Training and Implementation of RUBI in Community Mental Health Settings

Challenging behaviors exhibited by autistic youth have detrimental effects on their developmental outcomes and caregivers' self-efficacy and overall parenting. Autistic youth are reported to engage in these challenging behaviors more often and in more intensity than their typically developing peers or children with other developmental disabilities. Furthermore, researchers reported that many caregivers of young autistic children have a tendency to employ punishment-oriented behavior management strategies as these may come more naturally to them, which can lead to negative parent-child interactions and relationships. Unfortunately, they also increase the risk for needing more intensive services at school and in the community. The challenges caregivers face in raising an autistic child and the high demand of responsive community-based services has sparked interest in the use of parent training (PT) in this population, as it empowers caregivers to be the agent of change for their child. Therefore, it is needed to examine a function-based, positive parenting program to disseminate through existing infrastructure for child and caregiver mental health treatment.

The RUBI intervention is built on a set of basic assumptions: (1) children with ASD engage in unwanted behaviors for a reason (i.e. function): to gain access to a tangible item (e.g., food or a favorite toy); receive attention from others (positive reinforcement); escape or avoid a demand or an aversive stimulus (negative reinforcement); or receive sensory and other internal stimulation (automatic reinforcement); and (2) children with ASD are likely to have deficits in functional communication skills. Thus, RUBI involves therapists teaching caregivers how to assess the function of their child's behavior in order to implement behavioral strategies in a targeted manner (i.e. matching strategy to function). This is accomplished programmatically by first educating caregivers on the Antecedent-Behavior-Consequence (A-B-C) model, which identifies the environmental circumstances that may provoke the behavior (antecedents) and the responses that maintain it (consequences). By learning about the events surrounding a behavior, one can then hypothesize its purpose, or function. By understanding the function of the behavior problem, one can then learn to change the usual response in order to teach the child a more appropriate behavior.

RUBI consists of 11 sessions and was designed to be an outpatient service delivered one-to-one (therapist to caregiver). RUBI teaches caregivers a range of skills to support the building of a behavioral management "toolbox." The intervention emphasizes: 1) tailoring the intervention to the child; 2) identifying behavioral function instead of topography as a means to inform behavioral strategy choice (i.e., targeting what is "driving" the behavior, instead of the behavior itself); 3) decreasing behavioral excess as well as increasing appropriate behaviors; and 4) using positive behavioral supports, such as antecedent management (e.g. use of visual supports), reinforcement, and functional communication strategies as the means to modify behaviors. Finally, RUBI includes strategies designed to generalize positive outcomes and maintain progress over time, with long-term follow up data on RUBI indicating positive response maintains 6 months post-treatment. RUBI uses a behavioral skills training approach, which includes direct instruction, modeling, role-play and practice with feedback in order to train caregivers in the various RUBI skills. Sessions also have accompanying video vignettes that are used to illustrate skills or test parental understanding of session materials. Every session ends with creation of a homework assignment where parents track their daily implementation of the strategies during the week.

This is an open-label pragmatic trial designed to follow and assess RUBI clinical training and implementation outcomes with a subset of providers in the state of Maine who serve families of youth with ASD and/or IDD and are being trained clinically in the RUBI intervention. Because this project is studying providers engaged in a clinical training effort funded by the state of Maine, assignment to clinical training groups and Levels will not be random (see descriptions of Level 1 and Level 2 RUBI Trainings below).

400 providers are being invited to participate in the Level 1 RUBI Clinical Training, with up to 140 providers being invited to continue on to the Level 2 RUBI Clinical Training. This research project will recruit from this pool of 400 providers engaging in this clinical training, specifically:

Study 1: (1) 50 providers who completed only the 16-hr psychoeducational training either live or On Demand, (2) 50 providers who complete only the 16-hr training via the hybrid consultation/training ECHO model, and (3) 50 providers who complete intensive fidelity consultation training in addition to the 16-hr introductory training.

Study 2: 50 provider-caregiver dyads, where the provider has completed Level 1 RUBI Clinical Training and the caregiver is being served by the provider in the delivery of RUBI (noting enrollment of one caregiver per provider, resulting in 50 providers and 50 caregivers).