Handling the challenging behavior of children with autism spectrum disorder (ASD) can be extraordinarily stressful for parents and families. The high levels of stress and overwhelm many parents experience often manifests in high rates of parental accommodation. Since half of all children with ASD engage in disruptive behaviors, giving parents the tools to support their children is vital.
In BHCOE’s webinar The RUBI Autism Network: Parent Training for Disruptive Behaviors in Autism Spectrum Disorder, Karen Bearss, Ph.D., provided an overview of the evidence-based parent training as well as new applications of the program, including group and telehealth delivery methods.
“Parents are hungry for information and support on how to improve core symptoms, reduce challenging behaviors and improve adaptive functioning. It’s our job to create those supports through trainings for families to help them help their children,” says Dr. Bearss, associate professor, Seattle Children’s Autism Center, Department of Psychiatry and Behavioral Sciences at the University of Washington.
Dr. Bearss adds that until recently, parents were generally not an active part of treatment for children with ASD. “There’s been a lovely shift in the field,” she says. “There is great value in teaching parents to be the therapist for their child.”
The Elements of RUBI
RUBI is a training program for parents and other caregivers of children ages 3 to 10 with autism and mild to moderate behavior problems, such as tantrums, noncompliance, difficulties with transitions and aggression. Therapists work one-on-one to teach parents ways to reduce the children’s problem behavior and improve daily living skills, such as self-care and helping around the house.
RUBI parent training strategies focus on:
- How to prevent challenging behavior
- What to do when challenging behavior occurs
- How to promote positive behaviors
Like other parent programs for challenging behaviors in children with ASD, RUBI strategies include improving the parent-child relationship, reinforcement contingencies, planned ignoring and compliance training. But RUBI offers some unique elements that aren’t found in other programs, including antecedent management, the use of visual strategies, skill acquisition and other strategies detailed below.
Determining function of behavior: RUBI places a big emphasis on understanding the function of the child’s behavior to inform the treatment approach.
Appreciating underlying issues: The program also looks beyond behaviors as simply a product of oppositionality, appreciating the role of sensory problems, rigidities, anxiety and other issues that kids with ASD may face.
Antecedent management: Sometimes the first step in managing challenging behavior can be spotting the things that trigger it. That’s why RUBI spends two sessions on antecedent management approaches to work on preventing behavior problems from occurring in the first place.
Visual strategies: RUBI also leans heavily on the use of visual supports, such as video vignettes and pictures. “We teach parents how their kids do much better when they can see what is expected of them, versus just be told what’s expected,” says Dr. Bearss.
Skill acquisition: RUBI also focuses on adaptive skill acquisition. “It’s a lovely combination of not just focusing on decreasing behavioral challenges or excesses, but also working on skills acquisition,” says Dr. Bearss.
Functional communication: The program helps parents understand that their child’s behavior is a form of communication. The parent and therapist’s job is to determine what the child is trying to communicate so that they can put a more appropriate communication tool in place.
Generalization and maintenance: Kids may have difficulty generalizing skills or behaviors from one setting to another. RUBI reinforces the importance of ongoing work to maintain progress.
Besides the core components of RUBI described above, the program has seven supplemental elements, including toileting, feeding, sleep and time out. Home visits and telephone boosters supplement weekly sessions.
The RUBI Sweet Spot
According to Dr. Bearss, the ideal RUBI candidate is between 3 – 10 years old with mild to moderate disruptive behavior. When determining whether a child is an appropriate RUBI case, Dr. Bearss says it boils down to safety. She recommends assessing whether you feel like you will be able to instruct parents in weekly outpatient visits and if they’ll be able to implement the program safely.
The program works just as well for mild ASD as more severe cases. Similarly, it works well with a wide range of cognitive functioning. The child should have receptive language between 12 to 18 months at a minimum so that they’re capable of following simple, one-step instructions. It’s also critical to have a caregiver who can regularly attend the sessions – ideally the same person each week.
The Art and Science of RUBI
RUBI is delivered individually to parents and caregivers during 60-minute weekly sessions. Typically, a session begins with a homework review from the previous week, followed by didactic instruction. The program uses several tools to ensure parents understand the material, including activity sheets, video vignettes and role play. These tools are helpful in reinforcing a new concept and identifying whether the parents understand the concepts. Sessions conclude by developing a homework strategy for parents to implement during the upcoming week.
According to Dr. Bearss, the homework review and homework planning are the most important components of the weekly session. “I want parents to know exactly how, why and when they’re going to use a strategy, and how to respond when things go wrong,” she says. “I make sure they’re leaving with a solid homework plan so the parent is set up for success.”
The art of RUBI shines through in the partnership between the therapist’s knowledge and the family member’s expertise in their child and the unique circumstances in which they’re living. “I love doing this program because it really feels like a partnering effort to determine what is going to be the best approach for the family and child,” says Dr. Bearss.
Each RUBI family receives a behavior support plan, which is a living document that summarizes all of the strategies that were devised and implemented for the child. Each week homework strategies, challenges and other items are added to the plan. Dr. Bearss says the plan is valuable when a family that has finished treatment comes back when a new behavior pops up. “The first thing we do is take a look at the plan, talk about what we did and see if we can apply what they’ve already learned to the new behavior,” she says. “It’s a nice way to capture the progress and strategies that were developed over the course of the program.”
Research and New Applications
During the webinar, Dr. Bearss shared the highlights of a 24-week randomized clinical trial of RUBI versus psychoeducation. The 2015 study, which was published in The Journal of the American Medical Association, involved 180 kids from ages 3 to 7 with autism and co-occurring disruptive behavior. The families in the RUBI program saw a 48 percent decline in disruptive behavior compared to a 32 percent decline for families in the parent education program. About 70 percent of the families in the RUBI program reported their children being “much improved” or “very much improved” after the program.
“We followed those families six months after completing the clinical trial and found that those results maintained,” says Dr. Bearss. “We also found that reducing disruptive behavior improves adaptive skills, especially among higher cognitive functioning kids,” said Bearss.
Subsequent studies looked at the effectiveness of RUBI in different formats. A telehealth pilot study took place at the Marcus Autism Center in Atlanta, Georgia. The center conducted outreach to community mental health centers, schools and regional medical centers throughout Georgia. The results almost perfectly aligned with the 2015 clinical trial, producing a 50 percent reduction in problem behavior. The only significant modification required was eliminating the role-play, which doesn’t lend itself to a virtual format.
Another study looked at RUBI in a group setting. According to Dr. Bearss, the group format required some modifications, including extending the sessions from 60 to 90 minutes to get through all of the content. The homework planning portion requires more time in a group format to allow for tailoring the homework for each family. Bearss recommends limiting the group sessions to a maximum of four families.
To learn more about the RUBI Autism Network’s parent training, watch the full webinar at www.bhcoe.org/virtualacademy.
Stay current on issues affecting the ABA community by attending upcoming BHCOE webinars at www.bhcoe.org/events.