Category Archives: resources

Choosing a provider

Who provides ABA services?

A board-certified behavior analyst (BCBA) provides ABA therapy services. To become a BCBA, the following is needed:

  • Earn a master’s degree or PhD in psychology or behavior analysis
  • Pass a national certification exam
  • Seek a state license to practice (in some states)

ABA therapy programs also involve therapists, or registered behavior technicians (RBTs). These therapists are trained and supervised by the BCBA. They work directly with children and adults with autism to practice skills and work toward the individual goals written by the BCBA. You may hear them referred to by a few different names: behavioral therapists, line therapists, behavior tech, etc.

To learn more, see the Behavior Analyst Certification Board website.

What is the evidence that ABA works?

ABA is considered an evidence-based best practice treatment by the US Surgeon General and by the American Psychological Association.

“Evidence based” means that ABA has passed scientific tests of its usefulness, quality, and effectiveness. ABA therapy includes many different techniques.  All of these techniques focus on antecedents (what happens before a behavior occurs) and on consequences (what happens after the behavior).

More than 20 studies have established that intensive and long-term therapy using ABA principles improves outcomes for many but not all children with autism. “Intensive” and “long term” refer to programs that provide 25 to 40 hours a week of therapy for 1 to 3 years. These studies show gains in intellectual functioning, language development, daily living skills and social functioning. Studies with adults, though fewer in number, show similar benefits.

Is ABA covered by insurance?

Sometimes. Many types of private health insurance are required to cover ABA services. This depends on what kind of insurance you have, and what state you live in. Call us, we can help determine your benefits.

All Medicaid plans must cover treatments that are medically necessary for children under the age of 21. If a doctor prescribes ABA and says it is medically necessary for your child, Medicaid must cover the cost, pending medical necessity clinical review.

Where do I find ABA services?

To get started, follow these steps:

  1. Speak with your pediatrician or other medical provider about ABA. They can discuss whether ABA is right for your child.
  2. Check whether your insurance company covers the cost of ABA therapy, and what your benefit is. We can help with this!
  3. Ask your child’s doctor for recommendations.
  4. Call the ABA provider and request an intake evaluation. Have some questions ready (see below!)

What questions should I ask?

It’s important to find an ABA provider and therapists who are a good fit for your family. The first step is for therapists to establish a good relationship with your child. If your child trusts his therapists and enjoys spending time with them, therapy will be more successful – and fun!

The following questions can help you evaluate whether a provider will be a good fit for your family. Remember to trust your instincts, as well!

  1. How many BCBAs do you have on staff?
  2. Are they licensed with the BACB and through the state?
  3. How many behavioral therapists do you have?
  4. How many therapists will be working with my child?
  5. What sort of training do your therapists receive? How often?
  6. How much direct supervision do therapists receive from BCBAs weekly?
  7. How do you manage safety concerns?
  8. What does a typical ABA session look like?
  9. Do you offer home-based or clinic-based therapy?
  10. How do you determine goals for my child? Do you consider input from parents?
  11. How often do you re-evaluate goals?
  12. How is progress evaluated?
  13. How many hours per week can you provide?
  14. Do you have a wait list?
  15. What type of insurance do you accept?

What is Applied Behavior Analysis? 

What is Applied Behavior Analysis?

Applied Behavior Analysis (ABA) is a therapy based on the science of learning and behavior.

Behavior analysis helps us to understand:

  • How behavior works
  • How behavior is affected by the environment
  • How learning takes place

ABA therapy applies our understanding of how behavior works to real situations. The goal is to increase behaviors that are helpful and decrease behaviors that are harmful or affect learning.

ABA therapy programs can help:

  • Increase language and communication skills
  • Improve attention, focus, social skills, memory, and academics
  • Decrease problem behaviors

The methods of behavior analysis have been used and studied for decades. They have helped many kinds of learners gain different skills – from healthier lifestyles to learning a new language. Therapists have used ABA to help children with autism and related developmental disorders since the 1960s.

How does ABA therapy work?

Applied Behavior Analysis involves many techniques for understanding and changing behavior. ABA is a flexible treatment:

  • Can be adapted to meet the needs of each unique person
  • Provided in many different locations – at home, at school, and in the community
  • Teaches skills that are useful in everyday life
  • Can involve one-to-one teaching or group instruction
Positive Reinforcement

Positive reinforcement is one of the main strategies used in ABA.

When a behavior is followed by something that is valued (a reward), a person is more likely to repeat that behavior. Over time, this encourages positive behavior change.

First, the therapist identifies a goal behavior. Each time the person uses the behavior or skill successfully, they get a reward. The reward is meaningful to the individual – examples include praise, a toy or book, watching a video, access to playground or other location, and more.

Positive rewards encourage the person to continue using the skill. Over time this leads to meaningful behavior change.

Antecedent, Behavior, Consequence

Understanding antecedents (what happens before a behavior occurs) and consequences (what happens after the behavior) is another important part of any ABA program.

The following three steps – the “A-B-Cs” – help us teach and understand behavior:

  1. An antecedent: this is what occurs right before the target behavior. It can be verbal, such as a command or request. It can also be physical, such a toy or object, or a light, sound, or something else in the environment. An antecedent may come from the environment, from another person, or be internal (such as a thought or feeling).
  2. A resulting behavior: this is the person’s response or lack of response to the antecedent. It can be an action, a verbal response, or something else.
  3. consequence: this is what comes directly after the behavior. It can include positive reinforcement of the desired behavior, or no reaction for incorrect/inappropriate responses.

Looking at A-B-Cs helps us understand:

  1. Why a behavior may be happening
  2. How different consequences could affect whether the behavior is likely to happen again

EXAMPLE:

  • Antecedent: The teacher says “It’s time to clean up your toys” at the end of the day.
  • Behavior: The student yells “no!”
  • Consequence: The teacher removes the toys and says “Okay, toys are all done.”

How could ABA help the student learn a more appropriate behavior in this situation?

  • Antecedent: The teacher says “time to clean up” at the end of the day.
  • Behavior: The student is reminded to ask, “Can I have 5 more minutes?”
  • Consequence: The teacher says, “Of course you can have 5 more minutes!”

With continued practice, the student will be able to replace the inappropriate behavior with one that is more helpful. This is an easier way for the student to get what she needs!

What Does an ABA Program Involve?

Good ABA programs for autism are not “one size fits all.” ABA should not be viewed as a canned set of drills. Rather, each program is written to meet the needs of the individual learner.

The goal of any ABA program is to help each person work on skills that will help them become more independent and successful in the short term as well as in the future.

Planning and Ongoing Assessment

A qualified and trained behavior analyst (BCBA) designs and directly oversees the program. They customize the ABA program to each learner’s skills, needs, interests, preferences and family situation.

The BCBA will start by doing a detailed assessment of each person’s skills and preferences. They will use this to write specific treatment goals. Family goals and preferences may be included, too.

Treatment goals are written based on the age and ability level of the person with ASD. Goals can include many different skill areas, such as:

  • Communication and language
  • Social skills
  • Self-care (such as showering and toileting)
  • Play and leisure
  • Motor skills
  • Learning and academic skills

The instruction plan breaks down each of these skills into small, concrete steps. The therapist teaches each step one by one, from simple (e.g. imitating single sounds) to more complex (e.g. carrying on a conversation).

The BCBA and therapists measure progress by collecting data in each therapy session. Data helps them to monitor the person’s progress toward goals on an ongoing basis.

The behavior analyst regularly meets with family members and program staff to review information about progress. They can then plan ahead and adjust teaching plans and goals as needed.

ABA Techniques and Philosophy

The instructor uses a variety of ABA procedures. Some are directed by the instructor and others are directed by the person with autism.

Parents, family members and caregivers receive training so they can support learning and skill practice throughout the day.

The person with autism will have many opportunities to learn and practice skills each day. This can happen in both planned and naturally occurring situations. For instance, someone learning to greet others by saying “hello” may get the chance to practice this skill in the classroom with their teacher (planned) and on the playground at recess (naturally occurring).

The learner receives an abundance of positive reinforcement for demonstrating useful skills and socially appropriate behaviors. The emphasis is on positive social interactions and enjoyable learning.

The learner receives no reinforcement for behaviors that pose harm or prevent learning.

ABA is effective for people of all ages. It can be used from early childhood through adulthood!

Your baby at several milestones…..here are the checklists

CDC Development Checklists

How your child plays, learns, speaks, acts, and moves offers important clues about your
child’s development. Developmental milestones are things most children can do by a certain age.

Learn the Signs. Act Early.

A little about ABA

Behavior analysis is the science of behavior, with a history extending back to the early 20th century. Its underlying philosophy is behaviorism, which is based upon the premise that attempting to improve the human condition through behavior change (e.g., education, behavioral health treatment) will be most effective if behavior itself is the primary focus, rather than less tangible concepts such as the mind and willpower. To date, basic behavior-analytic scientists have conducted thousands of studies to identify the laws of behavior; that is, the predictable ways in which behavior is learned and how it changes over time. The underlying theme of much of this work has been that behavior is a product of its circumstances, particularly the events that immediately follow the behavior. Applied behavior analysts have been using this information to develop numerous techniques and treatment approaches for analyzing and changing behavior, and ultimately, to improve lives. Because this approach is largely based on behavior and its consequences, the techniques generally involve teaching individuals more effective ways of behaving and making changes to social consequences of existing behavior.

Applied behavior analysis (ABA) has been empirically shown to be effective in a wide variety of areas, including parent training, substance abuse treatment, dementia management, brain injury rehabilitation, occupational safety intervention, among others. However, because ABA was first applied to the treatment of individuals with intellectual disabilities and autism, this practice area has the largest evidence base and has received the most recognition.

For the purposes of BACB certifications and examinations, the BCBA/BCaBA Task List  and RBT Task List define applied behavior analysis.

Informational resource on identifying ABA Interventions. (APBA, 2017)

How Much ABA is Enough?

Applied Behavior Analysis, or ABA, is well recognized as the “gold standard” for treating Autism Spectrum Disorder (ASD). It works by harnessing the scientific principles of behavior into the everyday tasks and skills that most of us take for granted. ABA is also intense, with treatment being prescribed daily, up to 40 hours per week. This is a significant departure from the typical service model, which typically would involve monthly or weekly visits, often for as little as 30 minutes per week. But why does ABA want clients receiving 25 to 40 hours per week?

Research done starting in the late 1980’s by Ole Ivar Lovaas showed that roughly 50% of kids who received early and intense ABA (40 hours per week) were indistinguishable from their peers after several years. This meant that those kids achieved normal intellectual and educational functioning. This is compared with only 2% of kids in the non-intense ABA group, who were receiving only 10 hours per week.

Throughout the decades, other researchers replicated Lovaas’ original findings, all with similar results. They studied and measured the type and quantity of ABA the clients were receiving. Some of the research went as far as to compare groups of kids who were receiving exclusively ABA therapy, to those who were receiving an eclectic approach of Speech, OT, ABA, and special education. The ABA group significantly outperformed the eclectic group in treatment gains. In 2010 researchers reviewed the literature on early intensive ABA and determined that children receiving 35 hours per week or more had the best treatment gains when compared to those receiving less.

While the intensity or “dosage” of treatment varies by client, it generally is described as either focused or comprehensive treatment. Comprehensive treatment will mirror the research done by Lovaas, will have a large number of hours (25 to 40 hours), and is correlated with better outcomes. Focused treatment on the other hand will target a smaller sample of goals, and will be less hours, typically between 10-24. These distinctions are critical, as a lot of companies claim to “do ABA,” but if the service model is not based on the behavior analytic communities empirical research, it’s probably not ABA.  Whether evaluating a company as a parent for your child, or as a BCBA for prospective employment, make sure you review their service model.
Despite 30 years since the initial publication of Lovaas original research and the broad consensus amongst the scientific community, many parents, professionals, and even young or inexperienced practitioners often have reservations about the dosage recommendations made by Behavior Analysts. There are a few important considerations that I believe play into this.

“Table Time”

Whether a parent or a new practitioner, you should know that ABA should not look like extended hours in front of a table. “Table time” is not an ABA term, but rather a description of a technology that ABA uses, called Discrete Trial Teaching (DTT). DTT breaks down tasks into very small, discrete behaviors, and reinforces those behaviors so that they will occur more in the future. It’s kind of like building muscle memory, so that specific behaviors will happen in the future without having to think about it. It’s no doubt a very important part of ABA therapy, but it is only 1 of many different technologies that ABA uses.
Parents are rightfully skeptical of having their 3-year-old child sitting at a table for 40 hours per week. While DTT does play a major role, a good BCBA will also include Natural Environment Teaching (NET), Functional Communication Training (FCT), and host of other technologies into therapy.

Less Hours is OK.

A common misconception is if the parents and child can’t fit 25-40 hours into their schedule, that prescribing a smaller dosage (10-15 hours per week) is OK, and that the child will just learn fewer skills. Unfortunately, it’s not that simple. Research from Lovaas showed that only 2% of kids achieved normal intellectual and educational functioning when getting 10 hours per week. The “gold standard” language used to describe ABA is explicitly linked to early-intense ABA, not to those receiving the less hours.
Focused ABA is also very important, but it’s usually used with children 8 years old and above, or for those who’ve already received early-intense ABA in the past.  It’s often used as a step-down into lower intensity treatment as clients make progress.  It’s also usually focusing on a smaller sample of goals, like teaching some specific goal or trying to reduce some specific challenging behavior. The takeaway here is if you think you can just use a little bit of hours and you’ll just get there slower, you may have some misconceptions about ABA and what the research has indicated.

Tying it all together.

If you’re a parent just starting your child in a new ABA program, or you’re a new behavior analyst trying to weigh your recommendations against what parent can fit in their schedule, please consider what the research supports. While ABA is the gold standard for ASD treatment, it’s earned that reputation based on scientific rigor and structure. As such, your recommendations and the treatment options available should mirror that scientific rigor. For a young child diagnosed with ASD, best practices recommend receiving 25 to 40 hours per week of intense, Comprehensive ABA. For older children, typically 8 years and above, Focused ABA is probably appropriate, based on your goals and desired outcomes.

Is ABA a part of psychology or a separate discipline?

The answer to this question is that while many people have historically viewed behavior analysis as a branch of psychology, the two disciplines take fundamentally different and antithetical perspectives to account for variability in human behavior. This divergent view can be summed up as follows.

Psychology looks to explain behavioral variability by appealing to internal causes that are typically seen as inside the mind (e.g., mood states, personality traits, hypothesized structures such as ego, and/or drive states)

Behavior analysts seek to identify how changes in the environment that occur as function of a behavior occurring relate to the occurrence or non-occurrence of that behavior in the future. It looks to identify functional relations between these two variables (behavior and its consequences).  Analyses of behavior are conducted using the Operant Learning Paradigm.  This is commonly described as the ABC’s or Antecedent-Behavior-Consequence. The more technically correct version is the Stimulus-Response-Consequence (SRC) paradigm.

In short, the difference can be stated as follows: In the ENVIRONMENT (Behavior Analysis) versus inside the MIND (Psychology).

Psychology as a discipline largely hypothesizes internal explanations (personality traits, mediating forces, and other structures in the brain, etc.) explain differences in human behavior.

To demonstrate the difference here are two examples of how behavior analysts and psychologists account for or explain the same behavior.

  • Why does a person go to the refrigerator?
  • Psychologist: Because they are hungry.  The “hunger drive” causes the person to seek food in the refrigerator.  The cause of behavior is internal and precedes the occurrence of the behavior.  Hunger or being hungry is WHY and this “drive state” explains the behavior of going to the refrigerator.
  • Behavior analyst:  Views going to the refrigerator as a learned behavior.  A person “learns” to go to the refrigerator WHEN they are hungry because other behavior does not result in a reduction in being hungry.  The specific behavior of going to the refrigerator, opening it, taking food and eating it is learned as a function of the effects of going to the refrigerator.  Other behavior that does not result in a reduction in hunger are not learned under the antecedent condition of being hungry.  Reducing “hunger” is the consequence of going to the refrigerator and getting food.  This consequence SELECTS going to the refrigerator and not to the window or bedroom or any other behavior that the person could do at the moment they are “hungry”.   Hunger is a physiological state, and once in this state a person could do anything (and could learn to do anything). However, behaviors that diminish the state of being hungry are much more likely to be learned than behavior that does not.  In short it is the CONSEQUENCE of going to the refrigerator that teaches us to repeat that behavior, not the condition of being hungry.

Some examples of Antecedent Causes Consistent with a Psychology Perspective:  Being in a bad mood, being angry, feeling sad, having personality traits such as being quick to judge, easily frustrated, liking to criticize, being a “non-conformist”,

Antecedent Causes Consistent with a Behavior Analysis Perspective:  Antecedents and antecedent conditions “set the occasion” for behavior to occur, they do not cause behavior to occur.  However what behavior is learned and continues to occur over time is the behavior or behaviors that result in reinforcing consequences for the behavior.  Or that the behavior that is learned occurs because it enables the learner to escape or avoid non-preferred consequences.   It can be said that Antecedents “signal the availability” of reinforcement (or the ability to avoid non-preferred conditions). If you reliably hit the brakes on your car when you see a policeman with a radar gun, you are demonstrating this phenomenon. The radar gun does not “cause” you to slow down, rather the ability to avoid a ticket (consequence) is why you have learned to slow down at the sight of the officer. Failure to learn this lesson may result in an unpleasant consequence. As a result (for most people) hitting the brakes is selected over hitting the gas pedal in this environmental condition.

Interventions flow from philosophy:

Psychology: If you believe that the CAUSE of swearing or aggression is being in a bad mood or being angry, then hypothetically your treatment must remove the cause. In this case, making someone never be in a bad mood or never be angry is simply not possible. Treatment, from this perspective is therefore – NOT POSSIBLE.  Since I cannot make you NOT angry – (and anger causes you to swear or hit) I cannot make you not swear or hit others.

Behavior Analysis: If your perspective is that the consequences of behavior shape what is learned and not learned, then changing the environments response should enable you to change the behavior that is selected.

Applied Behavior Analysis (ABA) for Autism: What is the Effective Age Range for Treatment?

The Lovaas Model of Applied Behavior Analysis has undergone rigorous research at UCLA under the direction of Dr. Lovaas, proving its effectiveness in treating children with autism. There is extensive research in the field of Applied Behavior Analysis (ABA) that shows the effectiveness of focused treatment of behavior disorders with children who suffer from autism who are between the ages of five to twenty-one.

The link below is an article published by Dr. Eric Larsson from the Lovaas Institute for Early Intervention. Please click below to read the complete study.

Applied Behavior Analysis (ABA) for Autism: What is the Effective Age Range for Treatment? (PDF)

Working with Caregivers and other Professionals

Family Members/Others as Important Contributors to Outcomes

Family members, including siblings, and other community caregivers should be included in various capacities and at different points during both Focused and Comprehensive ABA treatment programs. In addition to providing important historical and contextual information, caregivers must receive training and consultation throughout treatment, discharge, and follow-up.

The dynamics of a family and how they are impacted by ASD must be reflected in how treatment is implemented. In addition, the client’s progress may be affected by the extent to which caregivers support treatment goals outside treatment hours. Their ability to do this will be partially determined by how well matched the treatment protocols are to the family’s own values, needs, priorities, and resources.

The need for family involvement, training and support reflects the following:

• Caregivers frequently have unique insight and perspective about the client’s functioning, information about preferences, and behavioral history.

• Caregivers may be responsible for provision of care, supervision, and dealing with challenging behaviors during all waking hours outside of school or a day treatment program. A sizeable percent¬age of individuals with ASD present atypical sleeping patterns. Therefore, some caregivers may be responsible for ensuring the safety of their children and/or implementing procedures at night and may, themselves, be at risk for problems associated with sleep deprivation.

• Caring for an individual with ASD presents many challenges to caregivers and families. Studies have documented the fact that parents of children and adults with ASD experience higher levels of stress than those of parents with typically developing children or even parents of children with other kinds of special needs.

•The behavioral problems commonly encountered with persons diagnosed with ASD (for example, stereotypy, aggression, tantrums) secondary to the social and language deficits associated with ASD, often present particular challenges for caregivers as they attempt to manage their behavior problems. Typical parenting strategies are often insufficient to enable caregivers to improve or manage their child’s behavior, which can impede the child’s progress towards improved levels of functioning and independence.

• Note that while family training is supportive of the overall treatment plan, it is not a replacement for professionally directed and implemented treatment.

Parent and Caregiver Training

Training is part of both Focused and Comprehensive ABA treatment models. Although parent and caregiver training is sometimes delivered as a stand-alone treatment, there are relatively few clients for whom this would be recommended as the sole or primary form of treatment. This is due to the severity and complexity of behavior problems and skill deficits that can accompany a diagnosis of ASD.

Training of parents and other caregivers usually involves a systematic, individualized curriculum on the basics of ABA. It is common for treatment plans to include several objective and measurable goals for parents and other caregivers. Training emphasizes skills development and support so that caregivers become competent in implementing treatment protocols across critical environments. Training usually involves an individualized behavioral assessment, a case formulation, and then customized didactic presentations, modeling and demonstrations of the
skill, and practice with in vivo support for each specific skill. Ongoing activities involve supervision and coaching during implementation, problem solving as issues arise, and support for implementation of strategies in new environments to ensure optimal gains and promote generalization and maintenance of therapeutic changes. Please note that such training is not accomplished by simply having the caregiver or guardian present during treatment implemented by a Behavior Technician.

The following are common areas for which caregivers often seek assistance. These are typically addressed in conjunction with a Focused or Comprehensive ABA treatment program:
• Generalization of skills acquired in treatment settings into home and community settings
• Treatment of co-occurring behavior disorders that risk the health and safety of the child or others in the home or community settings, including reduction of self-injurious or aggressive behaviors against siblings, caregivers, or others; establishment of replacement behaviors which are more effective, adaptive, and appropriate
• Adaptive skills training such as functional communication, participation in routines which help maintain good health (for example, participation in dental and medical exams, feeding, sleep) including target settings where it is critical that they occur
• Contingency management to reduce stereotypic, ritualistic, or perseverative behaviors and functional replacement behaviors as previously described
• Relationships with family members, such as developing appropriate play with siblings

Coordination with Other Professionals

Consultation with other professionals helps ensure client progress through efforts to coordinate care and ensure consistency including during transition periods and discharge.

Treatment goals are most likely to be achieved when there is a shared understanding and coordination among all healthcare providers and professionals. Examples include collaboration between the prescribing physician and the Behavior Analyst to determine the effects of medication on treatment targets. Another example involves a consistent approach across professionals from different disciplines in how behaviors are managed across environments and settings. Professional collaboration that leads to consistency will produce the best outcomes for the client and their families.

Differences in theoretical orientations or professional styles may sometimes make coordination difficult. If there are treatment protocols that dilute the effectiveness of ABA treatment, these differences must be resolved to deliver anticipated benefits to the client.

The BACB’s ethical codes (the current Guidelines for Responsible Conduct for Behavior Analysts and the impending Professional and Ethical Compliance Code for Behavior Analysts) require the Behavior Analyst to recommend the most effective scientifically supported treatment for each client. The Behavior Analyst must also review and evaluate the likely effects of alternative treatments, including those provided by other disciplines as well as no treatment.

In addition, Behavior Analysts refer out to professionals from other disciplines when there are client conditions that are beyond the training and competence of the Behavior Analyst, or where coordination of care with such professionals is appropriate. Examples would include, but are not limited to, a suspected medical condition or psychological concerns related to an anxiety or mood disorder.

BCBA Caseloads and Supervision

Case supervision activities can be described as those that involve contact with the client or caregivers (direct supervision, also known as clinical direction) and those that do not (indirect supervision). Both direct and indirect case supervision activities are critical to producing good treatment outcomes and should be included in service authorizations. It should be noted that direct case supervision occurs concurrently with the delivery of direct treatment to the client. On average, direct supervision time accounts for 50% or more of case supervision.

Some case supervision activities occur in vivo; others can occur remotely (for example, via secure telemedicine or virtual technologies). However, telemedicine should be combined with in vivo supervision. In addition, some case supervision activities are appropriate for small groups. Some indirect case supervision activities are more effectively carried out outside of the treatment setting.

Although the amount of supervision for each case must be responsive to individual client needs, 2 hours for every 10 hours of direct treatment is the general standard of care. When direct treatment is 10 hours per week or less, a minimum of 2 hours per week of case supervision is generally required. Case supervision may need to be temporarily increased to meet the needs of individual clients at specific time periods in treatment (for example, initial assessment, significant change in response to treatment).

This ratio of case supervision hours to direct treatment hours reflects the complexity of the client’s ASD symptoms and the responsive, individualized, data-based decision-making which characterizes ABA treatment. A number of factors increase or decrease case supervision needs on a shorter- or longer-term basis.

These include:
• treatment dosage/intensity
• barriers to progress
• issues of client health and safety (for example, certain skill deficits, dangerous problem behavior)
• the sophistication or complexity of treatment protocols
• family dynamics or community environment
• lack of progress or increased rate of progress
• changes in treatment protocols
• transitions with implications for continuity of care

Caseload Size

Behavior Analysts should carry a caseload that allows them to provide appropriate case supervision to facilitate effective treatment delivery and ensure consumer protection. Caseload size for the Behavior Analyst is typically determined by the following factors:
• complexity and needs of the clients in the caseload
• total treatment hours delivered to the clients in the caseload
• total case supervision and clinical direction required by caseload
• expertise and skills of the Behavior Analyst
• location and modality of supervision and treatment (for example, center vs. home,
individual vs. group, telehealth vs. in vivo)
• availability of support staff for the Behavior Analyst (for example, a BCaBA)

The recommended caseload range for one (1) Behavior Analyst supervising Focused treatment
› without support of a BCaBA is 10 – 15.*
› with support of one (1) BCaBA is 16 – 24.*
Additional BCaBAs permit modest increases in caseloads.

The recommended caseload range for one (1) Behavior Analyst supervising Comprehensive treatment
› without support by a BCaBA is 6 – 12.
› with support by one (1) BCaBA is 12 – 16.
Additional BCaBAs permit modest increases in caseloads.
* Focused treatment for severe problem behavior is complex and requires considerably greater
levels of case supervision, which will necessitate smaller caseloads.

 

Selection, Training, and Supervision of Behavior Technicians

• Behavior Technicians should receive specific, formal training before providing treatment. One
way to ensure such training is through the Registered Behavior Technician credential.

• Case assignment should match the needs of the client with the skill level and experience of the Behavior Technician. Before working with a client, the Behavior Technician must be sufficiently prepared to deliver the treatment protocols. This includes a review by the Behavior Analyst of the client’s history, current treatment programs, behavior reduction protocols, data collection procedures, etc.

• Caseloads for the Behavior Technician are determined by the:
– complexity of the cases
– experience and skills of the Behavior Technician
– number of hours per week the Behavior Technician is employed
– intensity of hours of therapy the client is receiving

• Quality of implementation (treatment integrity checks) should be monitored on an ongoing basis. This should be more frequent for new staff, when a new client is assigned, or when a client has challenging behaviors or complex treatment protocols are involved.

• Behavior Technicians should receive supervision and clinical direction on treatment protocols on a weekly basis for complex cases or monthly for more routine cases. This activity may be in client briefings with other members of the treatment team including the supervising Behavior Analyst, or individually, and with or without the client present. The frequency and format should be dictated by an analysis of the treatment needs of the client to make optimal progress.

• Although hiring qualifications and initial training are important, there must be ongoing observation, training, and direction to maintain

Treatment Delivery Models

Treatment dosage, which is often referenced in the treatment literature as “intensity,” will vary
with each client and should reflect the goals of treatment, specific client needs, and response to
treatment. Treatment dosage should be considered in two distinct categories: intensity and duration.

Intensity

Intensity is typically measured in terms of number of hours per week of direct treatment. Intensity often determines whether the treatment falls into the category of either Focused or Comprehensive.

Focused ABA Treatment

Focused ABA generally ranges from 10-25 hours per week of direct treatment (plus direct and indirect supervision and caregiver training). However, certain programs for severe destructive behavior may require more than 25 hours per week of direct therapy (for example, day treatment or inpatient program for severe self-injurious behavior).

Comprehensive ABA Treatment

Treatment often involves an intensity level of 30-40 hours of 1:1 direct treatment to the client per week, not including caregiver training, supervision, and other needed services. However, very young children may start with a few hours of therapy per day with the goal of increasing the intensity of therapy as their ability to tolerate and participate permits. Treatment hours are subsequently increased or decreased based on the client’s response to treatment and current needs. Hours may be increased to more efficiently reach treatment goals. Decreases in hours of therapy per week typically occur when a client has met a majority of the treatment goals and is moving toward discharge.

Although the recommended number of hours of therapy may seem high, this is based on research findings regarding the intensity required to produce good outcomes. It should also be noted that time spent away from therapy may result in the individual falling further behind typical developmental trajectories. Such delays will likely result in increased costs and greater dependence on more intensive services across their life span.

Duration

Treatment duration is effectively managed by evaluating the client’s response to treatment. This evaluation can be conducted prior to the conclusion of an authorization period. Some individuals will continue to demonstrate medical necessity and require continued treatment across multiple authorization periods.

 

TIERED SERVICE-DELIVERY MODELS AND BEHAVIOR TECHNICIANS

Most ABA treatment programs involve a tiered service-delivery model in which the Behavior Analyst designs and supervises a treatment program delivered by Assistant Behavior Analysts and Behavior Technicians.

Behavior Analyst’s clinical, supervisory, and case management activities are often supported by other staff such as Assistant Behavior Analysts working within the scope of their training, practice, and competence.

Following are two examples of tiered service-delivery models (among others), an organizational approach to treatment delivery considered cost-effective in delivering desired outcomes. In the first example (below), the Behavior Analyst oversees a treatment team of Behavior Technicians.

In the second example (below), the Behavior Analyst is supported by an Assistant Behavior Analyst; the two of them jointly oversee a treatment team of Behavior Technicians.

Such models assume the following:
1. The BCBA or BCBA-D is responsible for all aspects of clinical direction, supervision, and case
management, including activities of the support staff (for example, a BCaBA) and Behavior Technicians.
2. The BCBA or BCBA-D must have knowledge of each member of the treatment team’s ability to
effectively carry out clinical activities before assigning them.
3. The BCBA and BCBA-D must be familiar with the client’s needs and treatment plan and regularly
observe the Behavior Technician implementing the plan, regardless of whether or not there is clinical
support provided by a BCaBA.

 

Tiered service-delivery models that rely on the use of Assistant Behavior Analysts and
Behavior Technicians have been the primary mechanism for achieving many of the significant
improvements in cognitive, language, social, behavioral, and adaptive domains that have
been documented in the peer-reviewed literature.

• The use of carefully trained and well-supervised Assistant Behavior Analysts and Behavior
Technicians is a common practice in ABA treatment.
• Their use produces more cost-effective levels of service for the duration of treatment.
• The use of tiered service-delivery model enables healthcare funders and managers to ensure
adequate provider networks and deliver medically necessary treatment.
• It additionally permits sufficient expertise to be delivered to each client at the level needed
to reach treatment goals. This is critical as the level of supervision required may shift rapidly
in response to client progress or need.
• Tiered service-delivery models can also help with treatment delivery to families in rural and
underserved areas, as well as clients and families who have complex needs.

 

Medicaid and ABA

From the IHCP: “Effective February 6, 2016, applied behavioral analysis (ABA) therapy is covered for the treatment of autism spectrum disorder (ASD) for members 20 years of age and younger. ABA therapy is the design, implementation, and evaluation of environmental modification using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the direct observation, measurement, and functional analysis of the relations between environment and behavior. Coverage applies to dates of service (DOS) on or after February 6, 2016, for all IHCP programs, subject to limitations established for certain benefit packages. ABA therapy is available to members from the time of initial diagnosis through 20 years of age when it is medically necessary for the treatment of ASD.”

There have been several tweaks to the program of ABA in Indiana Medicaid since this information was released a while back. We have recently been successful a getting the Psychologist (HSPP) requirement removed from the program, so that BCBAs can commit to treatment with families in the manner we already do. This change is going into effect in the beginning of 2018.

Traditional v. MCE

Depending on who you chose to manage your medicaid benefits, you may have Traditional or MCE coverage. We breakdown the differences below. It is important to note that not all medicaid benefits and implementation is handled the same.

All providers rendering services to Hoosier Care Connect members must enroll with the Indiana Health Coverage Programs (IHCP) and with one or more of the managed care entities (MCE). To be reimbursed for services rendered to members in Hoosier Care Connect, IHCP-enrolled providers must be contracted with the managed care plan in which the member is enrolled.

The four MCEs are:

Anthem, CareSource, MHS, and MDwise

Hoosier Care Connect operates under a risk-based managed care (RBMC) service delivery system in which the State pays contracted managed care entities (MCEs) a set monthly fee for each member enrolled in the MCE’s plan. This fee, called a capitation premium, covers the cost of care for services covered under the MCE program and incurred by IHCP enrollees in the MCE plan. The MCE assumes financial risk for services rendered to members in its plan. It is important to families to note that each MCE is given flexibility on several aspects of its implementation of its services, including its network.

Each MCE maintains its own provider and member services units. Each MCE pays claims, performs prior authorization (PA), and is responsible for subrogation activities. Several of the MCEs insist they have adequate network coverage and are not accepting new facility providers, while others are actively building their networks for their consumers.

Insurance Mandates – Indiana

In July 2001, House Enrollment Act 1122 went into effect as Indiana Code 27-8-14.2, mandating insurance coverage for individuals with Autism Spectrum Disorders for any accident or health insurance policy that is issued on a group basis (large or small). Also, insurers selling individual policies must offer the option to include coverage for Autism Spectrum Disorders (ASD).

If you have questions on the nature of your coverage, feel free to contact us for a free insurance benefits screening.

Visit https://www.autismspeaks.org/state-initiatives for up to date information on other state initiatives if you are outside of Indiana

Is my Insurance Covered by the Indiana Autism Insurance Mandate?

The Indiana Autism Insurance Mandate covers any health or accident insurance policy that is issued on a group basis (small or large). Insurers selling individual policies must offer the individual the option to include coverage for ASDs, probably at additional premium costs. Odds are, if you receive insurance through an employer that is based in Indiana, your policy is probably covered under the mandate. It is important to check with your Human Resources Department or Benefits Manager to determine if your plan is covered under the mandate.

A large exception to the law is “self-insured” companies. Self-insured companies are usually large companies that have several hundred employees. Instead of contracting with an insurance company to provide health insurance, the employer essentially is the insurer and supplies its own health plan to its employees. This may be confusing, however, as many self-insured companies use an existing insurance company to “administer” its health plan. That is, the insurance company only provides many of the “paperwork” functions of the health plan, such as claims processing or producing and distributing materials for the employees. To find out if your health plan is “self-insured”, ask a Human Resources representative at your employer. If you are under a self-insured plan, your employer is not obligated to provide any insurance coverage for ASDs. They may be willing to do so, though, if several employees express the need, or as a means of working in “good faith” to provide important benefits to valued employees. Self-insured companies may also offer health plan options to employees that fall outside of the self-insured plan. These may be covered under the mandate.

Another exception to the law involves an employer that is not based in Indiana, but has employees in Indiana. For example, you work for X Co.’s Indianapolis office, but X Co.’s headquarters are in Kansas. X Co. has contracted for health insurance for all of its employees nationwide with Insurer Y. This contract was done under a master policy in Kansas – thus Kansas law, not Indiana law, regulates it, and you would not be able to get coverage for ASD if Kansas law does not mandate it. If you work for ZZ Inc., which is a national company, but it has its “corporate home” in Indiana, the health plan contract done under Indiana law would require that ZZ Inc.’s health plan offer coverage for ASDs to all of its employees, whether they worked in Indiana or in another state. Therefore, if you work for ZZ Inc., an Indiana-based national company, but transfer to another state, the coverage for ASDs would still have to follow Indiana’s mandate because the insurance contract is under Indiana state law.

To find out if your plan is covered by the mandate:

  1. Determine if you are under a “self-insured” plan.
  2. Determine if your health plan contract was issued under Indiana state law, if it is, and it is a group plan, you should be covered.
  3. If your health plan was issued in another state, call that state’s Department of Insurance Healthcare Commissioner’s office and ask if that state has an insurance mandate for autism (a handful of other states do!).
  4. If you purchase an individual plan for yourself and your dependents in the state of Indiana, ask for a “rider” for coverage for ASDs (this will most likely raise your premiums).

Self-Funded Plans

Self-funded insurance plans are one of the most widely used forms of insurance coverage offered by employers. Because such plans are covered under federal law, they are exempt from state autism insurance laws. As many opt not to cover ABA, Autism Speaks has created this tool kit to help families find the coverage they need. 

https://www.autismspeaks.org/advocacy/insurance/self-funded-employer-tool-kit

Insurance Terms

Understanding important terminology pertaining to health insurance is the first step to obtaining a cost-effective coverage plan that serves all of your individual or family needs.

Premium: The amount you pay your insurance company for health coverage each month or year.

Deductible: The amount of money you must pay out-of-pocket before coverage kicks in. Deductibles are usually set at rounded amounts (such as $500 or $1,000). Typically, the lower the premium, the higher the deductible.

Coinsurance: The amount of money you owe to a medical provider once the deductible has been paid. Coinsurance is usually a predetermined percentage of the total bill. If the policy’s co-insurance is set at 15% and the bill comes to $100, the policy-holder owes $15 in co-insurance.

Co-pay: This type of insurance plan is similar to co-insurance, but with one key exception: rather than waiting until the deductible has been paid out, you must make their copayment at the time of service. Most often, copayments are standardized by your plan, meaning you’ll pay the same $30 each time you see a physician, or the same $50 each time you see a specialist.

Out-of-pocket maximum: The amount of money you pay for deductibles and coinsurance charges within a given year before the insurance company starts paying for all covered expenses.

In-network: This term refers to physicians and medical establishments that deliver patient services covered under the insurance plan. In-network providers are generally the cheapest option for policyholders. Insurance companies typically have negotiated lower rates with in-network providers.

Out-of-network: This term refers to physicians and medical establishments not covered under your insurance plan. Services from out-of-network providers are usually more expensive than those rendered by in-network providers. This is because out-of-network providers have not negotiated lower rates with your insurer.

Pre-existing condition: Any chronic disease, disability, or other condition you have at the time of application. In some cases, symptoms or ongoing treatments related to pre-existing conditions cause premiums to be higher than usual.

Waiting period: Many employer-sponsored insurance plans mandate a period of 90 days before employees can enroll in their insurance plans.

Enrollment period / open enrollment: The window of time during which you can apply for health insurance or modify a plan to include your spouse and/or children. Policy-holders are unable to adjust their plan until the next open enrollment unless they experience a qualifying life event. These include a marriage, divorce, birth of a child, changes to individual/household income, or interstate residence relocation.

Dual coverage: The act of maintaining a health plan with more than one insurer. For example, many married people receive coverage from both their employers and their spouse’s employer. Others may opt to receive individual coverage from more than one insurer.

Coordination of benefits: This process is applied by individuals who have two or more existing policies to ensure that their beneficiaries do not receive more than the combined maximum payout for the plans.

Continuation of coverage: This is essentially an extension of insurance coverage offered to individuals no longer covered under a particular plan; it most often applies to former employees and retirees of companies that offer employee coverage. COBRA benefits qualify as continuation coverage.

Referral: An official notice from a qualified physician to an insurer that recommends specialist treatment for a current policy-holder.