The proposed three-year pilot randomized trial aims to test the effectiveness of the newly-redesigned paraeducator-delivered RUBI for use in Educational Settings (RUBIES) intervention compared to usual care training in reducing disruptive behavior in 80 elementary-school children with ASD. Given the critical need to understand not just whether, but also how interventions work, this study also will examine paraeducator- and child-level mechanistic pathways of the RUBIES intervention.

Autism spectrum disorder (ASD) is a pervasive developmental disorder characterized by deficits in social communication and the presence of restricted and/or repetitive behavior, with prevalence estimates as high as 1 in 54 children in the US. Approximately 50% of children with ASD exhibit disruptive behaviors, such as tantrums, aggression, and noncompliance, a rate that is higher than neurotypical peers in the school environment. Disruptive behaviors impact meaningful engagement in academic tasks and with peers, as well as result in placement in more restrictive settings, higher use of restraint procedures, and suspension, all of which have lasting negative impacts. School-based behavioral management approaches, while effective, are time-consuming and resource-intensive, resulting in high costs and delays in intervention deployment. There is a need for a paradigm shift in the care model for disruptive behaviors in the classroom, specifically an efficient and pragmatic intervention model that builds capacity with direct care providers, which in turn streamlines the intervention process, reduces the need for intensive behavioral supports (thus lowering costs), and increases the number of children with ASD who can be served.

Over the past decade, the Research Units in Behavioral Interventions (RUBI) Autism Network developed and systematically tested a low-intensity (11-session) manualized intervention for parents of children ages 3 to 14 with ASD and co-occurring disruptive behavior. Results across three large scale trials have demonstrated that RUBI significantly reduces child disruptive behavior, and treatment recipients are highly engaged in the intervention. To date, no studies have evaluated the effectiveness of RUBI in schools, the most accessed service system for children with ASD.

With NIMH funding from the University of Washington ALACRITY Center grant (P50MH115837), RUBI content was iteratively redesigned in collaboration with elementary school stakeholders (administrators, teachers, paraeducators) for use in educational settings using the novel Discover, Design, Build, and Test Framework, which combines human-centered design and implementation science. In addition, target end-users (paraeducators) were identified as they: 1) provide direct support to children with ASD in both general and special education classrooms for the majority of the school day; and 2) often do not receive specialized training on effective behavioral management strategies designed to support the unique needs of children with ASD. The proposed three-year pilot randomized trial extends our work to test the effectiveness of the newly-redesigned RUBI for use in Educational Settings (RUBIES) intervention compared to usual care training (UCT) in reducing disruptive behavior in 80 elementary-school children with ASD. Given the critical need to understand not just whether, but also how interventions work, this study also will examine paraeducator- and child-level mechanistic pathways of the RUBIES intervention. Study aims include:

Aim 1: Examine the acceptability and feasibility of RUBIES with paraeducators supporting children with ASD and disruptive behavior in schools. We will measure RUBIES' acceptability (attendance, attrition, satisfaction) and feasibility (demonstration of successful study design) to determine whether paraeducators can successfully implement the RUBIES intervention in schools.

Aim 2: Conduct exploratory analyses of the impact of RUBIES compared to Usual Care Training (UCT) on disruptive behavior. Results will allow us to estimate the means, standard deviations and intraclass correlations of RUBIES compared to UCT on disruptive behavior outcomes, which will be essential for sample size/power calculations for a future definitive longitudinal RCT. Exploratory Hypothesis 1: At Week 24, children whose paraeducator was randomized to RUBIES will exhibit lower rates of observed and reported disruptive behavior compared to children whose paraeducator received UCT.

Aim 3: Conduct exploratory analyses on RUBIES' proposed paraeducator- and child-level mechanisms of change on child disruptive behavior. Exploratory Hypothesis 2: RUBIES will improve paraeducator-level mechanisms (gains in knowledge; use of more effective strategies) which will improve child disruptive behavior compared to UCT. Exploratory Hypothesis 3: RUBIES will improve child-level mechanisms (functional communication skills) which will improve child disruptive behavior compared to UCT.

Specifically, a three-year pilot effectiveness randomized controlled trial will be conducted with 80 paraeducators who support a child with ASD (n=80) from 40 public elementary schools. The child's primary teacher (N=80) and caregiver (N=80) also will be consented to contribute to outcome data on the child's behavior. Thus, 80 "triads" made up of a child-paraeducator-teacher will be enrolled. Data will be collected at baseline, Weeks 8, 12 and 24. Schools will be recruited in three cohorts that align with the school year (Years 1 and 2: N=15 schools, 30 paraeducators, 30 children with ASD, and 30 teachers; Year 3: N=10 schools, 20 paraeducators, 20 children with ASD, and 20 teachers).

Successful completion of the proposed study will allow for a large-scale effectiveness trial of RUBIES in public schools, which has the potential to improve the quality of life for children with ASD across the country.

Inclusion Criteria:

• Paraeducators must be employed by the school district and work directly with children with ASD in the classroom at their school.
• Students with ASD will be included if they: 1) have a documented ASD diagnosis and a Social Responsiveness Scale-2 total raw score > 70 for males and 65 for females; 2) are enrolled in a Kindergarten-5th grade general or special education classroom and participate in a general education classroom for a minimum of 4 hours/week; 3) have a participating paraeducator; 4) have a teacher-rated Aberrant Behavior Checklist-Irritability (ABC-I) subscale score >15,; and 5) have a stable educational plan and placement.

Exclusion Criteria:

• Paraeducator is not supporting a student with autism in a general education classroom
• Student does not have a diagnosis of ASD or elevated disruptive behavior problems

Masked observers will complete the behavior observation of paraeducator use of RUBIES strategies (fidelity) and Behavior Observation of Students in School (BOSS; assessment of functional communication and classroom compliance) at all study points. Subject identity will be masked using numeric codes and only the principal investigator and research coordinator will have access to the password-protected master lists. Masked observers will receive identity coded videotapes to prevent unmasking of study condition or phase. Inclusion of UCT ensures that our behavior observation raters can remain masked to treatment assignment.