Applied Behavior Analysis: Medically Necessary Treatment for Autism Spectrum Disorders

1. Applied Behavior Analysis: Medically Necessary Treatment for Autism Spectrum Disorders West Virginia Autism Insurance Stakeholders Roundtable July 13, 2012 Stonewall Resort

2. What is Autism? What is Autism Spectrum Disorder • Autism spectrum disorder (ASD) and autism are both general terms for a group of complex neurodevelopmental disorders. • These disorders are characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors.

3. What is Autism Spectrum Disorder? (ASD) • It includes: • autistic disorder, • Rett syndrome, • childhood disintegrative disorder, • pervasive developmental disorder-not otherwise specified (PDD-NOS) and • Asperger Syndrome

4. What is Autism? What is Autism Spectrum Disorder • ASD can be associated with: • intellectual disability, • difficulties in motor coordination • attention • physical health issues such as: sleep and gastrointestinal disturbances.

5. What is Autism? What is Autism Spectrum Disorder • Autism appears to have its roots in very early neurodevelopment. However, the most obvious signs of autism and symptoms of autism tend to emerge between 18 months and 3 years of age.

6. A national public health crisis • Autism statistics from the U.S. Centers for Disease Control and Prevention (CDC) identify around 1 in 88 American children as on the autism spectrum–a ten-fold increase in prevalence in 40 years. • An estimated 1 out of 54 boys and 1 in 252 girls are diagnosed with autism in the United States.

7. What is Autism? What is Autism Spectrum Disorder • By way of comparison, more children are diagnosed with autism each year than with juvenile diabetes, AIDS or cancer, combined. • ASD affects over 2 million individuals in the U.S. and tens of millions worldwide.

8. Applied behavior analysis (ABA) • Behavior analysis: • A natural science approach to understanding and changing behavior; focus is on interactions between behavior and environment • A distinct discipline with theoretical, experimental, and applied branches and specific research methods, scientific journals, and scholarly/professional organizations • Applied behavior analysis (ABA): Application of scientific principles of behavior (e.g., positive reinforcement) to improve socially significant behavior to a meaningful degree • Many applications in addition to ASD treatment • Based on the work of many researchers and practitioners over 40+ years

9. ABA in practice • An approach comprising many evidence-based techniques or procedures for changing behavior • Stresses positive reinforcement and scientific evaluations of effectiveness • Highly individualized • Flexible and dynamic; intervention is adjusted continuously based on data • Delivered in a range of settings: homes, hospitals, clinics, schools, workplaces, community, etc. • Effective for improving functioning and reducing problematic behaviors in people of all ages, with and without disabilities, when implemented by professionals with bona fide training and experience in the discipline

10. ABA in practice • ABA is a distinct profession; not the same as clinical psychology, developmental psychology, educational psychology, counseling, special education, occupational therapy, etc. • The internationally accepted credentialing program for professional practitioners of ABA is managed by the nonprofit Behavior Analyst Certification Board, Inc. (BACB; see www.BACB.com) • Accredited by the National Council for Certifying Agencies, Institute for Credentialing Excellence • BACB-certified behavior analysts are recognized as qualified providers in autism insurance laws, Medicaid laws, and other laws and regulations in many states, and by the U.S. Department of Defense TRICARE health plan under its ABA benefit for military children with ASD.

11. ABA: Evidence-based treatment for ASD • Hundreds of published studies document the effectiveness of many specific, focused ABA techniques for building a wide range of important skills and reducing problem behaviors in people with ASD of all ages, in a variety of settings. • At least 11 controlled between-groups studies show that multiple ABA techniques combined into early comprehensive, intensive treatment programs can produce large improvements in symptoms and skill deficits in many young children with ASD when treatment is directed by qualified professional behavior analysts.

12. ABA: Medically necessary treatment for ASD • As a neurological disorder, ASD is clearly a medical condition. It is diagnosed by a physician or a licensed psychologist. • The CDC (Centers for Disease Control and Prevention) identifies autism as a: "national public health crisis."

13. ABA: Medically necessary treatment for ASD • A number of other government and national health organizations recognize ASD as a medical condition, including: • -The U.S. Surgeon General • -National Institutes of Health • -National Institute of Child Health and Human Development • -American Academy of Pediatrics ALL of these organizations recognize and recommend ABA as the only proven method for treating ASD.

14. ABA: Medically necessary treatment for ASD • On March 27, 2012, Florida Federal Judge Joan Lenard held that applied behavior analysis is medically necessary and not “experimental” as defined under Florida statutory and administrative law and federal law.

15. ABA: Medically necessary treatment for ASD • “Plaintiffs have established through their expert witnesses that there exists in the scientific and medical peer-reviewed literature a plethora of meta-analyses, studies and articles that clearly establish ABA as an effective and significant treatment to prevent disability and to restore children to their best possible functional level and restore their developmental skills.” Florida Federal Judge, Joan Lenard

16. ABA: Medically necessary treatment for ASD • The treatment for all other neurological disorders (such as traumatic brain injury, seizure disorders, ALS, Parkinson's Disease) is considered medically necessary. As a neurological disorder, ASD is no different.

17. ABA: Medically necessary treatment for ASD • Medically necessary treatments ameliorate or manage symptoms, improve functioning, and/or prevent deterioration. • ASDs are neurodevelopmental conditions that manifest in behavioral symptoms, i.e., behavioral abnormalities in three core domains: social interaction, communication, and interests and activities. • ABA treatment has proved effective for ameliorating those core symptoms as well as building other skills that enhance functioning and health in people with ASD, such as • Hygiene and self-care skills • Personal safety skills • Eating a healthy diet • Sleeping • Cooperating with medical and dental procedures

18. ABA: Medically necessary treatment for ASD • ABA interventions have also proved effective for decreasing behaviors that directly jeopardize the health and welfare of people with ASD, such as • Self-injurious behaviors • Property destruction • Pica (ingesting inedible items) • Aggression • Elopement • Obsessive behaviors • Hyperactivity • Fearful behaviors

19. Summary • Contemporary ABA intervention for ASD rests on more than 40+ years of scientific research. • At present, no other approach to ASD intervention has comparable scientific support • Best available scientific evidence indicates that competently directed anddelivered early intensive ABA intervention is especially effective for ameliorating and preventing symptoms of ASD.

20. Summary • ABA intervention is now deemed medically necessary for people with ASD by many public and private health plans around the U.S. • Health insurance coverage of ABA intervention for ASD provided by professionals credentialed by the Behavior Analyst Certification Board can save millions in health care and other costs over time.

21. For more information on ABA for ASD, please see… • www.autismspeaks.org/whattodo/what_is_aba.php (Autism Speaks) • www.behavior.org/autism (Cambridge Center for Behavioral Studies) • www.apbahome.net (Association of Professional Behavior Analysts) • www.asatonline.org (Association for Science in Autism Treatment)

22. For qualifications to practice ABA, please see… • Behavior Analyst Certification Board -- www.BACB.com • Association of Professional Behavior Analysts -- www.APBAhome.net • Association for Behavior Analysis Autism Special Interest Group Consumer Guidelines - http://www.autismsig.org

23. Acknowledgement We would like to express our sincere thanks to Gina Green, PhD, BCBA-D, Executive Director of the Association of Professional Behavior Analysts, for permission to redistribute her materials.

24. References Association for Science in Autism Treatment - reviews of evidence on autism treatments http://www.asatonline.org/resources/autismtreatments.htm Campbell, J.M. (2003). Efficacy of behavioral interventions for reducing problem behavior in persons with autism: A quantitative synthesis of single-subject research. Research in Developmental Disabilities, 24, 120-138. Cuvo, A. J., Reagan, A. L., Ackerlund, J., Huckfeldt, R., & Kelly, C. (2010). Training children with autism spectrum disorders to be compliant with a physical exam. Research in Autism Spectrum Disorders, 4, 168-185. Dawson, G.(2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorders. Development and Psychopathology, 20, 775-803. Eldevik, S., Hastings, R.P., Hughes, J.C., Jahr, E., Eikeseth, S., & Cross, S. (2009). Meta-analysis of early intensive behavioral intervention for children with autism. Journal of Clinical Child and Adolescent Psychology. Ganz, M.L. (2007). The lifetime distribution of the incremental societal costs of autism. Archives of Pediatric and Adolescent Medicine, 161, 343-349. Gillis, J.M., Natof, T.H., Lockshin, S. B., & Romanczyk, R.G. (2009). Fear of routine physical exams in children with autism spectrum disorders: Prevalence and intervention effectiveness. Focus on Autism and Other Developmental Disabilities, 24, 156-168.

25. References Green, G. (2008).  Single-case research methods for evaluating treatments for ASD. In S. C. Luce, D. S. Mandell, C. Mazefsky, & W. Seibert (Eds.), Autism in Pennsylvania: A Symposium Issue of the Speaker’s Journal of Pennsylvania Policy (pp. 119-132). Harrisburg, PA: Legislative Office for Research Liaison, Pennsylvania House of Representatives. Green, G. (in press). Early intensive behavior analytic intervention for autism spectrum disorders. In E. Mayville & J.Mulick (Eds.), Behavioral foundations of effective autism treatment. Sloan Publishing Hall, L.J. (1997). Effective behavioural strategies for the defining characteristics of autism. Behaviour Change, 14, 139-154. Jacobson, J.W., Mulick, J.A., & Green, G. (1998). Cost-benefit estimates for early intensive behavioral intervention for young children with autism: General model and single state case. Behavioral Interventions, 13, 201-226. Kodak, T., & Piazza, C. (in press). Assessment and treatment of feeding and sleeping disorders in children diagnosed with developmental disabilities. Child and Adolescent Psychiatry Clinic of North America. LeBlanc, L. A., Carr, J. E., Crossett, S. E., Bennett, C. M., & Detweiler, D. D. (2005). Intensive outpatient behavioral treatment of primary urinary incontinence of children with autism. Focus on Autism and Other Developmental Disabilities, 20, 98-105.

26. References Lilienfeld, S.O. (2005). Scientifically unsupported and supported interventions for childhood psychopathology: A summary. Pediatrics, 115, 761-764. Mandell, D.S. (2007). Psychiatric hospitalization among children with autism spectrum disorders. Journal of Autism and Developmental Disorders, available at www.springerlink.com Motiwala, S.S., Gupta, S., & Lilly, M.D. (2006). The cost-effectiveness of expanding intensive behavioural intervention to all autistic children in Ontario. Healthcare Policy, 1, 135-151. Myers, S.M., Johnson, C.P, & The Council on Children with Disabilities (2007). Management of children with autism spectrum disorders. Pediatrics, 120 (5), 1162-1182. National Autism Center (2009). National Standards Project Findings and Conclusions. Randolph, MA: Author. New York State Department of Health Early Intervention Program (1999). Clinical Practice Guideline: Autism/Pervasive Developmental Disorders-- Assessment and Intervention for Young Children (Age 0-3 Years). Health Education Services, P.O. Box 7126, Albany, NY 12224 (1999 Publication No. 4216).

27. References Perrin, C. J., Perrin, S. H., Hill, E. A., & DiNovi, K. (2008). Brief functional analysis and treatment of elopement in preschoolers with autism. Behavioral Interventions, 23, 87–95. Piazza, C. C., Hanley, G. P., Bowman, L. G., Ruyter, J. M., Lindauer, S. E., & Saiontz, D. M. (1997). Functional analysis and treatment of elopement. Journal of Applied Behavior Analysis, 30, 653–672. Piazza, C. C., Fisher, W. W., Hanley, G. P., LeBlanc, L. A., Worsdell, A. S., Lindauer, S. E., et al. (1998). Treatment of pica through multiple analyses of its reinforcing functions. Journal of Applied Behavior Analysis, 31, 165-189. Reichow, B. & Wolery, M. (2009). Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA Young Autism Project model. Journal of Autism and Developmental Disorders, 39, 23-41. Rogers, S. J. & Vismara, L. A. (2008) Evidence-based comprehensive treatments for early autism. Journal of Clinical Child & Adolescent Psychology, 37, 8 – 38. Simera, N., & Cuvo, A. J. (2009). Training vision screening behavior to children with developmental disabilities. Research in Autism Spectrum Disorders, 3, 409-420.

28. References Smith, T. (1999). Outcome of early intervention for children with autism. Clinical Psychology: Science and Practice, 6, 33-49. U.S. Department of Defense. (2007, July). Report and plan on services to military dependent children with autism. Washington, DC: Author. U.S. Surgeon General ‘s Report on Mental Health – Autism Section: www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html#autism Weiskop, S., Richdale, A., & Matthews, J. (2005). Behavioural treatment to reduce sleep problems in children with autism or fragile X syndrome. Developmental Medicine & Child Neurology, 47, 94-104. Wolery, M., Barton, E.E., & Hine, J.F. (2005). Evolution of applied behavior analysis in the treatment of individuals with autism. Exceptionality, 13, 11-23. Zachor, D.A., Ben-Itzchak, E., Rabinovich, A., & Lahat, E. (2007). Change in autism core symptoms with intervention. Research in Autism Spectrum Disorders, 1, 304-317.