention in schools may provide an essential support for students with ASD. Consistent with an integrated KT framework, a community-research partnership was established between knowledge users and researcher within a guided dialogue focused on FYF delivery in a school setting. The dialogue yielded detailed input from knowledge users aimed at enhancing the acceptability, feasibility, and sustainability of school-based FYF. Next, the proposed modified FYF intervention was implemented by natural change agents (i.e., educators) in a natural setting (i.e., school) under real world conditions (e.g., during school hours) offering greater understanding of feasibility and effectiveness of a school-based FYF. Taken together, integrating input from stakeholders and working in the natural environment with natural agents of change increases the likelihood of adoption and continuation of the intervention beyond the life of the  102 study, thus contributing to the overall implementation of empirically supported interventions in schools.   103 References Abramowitz, J. (2013). The practice of exposure therapy: Relevance of cognitive-behavioral theory and extinction theory. Behavior Therapy, 44, 548-558. doi: 0005-7894/44/548-558/$1.00/0 Adelman, H., & Taylor, L. (2006). Mental health in schools and public health. Public Health Reports, 121(3), 294-298. Allen, K. (2011). 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Cognitive behavioral therapy for early adolescents with autism spectrum disorders and clinical anxiety: A randomized, controlled trial. Behavior Therapy, 46, 7- 117 19. doi: 10.1016/j.beth.2014.01.002 Wood, J. J., Klebanoff, S., Renno, P., Fujii, C., & Danial, J. (2017). Individual CBT for anxiety and related symptoms in children with autism spectrum disorders. In C. M. Kerns, R. Renno, E. A. Storch, P. C. Kendall, & J. J. Wood (Eds.). Anxiety in children and adolescents with autism spectrum disorders: Evidence-based assessment and treatment (pp. 123–142). London: Elsevier/Academic Press.                    118 Appendix A Focus Group Consent Form for Study 1  DATE  School Based Facing Your Fears Anxiety Treatment for Children with Autism Spectrum Disorder: Educator and Parent Perspectives on Acceptability and Feasibility.   Principal Investigator:     Joseph M. Lucyshyn, Ph.D Associate Professor Faculty of Education University of British Columbia   Co-Investigators:    Karen Kester, M.A Doctoral Student Researcher Faculty of Education  University of British Columbia    Introduction  I am a Ph. D student in the Department of Education at the University of British Columbia. As part of my doctoral studies, I am conducting research under the supervision of Dr. Joseph Lucyshyn.  I am inviting you to participate in a research project entitled “School Based Facing Your Fears Anxiety Treatment for Children with Autism Spectrum Disorder: Educator and Parent Perspectives on Acceptability and Feasibility”.     Purpose:  The purpose of this study is to examine the acceptability and feasibility of using a manualized intervention (Facing Your Fears) to treat anxiety among children with Autism Spectrum Disorder (ASD) in the school setting. Specifically, we want to hear from educators and parents about the strengths of this intervention, any potential barriers of implementing this intervention in a school setting and some possible adaptations to enhance the intervention for the school setting. We will use this information to modify the Facing Your Fears program to better serve the needs of children with ASD and anxiety in the school setting.    Procedures:  If you participate in this study you will be in a group of 3-8 participants. There will be a facilitator who will ask questions and facilitate the discussion. You are asked to participate in two sessions, each lasting 1 hour. Discussion during the focus group session time will be audiotaped.    Prior to focus group: Prior to the first session, you will be provided access to a copy of the Facing Your Fears manual, as well as a summary and we ask you to read this information.   The time involved is at your own discretion, approximately 1.5 hours.  119 First group session: If you volunteer to participate in this focus group, you will be asked some questions relating to the strengths, potential barriers and prospective adaptations of materials you have read. This will take 1 hour.    Follow-up group session: A follow-up session will be held 2-3 weeks following your first session. A modified intervention will be presented for discussion based on feedback from the first session.  This will take 1 hour.    Potential Risks and Safeguards If you agree to participate in the focus groups, you will need to consider two potential risks: (1) psychological and (2) loss of privacy.    1. Psychological Risk   In expressing your opinion or voicing your suggestions with a group you may experience psychological risk.  That is, you may feel some discomfort or stress during the discussion.  To minimize this risk: a. At the beginning of each group discussion, the facilitator will review guidelines around focus group expectations (e.g. people speak one at a time, treating everyone with respect, discussion need to stay on topic)  b. You may choice to not contribute to any question during the discussion; and c. You may leave at any time without explanation if you are uncomfortable.   2. Loss of privacy   Participation in a focus group comes with the potential risk of loss of privacy.  Because focus groups include discussions of personal opinion, extra measures will be taken to protect each participant’s privacy:   a. The facilitator will begin the focus group by asking everyone to respect the privacy of other group members. She will also remind them at the end of the group not to discuss the material outside of the group. Although all participants will be asked to not disclose anything said within the context of the discussion, but it is important to understand that other people in the group with you may not keep all information private and confidential.   b. The names of individual participants in the study will not be mentioned within project reports or presentations generated from this study without your permission. c. Access to information will be restricted to members of the research team only  d. Study records, including the consent form signed by you, audio recordings and transcriptions of audio recordings, will be kept in a locked cabinet; and e. All data for the purpose of this study will be destroyed 5 years after the study is completed.   Potential Benefits Your participation in this study will contribute to knowledge about how to modify the Facing Your Fears intervention with the potential benefit of providing an acceptable and feasible intervention to treat anxiety in children with ASD in the school setting.    As a way to compensate for your time related to your participation, you will receive a one-time honorarium in the amount of $50 on completion of the focus groups.     120 Permission to Quote: I may wish to quote your words directly in reports and publications resulting from this. With regards to being quoted, please check yes or no for each of the following statements:  The use of direct quotes from you can be used in the following conditions:   Yes      No Agree to be quoted directly (name is used).   Yes      No Agree to be quoted directly if name is not published (remain anonymous).   Yes      No Agree to be quoted directly if a made-up name (pseudonym) is used.  Contact for information about the study.  Your participation in this study is completely voluntary. If you decide to take part in this study, you are free to withdraw at any time without penalty or giving a reason for your decision. If you wish to participate, you will be asked to sign this form.  If you have any questions or would like additional information about this study, you may contact either Karen Kester (UBC graduate student researcher) or Dr. Joseph Lucyshyn (UBC Professor). If you have any concerns about your rights as a research participant, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or via e-mail at RSIL@ors.ubc.ca.  Your signature below indicates that you consent to participation in the study.                              121 CONSENT FORM FOR PARTICIPATION IN FOCUS GROUP  Study Title: School Based Facing Your Fears Anxiety Treatment for Children with Autism   Spectrum Disorder: Educator and Parent Perspectives on Acceptability and Feasibility.  Principal  Investigator: Joseph M. Lucyshyn, Ph.D., Faculty of Education, University of British Columbia  Co-Investigator: Karen Kester, M.A., Faculty of Education, University of British Columbia   I have read and received a copy of this consent form and have had an opportunity to ask questions about the research project and focus group process.  I have received an adequate description of the purpose, goals, and procedures of the focus group, and I consent to participate in the focus group.  I understand that all information will be kept confidential, that my participation is voluntary, and that I may withdraw consent at any time and discontinue participation at any time.  By signing this consent form, you are indicating that you fully understand the above information and agree to participate in this focus group.     _____________________________________  ______________________________ Participant’s signature      Date  _____________________________________                         Printed name    PLEASE RETURN THIS PAGE TO: Faculty of Education University of British Columbia 2125 Main Mall Vancouver, B.C. V6T 1Z4            122 Appendix B Parent-Child Invitation Letter for Study 2  DATE  Dear Parent/Guardian,  We would like to inform you of an opportunity to participate in a research study entitled “Evaluating the Effectiveness of Educators Implementing a School-based Facing Your Fears Anxiety Treatment for Children with Autism Spectrum Disorder”. The study will be conducted by the University of British Columbia.  The Principal Investigator (PI) of the study is Joseph Lucyshyn, Associate Professor in the Faculty of Education of the University of British Columbia.  The graduate student researcher is Karen Kester, Ph.D. student in the Faculty of Education at the University of British Columbia. The research study is for the fulfillment of degree requirements for the Doctor of Philosophy degree.  As you may be aware, anxiety disorders are a growing mental health concern among children, including children with Autism Spectrum Disorders. Facing Your Fears is a group therapy program that uses cognitive behaviour therapy (CBT) to treat anxiety in children with ASD. Last year, I worked with a group of educators and parents to modified the Facing Your Fears program to better suit the unique characteristics of the school setting. The purpose of this study is to examine the effectiveness of this modified school-based Facing Your Fears program to treat anxiety symptoms in children ASD. Interested educators (Counsellors, Learning Support Teachers, Educational Assistants) will be trained as group facilitators and coaches to deliver Facing Your Fears in schools.  We are hoping to recruit up to 8 children and their parent or caregiver for this study. To qualify for this study, a child must  o be diagnosed with an autism spectrum disorder o be between 8-12 years old o demonstrate concerning anxiety-related behaviours and symptoms o have an estimated IQ of 70 or above o have a parent willing to participate in parent sessions   The school-based Facing Your Fears (FYF) is a 10-week intervention program with three group components: small group (10 sessions), class group (3 sessions), and parent group (5 sessions). Small group and class-wide FYF sessions will occur during the school day and parent sessions will occur in the evening. Each session will be 1 hour in length, with 3-4 students/parents per group. The FYF intervention will begin in October 2018.     Research activities will include:   1) preliminary assessment of child anxiety symptoms  2) child participation in small group (3-4 students) FYF sessions facilitated by school-based counsellor for 10 consecutive weeks.    123 3) child participation in class wide FYF sessions facilitated by school-based counsellor for a total of 3 sessions within the 10-week intervention period.  4) video-recordings of FYF sessions  5) parent/caregiver participation in parent FYF sessions facilitated by school-based counsellor for a total of 5 sessions within the 10-week intervention period 6) post-intervention assessment of child anxiety symptoms  7) complete a self-reported questionnaire assessing your experience during your participation in the program at the end of the 10-week intervention  8) parent participation in a focus group discussion post-program. A facilitator will use open-ended questions to obtain parents’ perspectives on the acceptability and feasibility of the school-based FYF program. The focus group will be 1 hour.   Your involvement in this study is voluntary. Any information that you and your child share with us will be kept private and confidential. All documents will be identified only by code number and kept in a locked filing cabinet in the UBC project office. As with all psychosocial programs, there is risk that a previously unknown problem will be made known. The potential benefits for you include improved knowledge of strategies for supporting your child cope with their anxiety. The potential benefits for your child include a reduction of anxiety symptoms and increased engagement in school activities. In addition, your participation will contribute to the urgent need for research about how to support students with ASD and anxiety in the school setting. All participants will receive a $50 honorarium as a token of appreciation for your contribution to the research.   If you are interested in participating in this study, or learning more about the study, please let us know by contacting Karen Kester.  You may also contact Joe Lucyshyn.  Sincerely,           Associate Professor     Graduate Student Researcher Faculty of Education      Faculty of Education  University of British Columbia   University of British Columbia            124 Appendix C Fidelity Checklist Scoring Definitions: School-Based Facing Your Fears  Adherence Measure: Evaluate for each activity per session ~ Adherence = This item evaluates the degree to which the facilitator implements activities prescribed in the FYF manual  Competence Rating Measure: Evaluate overall in each session ~ Comprehension = This item measures the facilitator’s ability to use a CBT model and concepts throughout the session.  ~ Group Participation = This item evaluates the overall group participation level based on participation of all group members. ~ Language = This item rates how well the facilitator matches their language to the comprehension level of child/parent.  ~ Time Management = This item evaluates how appropriately the facilitator manages time during the session.  ~ Behaviour Management = This item rates how well the facilitator manages problem behaviour during the session.   The rater should use the following definitions to evaluate the level of implementation/skill rating.  0 1 2 9  Not Present Partial Implementation Full Implementation Not applicable Adherence The section was not discussed. The section was not adequately covered. Examples include covering only part of the section.  The section was thoroughly covered. Examples include bring in real life examples.  This code is used when it is not appropriate to code for a particular activity. Comprehension Facilitator missed important opportunities to explain CBT concepts Facilitator mentioned CBT concepts but not in a timely manner or relevant to the child/parent.  Facilitator described the relevant CBT concepts.  Group Participation Group members demonstrated a low level of participation (i.e., child/parent was mostly reticent throughout the session).  Group participation was moderate (i.e., a mix of low and high participation) during activity.  Group participation was high for all group members (i.e., all group members actively participated throughout the session).   125 Language Facilitator used unclear language throughout the activity (i.e., above or below comprehension level of child/parent) Facilitator used mix of unclear and clear language.  Facilitator used clear language (matched comprehension level of child/parent).   Time Management Facilitator was unfocused and the session seemed aimless Facilitator seemed to have some direction but was distracted by peripheral issues.  Facilitator used time extremely effectively by directing the flow of conversation and redirecting when necessary; session seemed well-paced, focused and structured.  Behaviour Management Facilitator compounds the problem and/or misses clear opportunities to appropriately manage behaviour Facilitator implements strategies: problem behaviour continues but does not make it worse.  Facilitator handles problems well, using appropriate strategies and behaviour remits.                      126 Appendix D Social Validity Questionnaire (Educator)  I am interested in your feedback about aspects of the school-based Facing Your Fears. Please take a few minutes to complete the questions below. Thank you for your input.    Strongly  Disagree Disagree Neutral Agree Strongly  Agree 1. I enjoyed participating in the Facing Your Fears program.   1 2 3 4 5 2. The training workshop included useful information about autism and anxiety.  1 2 3 4 5 3. The workshop information was presented in a way that made it easy for me to apply the CBT concepts in group.  1 2 3 4 5 4. The feedback sessions helped me apply the CBT concepts I learned during the workshop.  1 2 3 4 5 5. The feedback sessions and in-group coaching was supportive and positive for me.  1 2 3 4 5 6. Overall, I found the Facing Your Fears group helpful in teaching me how to help students with autism cope with their anxiety.  1 2 3 4 5 7. I have learned important skills by participating in the Facing Your Fears group. 1 2 3 4 5 8. I think I am more prepared to support students with autism cope with their anxiety. 1 2 3 4 5 9. The skills taught to learn how to face fears were easy to understand and learn. 1 2 3 4 5 10. The CBT concepts and tools were easy to implement.  1 2 3 4 5 11. I felt overwhelmed by the amount of information presented in each group session. 1 2 3 4 5 12. The students who participated in the Facing Your Fears group benefited from the sessions.  1 2 3 4 5 13. I will continue to use the Facing Your Fears program in my school.  1 2 3 4 5 14. I would choose to participate in the Facing Your Fears group again. 1 2 3 4 5 15. I would recommend the Facing Your Fears group to other parents and students.  1 2 3 4 5         127 Please rate how helpful the following tools learned in the Facing Your Fears program are to you when supporting a student with autism cope with their anxiety:   Not helpful  Somewhat Helpful  Extremely Helpful • Relaxation exercises and deep breathing 1 2 3 4 5 • Calming Kit   1 2 3 4 5 • Changing unhelpful thoughts to helpful thoughts 1 2 3 4 5 • Stress-o-meter for worry ratings 1 2 3 4 5 • Making a Fear Hierarchy 1 2 3 4 5 • Practicing facing fears 1 2 3 4 5 • Psychoeducation: Model of Anxiety  1 2 3 4 5   What did you like most about the Facing Your Fears program?       What so you think should be changed about the Facing Your Fears program?        Any other comments?          128 Appendix E Social Validity Questionnaire (Parent)  I am interested in your feedback about aspects of the school-based Facing Your Fears. Please take a few minutes to complete the questions below. Thank you for your input.    Strongly  Disagree Disagree Neutral Agree Strongly  Agree 1. I enjoyed participating in the Facing Your Fears group.   1 2 3 4 5 2. My child enjoyed going to the Facing Your Fears group.  1 2 3 4 5 3. Overall, I found the Facing Your Fears group helpful in teaching me how to help my child cope with their anxiety.  1 2 3 4 5 4. Overall, I found the Facing Your Fears group helpful in enhancing my child’s coping skills. 1 2 3 4 5 5. I have learned important skills by participating in the Facing Your Fears group. 1 2 3 4 5 6. I feel confident that I have learned skills to help my child face their fears.  1 2 3 4 5 7. My child is able to use the tools that they learned in the Facing Your Fears group. 1 2 3 4 5 8. The skills I learned will be helpful to me and my child in the future. 1 2 3 4 5 9. The skills taught to learn how to face fears were easy to understand and learn. 1 2 3 4 5 10. I would choose to participate in the Facing Your Fears group again. 1 2 3 4 5 11. I would recommend the Facing Your Fears group to other parents. 1 2 3 4 5       Please rate how helpful the following tools learned in the Facing Your Fears program are to you:  Not helpful  Somewhat Helpful  Extremely Helpful • Relaxation exercises and deep breathing 1 2 3 4 5 • Calming Kit   1 2 3 4 5 • Changing unhelpful thoughts to helpful thoughts 1 2 3 4 5 • Stress-o-meter for worry ratings 1 2 3 4 5 • Making a Fear Hierarchy 1 2 3 4 5 • Practicing facing fears 1 2 3 4 5 • Psychoeducation: Model of Anxiety  1 2 3 4 5    129 What did you like most about the Facing Your Fears program?       What so you think should be changed about the Facing Your Fears program?        Any other comments?                           130 Appendix F Social Validity Questionnaire (Child)  Tell me what you thought about Facing Your Fears group.  Please circle the face that you think best describes what you think about Facing Your Fears group.   1. I liked going to Facing Your Fears group  2. I know how to use Calm Body and Calm Mind tools  3. I can calm myself down when I am worried.   4. The tools taught to learn how to face my fears were easy to understand and learn.    5. I would like to go to Facing Your Fears group again.     In group, you learned some new tools. Circle the face that best describes how helpful each tool is to you:  • Relaxation exercises   • Deep breathing    • Worry Bug and Helper Bug  • Calming Kit  • Changing unhelpful thoughts to helpful thoughts    • Using my stress-o-meter  • Making a Fear Hierarchy   • Making movies   131   Appendix G School-Based Facing Your Fears: Session Outline  Week Small Group Class Parent 1 Welcome to the Group Getting to know you  - About me game - Create points cards/sticker program  - Generate rules for the group  Learning about emotions - Sort emotions words relay game  - Emotion game: match feeling word to a situation What makes me Worry  - Identify situations that make child worried  § My Checklist of Fears, Worries, and Irritations worksheet Prizes  Understanding Worry Understanding Feelings  What Makes me worry  - Identify situations that make student worry § Everybody Worries worksheet What Worry Does to my Body  - Identify body’s reaction to worry  § How I React When I Worry worksheet False Alarm/ Real Danger  - Introduce metaphor or an alarm in our bodies when in danger  - Brain Science: amygdala, prefrontal cortex Introduction Overview of program  - Identify symptoms and situations - Context for thinking about anxiety - Introduce tools/strategies  - Steps to success - Reinforcement - Self-evaluation - Relapse prevention Parent Role in helping kids Face Fears - Model courageous behaviour - Thoughts-feelings-actions connection - Reward courage- ignore excessive display  - Recognise parental anxiety  Questions/Answers 2 Understanding Worry Time Spent Worrying  - Visually show how much time a child spends worrying (based on number of worries, intensity and size) and how that interferes with having fun § Time spent worrying now worksheet § Time spent worrying in the future worksheet § When worry goes away worksheet False alarm/real danger  - Review the metaphor of an alarm in our bodies when in danger.  Make a distinction between ‘false alarms’ and ‘real dangers’ through examples.        132  What worry does to my body  - The body’s reaction to worry – identifying the physiological reactions when feel anxious.  § What worry does to your body life size body drawing   Relaxation Training  - Introduce calm body strategies (deep breathing, PMR)  Prizes 3 The Mind-Body Connection Deep breathing  Measuring anxiety  -  introduction to stress-o-meter § My Checklist of Fears, Worries, and Irritations worksheet Tracking worries  -  children identify 5 priority worries to monitor for the remainder of group § Fear Tracker worksheet Worried Minds  - identify false alarms and real dangers  § Active Minds worksheet  - generate helpful thoughts  § Helpful Thoughts worksheet  - Story: use story to highlight concepts (false alarms, body reactions, negative thinking).  - Alarm Chain Reaction (optional)—as worry thought gets bigger our body feeling gets bigger Prizes Calm Body – Calm Mind Externalizing Worry  - Worry bug/helper bug Thoughts- Feelings-Actions Calm Body strategies  - PMR - Deep breathing  - Calm kit  Calm Mind strategies  - Helpful thoughts    Understanding Facing Your Fears Adaptive/Excessive protection - Cycle of anxiety  - Parental anxiety  Worried Minds - Differentiate real danger/false alarm Plan to Get to Green  - Stress-o-meter - Cognitive restructuring  - Calm body – calm mind  Creating exposure hierarchies/Steps to success - Gradual exposure  4  Calm Body, Calm Mind Deep Breathing  Facing Fears - Learning to face fears- practice creating steps  § Facing Fear of…. worksheets  - Watch movie: example of steps child uses to face fear of dogs.  Discuss the steps and identify the helpful thoughts and other strategies the child uses in the video to face his fear    133  Plan To Get to Green - Strategies for calming down  Prizes 5 Steps to Success – Introduction to Exposure Deep Breathing  Fear Tracker Create exposure hierarchy  - Picking a Target  - begin to identify their own target goal and the steps to face their fear  § Finding my target worksheet § Steps to Success: Where Do We Begin? worksheet Facing Fears  - Watch movie: example of steps child uses to face fear of talking on the phone.  Discuss the steps and identify the helpful thoughts and other strategies the child uses in the video to face his fear.  Prizes  Steps to Success Fear Hierarchies  - Creating an exposure hierarchy  § Finding my target worksheet § Steps to Success: Where Do We Begin? worksheet - introduce use Facing Fears Planning Sheet  - practicing at home 6 Practicing Exposure and Making Movies  Deep Breathing  Fear Tracker Practice Facing Fears  - use Facing Fears Rating Sheet to practice role playing and/or in vivo exposure - How Did I Do? – Children will complete a self-evaluation of how practice exposures went Make a movie  - Starting to make a movie – begin to fill in Plan for My Movie script Prizes Calm Body –Calm mind Plan to Get to green  - Review calm body-calm mind strategies   Learning to set Goals  7 Practicing Exposure and Making Movies Deep Breathing  Fear Tracker Practice Facing Fears  - use Facing Fears Rating Sheet to practice role playing and/or in vivo exposure  Exposure Coaching Review student progress - Video review - Role play Fear hierarchies  Questions/Answers   134 - How Did I Do? – Children will complete a self-evaluation of how practice exposures went Make a movie  - Starting to make a movie – begin to fill in Plan for My Movie script Prizes 8 Practicing Exposure and Making Movies Deep Breathing  Fear Tracker Practice Facing Fears  - use Facing Fears Rating Sheet to practice role playing and/or in vivo exposure - How Did I Do? – Children will complete a self-evaluation of how practice exposures went Make a movie    9 Practicing Exposure and Making Movies Deep Breathing  Fear Tracker Practice Facing Fears  - use Facing Fears Rating Sheet to practice role playing and/or in vivo exposure - How Did I Do? – Children will complete a self-evaluation of how practice exposures went Make a movie   Exposure Coaching Review student progress - Video review - Role play Fear hierarchies  Relapse Prevention  How to identify and target new worries   10 Graduation Watching movies  Lessons learned  Graduation and awards Prizes and goodbyes       

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