Implementation of the Rubi Parent Training Program for Children with Autism Spectrum Disorder and Disruptive Behavior in Clinical Settings

Background: There is a pressing need to close the chasm between demonstrated efficacy of interventions for youth with autism spectrum disorder (ASD) validated under ideal conditions and their effectiveness when implemented in community settings. The Research Unit on Behavioral Interventions (RUBI) Autism Network developed a manualized parent training program for families of children with ASD and co-occurring disruptive behaviors. RUBI utilizes techniques grounded in applied behavior analysis to teach parents how to manage their child’s behavioral problems over 11 outpatient visits. With over a dozen published research studies, RUBI has been found to be acceptable to parents, reliably delivered by trained therapists, and effective in reducing disruptive behavior when evaluated under ideal conditions (i.e. efficacy trials). RUBI is emerging as an important component of short-term, effective treatment for children with ASD. This is the first large-scale examination of efforts to deliver RUBI under real-world conditions.

Objectives: This trial evaluates the feasibility and efficacy of RUBI when delivered at two independent hospital-based clinics [Marcus Autism Center (MAC); Seattle Children’s Autism Center (SCAC)] serving families of children with ASD.

Methods: All children, ages 2-12 with a community diagnosis of ASD and disruptive behavior, who participated in RUBI at two clinical sites (MAC, SCAC) between June 2015 and October 2018 were included in the analyses. Demographics (e.g., age, sex, race, ethnicity, school placement) were collected through medical record and intake documentation. Children were characterized at intake using a standardized battery (Social Responsiveness Scale, Adaptive Behavior Assessment System, Stanford-Binet). Primary outcomes include treatment feasibility (e.g. attendance, attrition), which denotes evidence that the treatment is acceptable to families. Efficacy (reduction in child behavior problems) is examined through change on the parent-rated Aberrant Behavior Checklist-Irritability subscale (ABC-I). Results from the large-scale trial of RUBI (RUBI-RCT) are used as benchmarks to compare to findings from the two clinical sites.

Results: 180 children completed intakes across the two sites, with 166 initiating RUBI. Mean age was 6.6 ± 2.2 (MAC) and 6.4 ± 2.4 (SCAC) suggesting an older population than RUBI-RCT. Compared to RUBI-RCT, the two clinical sites served a more diverse population [IQ below 70 = 26% RUBI-RCT vs. 48% MAC, 31% SCAC; Caucasian = 73% RUBI-RCT vs. 42% MAC, 72% SCAC; on medication = 13% RUBI-RCT vs. 62% MAC, 42% SCAC]. Feasibility outcomes suggest high parental engagement, with attrition rates similar between RUBI-RCT (11%), MAC (20%) and SCAC (14%). Parents reported a 46.9% (MAC) and 31.6% (SCAC) decrease in disruptive behaviors on the ABC-I from baseline to endpoint (both significant at p<0.001), which is comparable to RUBI-RCT (47.7% decrease). Findings from key secondary outcomes (e.g., Home Situations Questionnaire, Parenting Stress Index) will be reported.

Conclusions: When delivered in a community setting, RUBI appears to be acceptable to parents. Outcomes indicate notable reductions in child disruptive behaviors with a diverse population, with findings comparable to those from a large scale efficacy trial. Discussion will include a review of barriers to delivering RUBI in clinical settings, including modifications required to meet clinic and billing demands.