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

In the autism field, there is increasing interest in translating evidence-based interventions (EBIs) into systems that serve young autistic children and their families. Public Early Intervention systems have been a focal point of research-based implementation efforts given that these systems are federally mandated to provide services to children birth to three years of age with developmental delays under Part C of the Individuals with Disabilities Education Act. Although a growing number of research studies are now training Early Intervention providers to deliver autism EBIs, this work has been conducted on a relatively small scale and has only just begun to consider the alignment of these models with Early Intervention systems and whether sufficient infrastructure exists to scale up these training efforts and to sustain their public health impact. This commentary aims to address this gap by reviewing factors that have been found to uniformly impact the scale-up of EBIs across diverse public systems (Fagan 20, 1147-1168, 2019), and to extend this framework to the implementation of EBIs within public Early Intervention systems. These factors include developer and funder capacity, the public's awareness of and support for EBIs, the system's leadership support for EBI use, the capacity for community engagement in implementation efforts, the availability of a skilled workforce capable of delivering EBIs, and the capacity for data monitoring and quality improvement. This commentary discusses how these factors may specifically impact the scale-up of autism EBIs within EI systems to support toddlers and young, autistic children, and implications for autism researchers.

Naturalistic developmental behavioral interventions are an empirically supported intervention approach for young autistic children. Despite the prevalence of disruptive behaviors among autistic children, most manualized caregiver-mediated naturalistic developmental behavioral interventions include limited formal guidance on when and how to manage disruptive behavior. The present study sought to characterize how clinicians address disruptive behaviors within the caregiver-mediated naturalistic developmental behavioral intervention, Project ImPACT, the effect of disruptive behavior on Project ImPACT delivery, and the extent to which disruptive behavior impacts social communication outcomes. Data collection was embedded within outpatient early intervention services and included clinicians' report of adaptations to address behavior within the electronic medical record, child social communication outcomes from 124 children and their caregivers, and interviews with certified Project ImPACT coaches and trainers. Results indicate that close to one-third of Project ImPACT sessions included adaptations made to address behavior and regulation. Furthermore, adaptations made to address disruptive behavior were associated with more adaptations to Project ImPACT overall, although behavior adaptations were not associated with child social communication outcomes. Qualitatively, clinicians described using a flexible approach to integrate content and coaching related to behavior and regulation. The present study indicates several future directions for supporting clinicians in addressing behavior and regulation within the naturalistic developmental behavioral intervention framework.

Despite consensus on the importance of early detection and intervention for autistic children, health disparities exist, limiting access to timely services. One specific service type in the United States is Individuals with Disabilities Education Act, Part C Early Intervention programs, which are federally funded interventions for children birth-to-three with developmental delays. This study aimed to assess access to Part C, Early Intervention services for children who were evaluated for autism spectrum disorder and to examine factors that predicted parent-reported access to these services. This study extracted sociodemographic and service access data from the medical records of 709 children aged 12-40 months who were evaluated for autism spectrum disorder. Results showed that only 50% of the sample had reportedly accessed Part C, Early Intervention services. Those who identified as Black had decreased odds of having accessed Part C, Early Intervention, relative to those who identified as White, while those with a lower age of first parent concern had increased odds of having accessed Part C, Early Intervention. When inputting the independently significant variables into the model, both variables, identifying as Black and a lower age of first concern, remained significantly associated with accessing Part C, Early Intervention. Future work should investigate how these disparities come to be.

Naturalistic, Developmental, and Behavioral Interventions (NDBIs) are an empirically supported intervention approach for young autistic children and their families. Spanish-speaking (SS) Latinx families have been underrepresented in autism intervention research, limiting our understanding of whether NDBIs are aligned with Latinx family values and belief systems. This study piloted a parent-mediated NDBI, Project ImPACT, within outpatient services for SS Latinx families. We aimed to examine the preliminary impact of Project ImPACT on family and child outcomes while using the Ecological Validity Model to evaluate program adaptations made by bilingual clinicians. Results from 15 families indicated good treatment completion and high satisfaction, alongside significant increases in child social communication skills and parent self-efficacy in supporting their child's development. Mixed-methods data examining program adaptations indicated the need to provide additional information related to autism, bilingual language development, and service navigation, as well as adaptations to language and metaphors used in the program.

Parent-mediated interventions (PMIs) are considered an evidence-based practice for fostering social communication skills in young autistic children and for promoting parent responsivity and empowerment, yet barriers to caregiver engagement are evident when PMIs are implemented within historically underserved community settings. Issues of caregiver engagement can reflect a lack of fit between PMIs and the needs of diverse families. We used a mixed methods approach to examine barriers to participating in an evidence-based PMI, Project ImPACT (Ingersoll & Dvortcsak, 2019), within an outpatient setting, as well as strategies that clinicians reported using to deliver and adapt Project ImPACT for minoritized families. Participants included 134 caregivers of a child 13 to 48 months with autism or other social communication differences and six clinicians delivering Project ImPACT. Findings suggest that caregivers experience barriers to participating in Project ImPACT and that these barriers are associated with caregivers' ability to complete the program. Although quantitative findings indicate that adaptation to Project ImPACT did not differ by caregiver and child background, qualitative findings highlighted that clinicians attempt to deliver Project ImPACT to respond to the needs of families from minoritized backgrounds by actively considering the family's culture, psychosocial experiences, goals, and specific barriers. Further, both qualitative and quantitative findings suggest that culturally responsive care and adaptations may support caregiver engagement, including rapport, trust, buy-in, and attendance. Approaches to center cultural alongside contextual/psychosocial considerations within family-centered care in the implementation of PMIs are also highlighted.

Autistic youth frequently experience interfering anxiety, and schools may be an ideal setting to deliver mental health care. A type 1 hybrid-effectiveness, cluster randomized trial was used to examine the effectiveness of school-based Facing Your Fears compared to usual care. Change in provider cognitive behavior therapy knowledge and treatment fidelity (adherence and provider competence) were also examined. Seventy-seven interdisciplinary school providers across 25 elementary/middle schools were trained via a train-the-trainer approach. Eighty-one students, ages 8-14 years, with autism or suspected autism and anxiety participated. Students who received school-based Facing Your Fears displayed significantly greater reductions in anxiety compared to students in usual care according to caregiver and child report (Screen for Anxiety and Related Emotional Disorders). Significant reductions in total anxiety (p = 0.012), separation (p = 0.002), and social anxiety (p = 0.003) subscales occurred, according to parent report. Student self-report indicated significant reductions on the social anxiety subscales (p = 0.001). Interdisciplinary school providers demonstrated significantly increased cognitive behavior therapy knowledge following training (p < 0.001). Mean adherence and competence ratings were strong. The positive effectiveness and implementation outcomes are encouraging. Training interdisciplinary school providers to deliver school-based Facing Your Fears has the potential to increase access to care for anxious autistic students. Future directions and limitations are discussed.