Youth who experience anxiety frequently present with problems in other domains as well (e.g., depression, oppositional behavior) and such comorbidity appears to be associated with higher impairment in school functioning (Kendall, Brady, & Verduin, 2001; Kendall, Kortlander, Chansky, & Brady, 1992; Mychailyszyn, Mendez, & Kendall, 2010). These findings underscore the need for interventions that can be responsive to the needs of diverse client populations, rather than single diagnoses. To address this reality, multiple authors have suggested that modular approaches to the organization and delivery of intervention content may be particularly appropriate for use in schools (Lyon, Charlseworth-Attie, Vander Stoep, & McCauley, 2011; Stephan, Wissow, & Pichler, 2010; Weist et al., 2009). Modular psychotherapy has been defined as involving “self-contained functional units [modules] that connect with other units, but do not rely on those other units for their own stable operations” (Chorpita, Daleiden, & Weisz, 2005). In this way, modular approaches have the potential to be more flexible than traditional manualized treatment protocols, which may be/are more compatible with the characteristics of the unpredictable school environment (Lyon et al., 2013). Recent evidence has demonstrated the superiority of a modular intervention to both standard-arranged manuals and usual care for youth receiving services in both clinic and school settings (Weisz et al., 2012).

Trials of modular interventions that were specific to schools for a full range of youth mental health problems have been described, and some researchers have examined the use of modular protocols for treating anxiety or internalizing problems (Stephan et al., 2010; Weist et al., 2009). Lyon and colleagues (2011) trained a small group of school-based clinicians to use a modular approach to treat children and adolescents with primary problems of anxiety or depression and found that participating clinicians were able to effectively select and use modules in the context of ongoing progress monitoring. Similarly, Becker, Becker, and Ginsberg (2012) described the use of a school-based modular approach that was specific to anxiety (including seven modules: psychoeducation , exposure , cognitive restructuring, contingency management, problem solving, relaxation, and relapse prevention). They found that trained practitioners delivered the exposure module most frequently with their clients, followed by psychoeducation and cognitive restructuring. Despite these promising findings, additional research is needed related to the effectiveness of modular approaches to augment existing feasibility studies.

The identification and development of a number of practices that appear to have utility in the treatment of youth anxiety in schools is ongoing, but similar to other service delivery contexts, the routine use of these practices in schools is uncommon (Evans & Weist, 2004). It has been suggested that research devoted to understanding implementation processes in SBMH has lagged behind implementation research in the larger mental health field (Lyon, McCauley, & Vander Stoep, 2011). Nevertheless, recent studies indicate that many of the most significant implementation issues encountered in schools are similar to those in the broader literature. Forman and Bakarat (2011), for example, reviewed studies that implemented cognitive behavioral interventions for youth mental health in schools and found that the factors most frequently identified were organizational structure, program characteristics, fit with school goals, policies and program, training/technical assistance, and administrator support. Furthermore, they articulated three overarching characteristics of implementation initiatives related to success: (1) characteristics of the innovation being implemented (e.g., relative advantage over current practices), (2) characteristics of the implementer (e.g., attitudes/beliefs, knowledge), and (3) characteristics of the organization (e.g., organizational climate). These factors, interactions among them, and the specific importance of organization-level processes have been repeatedly echoed throughout the implementation literature (e.g., Aarons, Hurlburt, & Horwitz, 2011; Beidas & Kendall, 2010; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005).