Category Archives: resources

Resources For Parents of a Child in Occupational Therapy

Your child’s occupational therapist will be the biggest advocate on your child’s team. Use them as a resource! However, I wanted to offer resources here as well. These are great places to start when it comes to discovering tools, strategies, and specific activities that can help your child. I’ve had many parents of kids receiving therapy tell me that they’ve passed information and resources from this site onto their therapists. I’ve also had many therapists tell me that they’ve found this site because of a parent’s recommendation or request to work on specific areas of need. This is your starting space to find the resources and tools that will best serve your child.

Executive Function Resources for Parents

Below you’ll find resources for activities, strategies to address attention, impulse control, planning, prioritization, organization, problem solving and other brain-related challenges that impact learning and accomplishing chores or daily tasks at home.

Fine Motor Resources for Parents

Below you’ll find specific activities designed to help kids develop stronger hands so they can manipulate toys and clothing fasteners…or have enough endurance to color a picture without complaining their hands are tired…or have strong fingers that can hold the pencil so they can write neatly and so you can read their handwriting.

Occupations Of Kids…Resources for Parents to Help Kids Become More Independent

Below you’ll find resources to help your child build independence in their daily tasks like getting themselves dressed, tying their shoes, learning to type, potty training, staying safe in the community, and all of the exact ways that parents want their children to grow and learn.

Handwriting

Below you’ll find resources and specific strategies to help kids write on the lines, space between words, form letters accurately, learn cursive writing, so they can write independency and so you and others can read their writing.

Sensory

Below are resources to help your child manage their behaviors, emotions, and all things “sensory”. OTs help kids tolerate and accommodate for sensory input like that scratchy tag on their clothes or their hatred for the sock seam on their feet. They can help kids with the tools they need for picky eating, specific sounds, or other sensory issues. Therapists can help you create a sensory diet that works and that kids actually want to do. There is so much to sensory and you can find activities and tools to help.

Vision

Below is information on what’s going on behind trouble with reading, coordination troubles, or even math. Did you know that vision is related to all these things? It’s true! Here, you’ll find your way on how to help your child with visual perceptual skills, visual motor skills, eye-hand coordination, and even motor planning! Wondering what these words even mean and how they relate to your kiddo? We’ve got you covered!

Information provided by The OT Toolbox.

Occupational Therapy Tips for Homework Success

Homework. The term often instills dread among students. Back-to-school time is a good opportunity to review work and study habits that promote academic success. Occupational therapy practitioners are a valuable resource in schools to support students, teachers, and parents as classroom routines and demands are established. The goal is for students to be as independent as possible throughout the school day, which includes successful completion of homework. Consider these tips to help your child establish good habits and reduce the stress of homework.

Set up a workstation at home that is designated for homework. The station should be clear of clutter and extraneous noises such as TV, video games, and radio. This structured area limits distractions and provides a well-organized environment for work.
Encourage your child to sit in a firm chair with his or her feet planted on the ground or on a footrest. Consider using an office chair to adjust the chair height. The child’s back should be supported against the backrest. Good posture prevents back and neck stress and promotes ease in completing assignments. Stretching exercises can also support a healthy back. Encourage your child to take a stretch break from sitting every 20 minutes.
Promote active play and physical activities that are alternated with more sedentary activities such homework and computer tasks. Carefully placed homework breaks reduce fatigue and support students’ attention and concentration.
Create a system to monitor homework assignments and their completion. Your child should be encouraged to manage his or her schedule by using a planner to organize activities.
Monitor your child’s level of frustration and amount of time necessary to complete assignments. Seek advice when appropriate from school personnel, including occupational therapy practitioners, about your child’s performance in school. Work as a team to support his or her academic and emotional needs.
Develop a homework plan that best meets the needs of your child. Consider sensory needs or distractions, like hunger fatigue or noise, as well as habits and preferences to determine the best times to complete homework assignments. Some children work best before dinner time, and others need a rest break after school before completing homework assignments.
Work in an area with proper lighting that avoids glare and reflections. Limit eye strain by following the “20/20/20” rule: take a break every 20 minutes, stop for 20 seconds, and look at least 20 feet away from the homework or computer monitor.
When using a computer, encourage the child to work comfortably and shift position often. If your child uses a notebook computer, set it up with a separate keyboard and mouse and adjust the notebook to be used only as a monitor.

Information provided by the American Occupational Therapy Association.

Medicaid and OT

Occupational, Physical, and Respiratory Therapy and Speech Pathology Services

The Indiana Health Coverage Program (IHCP) requires Prior Authorization (PA) for all occupational therapy, physical therapy, respiratory therapy, and speech pathology services, with the following exceptions:

Initial evaluations
Emergency respiratory therapy
Any combination of therapy services ordered in writing before a member’s release or discharge from an inpatient hospital, continuing for a period not to exceed 30 units in 30 calendar days
Deductible and copay or coinsurance for services covered by Medicare Part B
Oxygen equipment and supplies necessary for the delivery of oxygen, with the exception of concentrators
Therapy services provided by a nursing facility or large private or small intermediate care facility for individuals with intellectual disabilities (ICF/IID), which are included in the facility’s per diem rate
Respiratory therapy services ordered in writing for the acute medical diagnosis of asthma, pneumonia, bronchitis, or upper respiratory infection (not to exceed 14 hours or 14 calendar days without PA)

The following PA criteria apply to occupational therapy, physical therapy, respiratory therapy, and speech pathology services:

The IHCP requires written evidence of physician involvement and personal patient evaluation to document acute medical needs.
The therapy must be ordered by a qualifying provider, as indicated in the subsections of this module for each type of therapy.
Providers must attach a current plan of treatment and progress notes indicating the necessity and effectiveness of therapy to the PA request and make this documentation available for audit.
The therapy must be provided by a qualified therapist, or a qualified assistant under the direct supervision of the therapist, as appropriate.
The level of complexity and sophistication of the therapy and the condition of the member must be such that the judgment, knowledge, and skills of a qualified therapist are required.
The therapy must be medically necessary.
The IHCP does not cover therapy rendered for diversional, recreational, vocational, or avocational purposes; for the remediation of learning disabilities; or for developmental activities that can be conducted by nonmedical personnel.
The IHCP covers rehabilitative therapy services for members under 21 years of age when determined medically necessary. For members 21 years of age and older, the IHCP covers rehabilitative therapy services for no longer than 2 years from the initiation of the therapy, unless a significant change in medical condition requires longer therapy. Providers can prior authorize respiratory therapy services for a longer period on a case-by-case basis.
The IHCP covers habilitative therapy services for members under 21 years of age on a case-by-case basis, subject to prior authorization. (Educational services, including, but not limited to, the remediation of learning disabilities, are not considered habilitative therapy and are not covered.) Habilitative therapy is not a covered service for members 21 years of age and older.

When a member is enrolled in therapy, ongoing evaluations to assess progress and redefine therapy goals are part of the therapy program. The IHCP does not separately reimburse for ongoing evaluations.
One hour of billed therapy must include a minimum of 45 minutes of direct member care, with the balance of the hour spent in related patient services.
The IHCP does not reimburse therapy services for more than 1 hour per day per type of therapy; additional therapy services require prior authorization and must be medically necessary.
The IHCP does not authorize requests for therapy that would duplicate other services provided to a member.

Occupational Therapy Services

For IHCP reimbursement, occupational therapy services must be ordered by one of the following providers:

Physician (doctor of medicine or doctor of osteopathy)
Podiatrist
Advanced practice registered nurse
Optometrist
Physician assistant
Chiropractor
Psychologist

Occupational therapy services must be performed by a licensed occupational therapist or a licensed occupational therapy assistant under the supervision of a licensed occupational therapist. For IHCP reimbursement to be made, a licensed occupational therapist must perform an evaluation.

The IHCP limits evaluations and reevaluations to 3 hours of service per evaluation.

The IHCP does not cover the following occupational therapy services:

General strengthening exercise programs for recuperative purposes
Passive range-of-motion services (as the only or primary mode of therapy)
Occupational therapy psychiatric services

The IHCP does not reimburse separately for occupational therapy services provided by a nursing facility or a large private or small ICF/IID. These services are included in the facility’s established per diem rate and do not require PA.

Who Needs Occupational Therapy?

The above lists might help explain the question of who OTs service, but it can be helpful to have a list of those who benefit from occupational therapy. This diagnosis list should give you a starting point but know that OT works with anyone struggling to achieve functional skills or independence in an aspect of any task! This page is referring to pediatric occupational therapy interventions.

Autism Spectrum Disorder
Sensory processing disorders
Auditory processing disorders
Visual processing impairments
PANDAs
Birth injuries or birth defects
ADHD/ADD
Behavioral or mental health impairments
Visually impaired
Traumatic injuries to the brain or spinal cord
Traumatic injuries to the body- amputation’s, etc.
Learning disabilities or learning problems
Developmental delays
Brachial plexus injuries
Down Syndrome
Rett’s Syndrome
Spina Bifida
Cerebral palsy
Childhood stroke
Pediatric rheumatoid arthritis
Cognitive disorders
Broken bones, injuries, surgical impairments, or other orthopedic injuries
Post-surgical impairments or conditions
Motor or coordination impairments

What Is Occupational Therapy?

Occupational Therapy (OT) is a service that helps people of all ages and abilities achieve function and independence in the things that are important to them…in the things that occupy one’s day. Occupational Therapists do this by offering adaptations, modifications, and by addressing underlying factors that impact independence.

Let’s take it a step further; Think about what you do in a single day: getting out of bed, brushing your teeth, getting dressed, making the bed, making and eating breakfast, getting out the door on time and with everything you need for the day, doing your job at work and everything that entails, driving, shopping for groceries, setting the table, balancing your checkbook. This list could go on and on and on!

All these skills are your daily occupations, or things that occupational therapists can help one accomplish so they are as independent and functional as possible. But there’s more to it than just the daily tasks. There’s also the ability to physically accomplish these jobs. There’s the ability to staying focused on the task at hand, prioritize what’s important, and to stay organized. There’s safety and higher-level thinking involved. There’s tolerance to one’s senses and the world around you. There’s balance, vision, coordination, and endurance involved. Essentially, every system in your body needs to be working optimally so that you can be as functional as possible during each task that you accomplish during the day.

**What do Occupational Therapists work on with kids?**

Occupational therapists can work on many different things in a variety of settings:

In schools:

Any need that impacts education or learning
Fine motor skills
Cutting with scissors
Handwriting
Assistive technology to improve education or learning
Managing containers in the lunchroom
Keyboarding or typing as an accommodation to learning
Sensory needs that impact education
Staying organized
Cognitive processing
Attention
Visual processing
Executive functioning
Motor abilities
Self-regulation
Participation in the classroom

In clinics:

Play
Self-care skills- getting dressed, grooming, bathing, caring for oneself and the tasks associated with self-care
Leisure activities
Sleep
Toileting and potty training
Safety in the community
Feeding and oral motor skills
Sensory processing
Self-regulation
Emotional regulation
Social participation
Executive functioning skills- organization, attention, working memory, planning, prioritization, impulse control, and other skills
Fine and gross motor skills
Eye-hand coordination
Balance and gross motor coordination

Occupational therapy can also work with children in early intervention (birth though 3 years of age) on development of skills. This can occur because of a disability or difficulty in developing certain skills. Still other aspects of care can be related to autism, sensory integration needs, mental health, and specific diagnoses.

Scope of Occupational Therapy practice may include Behavioral Health services

The Indiana Health Coverage Programs (IHCP) clarified that the scope of occupational therapy practice includes the provision of psychosocial interventions. It was further stated that occupational therapy can be included in the treatment plan of members receiving behavioral health treatment services. “The IHCP supports including occupational therapists on a substance use disorder (SUD) or behavioral health treatment team, when the occupational therapists provide services within their scope of licensure.”

Many state occupational therapy associations have advocated for recognition of occupational therapy practitioners in the mental health space. Some states recognize occupational therapists as qualified mental health practitioners (this terminology may vary from state to state), which allows for state-level reimbursement for those services, as well as the ability to supervise, complete evaluations, and provide interventions for individuals living with chronic mental illness. This recognition may not be an appropriate goal in every state – several states do not define mental health professionals at all or they may define it in such a way that OT practitioners would not want to be included in that definition. Several states have added language to their practice acts, consistent with the recently updated definition of occupational therapy, regarding occupational therapy’s role in mental health; advocated for reimbursement under Medicaid for OT mental health services; and discussed opportunities for OT and the role OT plays in mental health with other mental health provider associations in the state.

Information provided by The American Occupational Therapy Association

How Does Your Child Hear and Talk?

Your child starts communicating with you long before he says his first word. Learn more about what your child should do in his first 5 years and how you can help.

Speech, language, or hearing problems can lead to trouble making friends and doing well in school. Give your child success—get help early.

Find your child’s age below and learn about her speech, language, and hearing development.

Children develop at their own rate. Your child might not have all skills until the end of the age range. These charts tell you when most children who speak only one language will reach each milestone. Your child should master the skills listed by the time he reaches the top of the age range. Missing one skill in the age range does not mean he has a problem. You may want to seek help if you answer “no” to most of the skills.

Birth to One Year

What should my child be able to do?

0 TO 3 MONTHS

HEARING + UNDERSTANDING

Startles at loud sounds
Quiets or smiles when you talk
Seems to recognize your voice. Quiets if crying.

TALKING

Makes cooing sounds
Cries change for different needs
Smiles at people

4 TO 6 MONTHS

HEARING + UNDERSTANDING

Moves eyes in the direction of sounds
Responds to changes in your tone of voice
Notices toys that make sounds
Pays attention to music

TALKING

Coos and babbles when playing alone or with you
Makes speech-like babbling sounds, like pa, ba and mi.
Giggles and laughs
Makes sounds when happy or upset

7 MONTHS TO 1 YEAR

HEARING + UNDERSTANDING

Turns and looks in the direction of sounds
Looks when you point
Turns when you call his/her name
Understands words for common items and people. Words like cup, truck, juice or daddy.
Starts to respond to simple words and phrases like “No”, “Come here” and “Want more?”
Plays games with you like peek-a-boo and pat-a-cake
Listens to songs and stories for a short time

TALKING

Babbles long strings of sounds, like mimi upup babababa.
Uses sounds and gestures to get and keep attention.
Points to objects and shows them to others.
Uses gestures like waving bye, reaching for “up,” and shaking his head no.
Imitates different speech sounds.

What can I do to help?

Check if your child can hear. See if she turns to noises or looks at you when you talk. Pay attention to ear problems and infections and see your doctor.
Respond to your child. Look at him when he makes noises. Talk to him. Imitate the sounds he makes.
Laugh when she does. Imitate the faces she makes.
Teach your baby to imitate actions, like peek-a-boo, clapping, blowing kisses, and waving bye-bye. This teaches him how to take turns. We take turns when we talk.
Talk about what you do during the day. Say things like “Mommy is washing your hair”; “You are eating peas”; and “Oh, these peas are good!”
Talk about where you go, what you do there, and who and what you see. Say things like, “We are going to Grandma’s house. Grandma has a dog. You can pet the dog.”
Teach animal sounds, like “A cow says ‘moo.’”
Read to your child every day.
Talk to your child in the language you are most comfortable using.

One to Two Years

What should my child be able to do?

HEARING + UNDERSTANDING

Points to a few body parts when you ask.
Follows 1-part directions, like “Roll the ball” or “Kiss the baby.”
Responds to simple questions, like “Who’s that?” or “Where’s your shoe?”
Listens to simple stories, songs, and rhymes.

TALKING

Uses a lot of new words.
Uses p, b, m, h, and win words.
Starts to name pictures in books.
Asks questions, like “What’s that?”, “Who’s that?”, and “Where’s kitty?”

What can I do to help?

Talk to your child as you do things and go places. For example, when taking a walk, point to and name what you see. Say things like, “I see a dog. The dog says ‘woof.’ This is a big dog. This dog is brown.”
Use short words and sentences that your child can imitate. Use correct grammar.
Talk about sounds around your house. Listen to the clock tick, and say “t-t-t.” Make car or plane sounds, like “v-v-v-v.”
Play with sounds at bath time. You are eye-level with your child. Blow bubbles, and make the sound “b-b-b-b.” Pop bubbles, and make a “p-p-p-p” sound. Engines on toys can make the “rrr-rrr-rrr” sound.
Add to words your child says. For example, if she says “car,” you can say, “You’re right! That is a big red car.”
Read to your child every day. Try to find books with large pictures and a few words on each page. Talk about the pictures on each page.
Have your child point to pictures that you name.
Ask your child to name pictures. He may not answer at first. Just name the pictures for him. One day, he will surprise you by telling you the name.
Talk to your child in the language you are most comfortable using.

Two to Three Years

What should my child be able to do?

HEARING + UNDERSTANDING

Understands opposites, like go–stop, big–little, and up–down.
Follows 2-part directions, like “Get the spoon and put it on the table.”
Understands new words quickly.

TALKING

Has a word for almost everything.
Talks about things that are not in the room.
Uses k,g, f, t, d, and n in words.
Uses words like in, on, and under.
Uses two- or three- words to talk about and ask for things.
People who know your child can understand him.
Asks “Why?”
Puts 3 words together to talk about things. May repeat some words and sounds.

What can I do to help?

Use short words and sentences. Speak clearly.
Repeat what your child says, and add to it. If she says, “Pretty flower,” you can say, “Yes, that is a pretty flower. The flower is bright red. It smells good too. Do you want to smell the flower?”
Let your child know that what he says is important to you. Ask him to repeat things that you do not understand. For example, say, “I know you want a block. Tell me which block you want.”
Teach your child new words. Reading is a great way to do this. Read books with short sentences on each page.
Talk about colors and shapes.
Practice counting. Count toes and fingers. Count steps.
Name objects, and talk about the picture on each page of a book. Use words that are similar, like mommy, woman, lady, grown-up, adult. Use new words in sentences to help your child learn the meaning.
Put objects into a bucket. Let your child remove them one at a time, and say its name. Repeat what she says, and add to it. Help her group the objects into categories, like clothes, food, animals.
Cut out pictures from magazines, and make a scrapbook. Help your child glue the pictures into the scrapbook. Name the pictures, and talk about how you use them.
Look at family photos, and name the people. Talk about what they are doing in the picture.
Write simple phrases under the pictures. For example, “I can swim,” or “Happy birthday to Daddy.” Your child will start to understand that the letters mean something.
Ask your child to make a choice instead of giving a “yes” or “no” answer. For example, rather than asking, “Do you want milk?” ask, “Would you like milk or water?” Be sure to wait for the answer, and praise him for answering. You can say, “Thank you for telling mommy what you want. Mommy will get you a glass of milk.”
Sing songs, play finger games, and tell nursery rhymes. These songs and games teach your child about the rhythm and sounds of language.
Talk to your child in the language you are most comfortable using.

Three to Four Years

What should my child be able to do?

HEARING + UNDERSTANDING

Responds when you call from another room.
Understands words for some colors like red, blue and green.
Understands words for some shapes, like circle and square.
Understands words for family, like brother, grandmother and aunt.

TALKING

Answers simple who, what, and where questions.
Says rhyming words, like hat–cat.
Uses pronouns, like I, you, me, we, and they.
Uses some plural words, like toys, birds, and buses.
Most people understand what your child says.
Asks when and how questions.
Puts 4 words together. May make some mistakes, like “I goed to school.”
Talks about what happened during the day. Uses about 4 sentences at a time.

What can I do to help?

Cut out pictures from old magazines. Make silly pictures by gluing parts of different pictures together. For example, cut out a dog and a car. Glue the dog into the car as the driver. Help your child explain what is silly about the picture.
Sort pictures and objects into categories, like food, animals, or shapes. Ask your child to find the picture or object that does not belong. For example, a baby does not belong with the animals.
Read, sing, and talk about what you do and where you go. Use rhyming words. This will help your child learn new words and sentences.
Read books with a simple story. Talk about the story with your child. Help her retell the story, or act it out with props and dress-up clothes. Tell her your favorite part of the story. Ask for her favorite part.
Look at family pictures. Have your child tell a story about the picture.
Help your child understand by asking him questions. Have him try to fool you with his own questions. Make this a game by pretending that some of his questions fool you.
Act out daily activities, like cooking food or going to the doctor. Use dress-up and role-playing to help your child understand how others talk and act. This will help your child learn social skills and how to tell stories.
Talk to your child in the language you are most comfortable using.

Four to Five Years

What should my child be able to do?

HEARING + UNDERSTANDING

Understands words for order, like first, next, and last.
Understands words for time, like yesterday, today, and tomorrow.
Follows longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book.”
Follows classroom directions, like “Draw a circle on your paper around something you eat.”
Hears and understands most of what she hears at home and in school.

TALKING

Says all speech sounds in words. May make mistakes on sounds that are harder to say, like l, s, r, v, z, ch, sh, and th.
Responds to “What did you say?”
Talks without repeating sounds or words most of the time.
Names letters and numbers.
Uses sentences that have more than 1 action word, like jump, play, and get. May make some mistakes, like “Zach gots 2 video games, but I got one.”
Tells a short story.
Keeps a conversation going.
Talks in different ways, depending on the listener and place. Your child may use short sentences with younger children. He may talk louder outside than inside.

What can I do to help?

Talk about where things are in space, using words like first and last or right and left. Talk about opposites, like up and down or big and little.
Give your child clues, and have him guess the object.
Talk about categories, like fruits, furniture, and shapes. Sort items into categories. Have your child tell you which item does not belong. Talk about why it doesn’t belong.
Let your child tell you how to do something.
Pay attention when your child speaks. Respond, praise, and encourage him when he talks. Get his attention before you speak. Pause after speaking, and let him respond to what you said.
Keep teaching your child new words. Define words, and help your child understand them. For example, say, “This vehicle is on the highway. It is a car. A bus is another kind of vehicle. So are a train and an airplane.”
Teach your child to ask for help when she does not understand what a word means.
Point out objects that are the same or different. Talk about what makes them the same or different. Maybe they are the same color. Maybe they are both animals. Maybe one is big and one is little.
Act out stories. Play house, doctor, and store using dolls, figures, and dress-up clothes. Have the dolls talk to each other.
Read stories that are easy to follow. Help your child guess what will happen next in the story. Act out the stories, or put on puppet shows. Have your child draw a picture of a scene from the story. You can do the same thing with videos and TV shows. Ask who, what, when, where, or why questions about the story.
Play game like “I Spy.” Describe something you see, like, “I spy something round on the wall that you use to tell the time.” Let your child guess what it is. Let your child describe something he sees. This helps him learn to listen and to use words to talk about what he sees.
Give your child 2-step directions, like “Get your coat from the closet and put it on.” Let your child tell you how to do something. Draw a picture that he describes. Write down your child’s story as she tells it. Your child will learn the power of storytelling and writing.
Play board games with your child. This will help him learn to follow rules and talk about the game.
Have your child help you plan daily activities. For example, have her make a shopping list for the grocery store. Or, let her help you plan her birthday party. Ask her opinion, and let her make choices.
Talk to your child in the language you are most comfortable using.

Information provided by the American Speech-Language-Hearing Association.

Why do some children need speech-language therapy?

Kids might need speech-language therapy for many reasons, including:

Hearing impairments
Cognitive (intellectual, thinking) or other developmental delays
Weak oral muscles
Chronic hoarseness
Cleft li or palate
Autism Spectrum Disorder
Motor planning problems
Articulation problems
Fluency disorders
Respiratory problems (breathing disorders)
Feeding and swallowing disorders
Traumatic brain injury

Therapy should begin as soon as possible. Children who start therapy early (before they’re 5 years old) tend to have better results than those who begin later.

This doesn’t mean that older kids won’t do well in therapy. Their progress might be slower, though, because they have learned patterns that need to be changed.

Where do I find a speech-language therapist?

Here at Child’s Play Plus we have experienced, enthusiastic speech therapy providers who will take the time to get to know each of their patients to make therapy as successful as possible. They will learn not only what motivates each patient, but what areas to focus therapy on to make life as independent as possible. As our program grows, our providers grow as well; we actively recruit more qualified providers as we take on more patients.

What do SLPs do?

In speech-language therapy, an SLP works with a child one-on-one, in a small group, or in a classroom to overcome problems.

Therapists use a variety of strategies, including:

Language intervention activities: The SLP will interact with a child by playing and talking, using pictures, books, objects, or ongoing events to stimulate language development. The therapist may model correct vocabulary and grammar, and use repetition exercises to build language skills.
Articulation therapy: Articulation, or sound production, exercises involve having the therapist model correct sounds and syllables in words and sentences for a child, often during play activities. The level of play is age-appropriate and related to the child’s specific needs. The SLP will show the child how to make certain sounds, such as the “r” sound, and may show how to move the tongue to make specific sounds.
Oral-motor/feeding and swallowing therapy: The SLP may use a variety of oral exercises — including facial massage and various tongue, lip, and jaw exercises — to strengthen the muscles of the mouth for eating, drinking, and swallowing. The SLP may also introduce different food textures and temperatures to increase a child’s oral awareness during eating and swallowing.

Who provides speech-language therapy?

Speech-language pathologists (SLPs), often called speech therapists, are educated in the study of human communication, its development, and its disorders. SLPs assess speech, language, cognitive-communication, and oral/feeding/swallowing skills. This lets them identify a problem and the best way to treat it.

SLPs have:

A degree
State certification/licensure in the field
A certificate of clinical competency from the American Speech-Language-Hearing Association (ASHA)

An ASHA-certified SLP has passed a national exam and completed an ASHA-accredited supervised clinical fellowship.

Sometimes, speech assistants help give speech-language services. They usually have a 2-year associate’s or 4-year bachelor’s degree, and are supervised by an SLP.

How can parents help?

Parents are key to the success of a child’s progress in speech or language therapy. Kids who finish the program quickest and with the longest-lasting results are those whose parents were involved.

Ask your therapist what you can do. For instance, you can help your child do the at-home activities that the SLP suggests. This ensures the continued progress and carry-over of new skills.

Overcoming a speech or language disorder can take time and effort. So it’s important that all family members be patient and understanding with the child.

Speech and Language Disorders Explained

What is Speech-Language Therapy?

Speech-language therapy is the treatment for most kids with speech and/or language disorders.

What are speech disorders?

A speech disorder refers to a problem with making sounds. Speech disorders include:

Articulation disorders: These are problems with making sounds in syllables, or saying words incorrectly to the point that listeners can’t understand what’s being said.
Fluency disorders: These include problems such as stuttering, in which the flow of speech is interrupted by unusual stops, partial-word repetitions (“b-b-boy”), or prolonging sounds and syllables (sssssnake).
Resonance or voice disorders: These are problems with the pitch, volume, or quality of the voice that distract listeners from what’s being said. These types of disorders may also cause pain or discomfort for a child when speaking.

What are language disorders?

A language disorder refers to a problem understanding or putting words together to communicate ideas. Language disorders can be either receptive or expressive:

Receptive disorders are problems with understanding or processing language.
Expressive disorders are problems with putting words together, having a limited vocabulary, or being unable to use language in a socially appropriate way.
Cognitive-communication disorders are problems with communication skills that involve memory, attention, perception, organization, regulation, and problem solving.

What are feeding disorders?

Dysphagia or oral feeding disorders are disorders in the way someone eats or drinks. They include problems with chewing and swallowing, coughing, gagging, and refusing foods.

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.

Hearing & Communicative Development Checklist

From the American Speech-Language-Hearing Association

0 to 3 Months

Reacts to loud sounds
Calms down or smiles when spoken to
Recognizes your voice and calms down if crying
When feeding, starts or stops sucking in response to sound
Coos and makes pleasure sounds
Has a special way of crying for different needs
Smiles when he or she sees you

4 to 6 Months

Follows sounds with his or her eyes
Responds to changes in the tone of your voice
Notices toys that make sounds
Pays attention to music
Babbles in a speech-like way and uses many different sounds, including sounds that begin with p, b, and m
Laughs
Babbles when excited or unhappy
Makes gurgling sounds when alone or playing with you

7 to 12 Months

Enjoys playing peek-a-boo and pat-a-cake
Turns and looks in the direction of sounds
Listens when spoken to
Understands words for common items such as “cup,” “shoe,” or “juice”
Responds to requests (“Come here”)
Babbles using long and short groups of sounds (“tata, upup, bibibi”)
Babbles to get and keep attention
Communicates using gestures such as waving or holding up arms
Imitates different speech sounds
Has one or two words (“Hi,” “dog,” “Dada,” or “Mama”) by first birthday

12 to 24 Months

Knows a few parts of the body and can point to them when asked
Follows simple commands (“Roll the ball”) and understands simple questions (“Where’s your shoe?”)
Enjoys simple stories, songs, and rhymes
Points to pictures, when named, in books
Acquires new words on a regular basis
Uses some one- or two-word questions (“Where kitty?” or “Go bye-bye?”)
Puts two words together (“More cookie”)
Uses many different consonant sounds at the beginning of words

2 to 3 Years

Has a word for almost everything
Uses two- or three-word phrases to talk about and ask for things
Uses k, g, f, t, d, and n sounds
Speaks in a way that is understood by family members and friends
Names objects to ask for them or to direct attention to them

3 to 4 Years

Hears you when you call from another room
Hears the television or radio at the same sound level as other family members
Answers simple “Who?” “What?” “Where?” and “Why?” questions
Talks about activities at daycare, preschool, or friends’ homes
Uses sentences with four or more words
Speaks easily without having to repeat syllables or words

4 to 5 Years

Pays attention to a short story and answers simple questions about it
Hears and understands most of what is said at home and in school
Uses sentences that give many details

Huntington County Community Resource Guide

The Huntington County Community Resource Guide offers helpful contact information to financial assistance, food assistance, mental health & addictions, furniture & clothing assistance, employment services, housing & transportation, health care services, transitional housing, support groups, legal services, general education, youth services, recreation & hobbies and hotlines in Huntington County, Indiana.

Allen County Community Resource Guide

The Allen Co. Northeast Community Resource Guide contains helpful contact information for emergency, legal, housing, food & clothing, social services, children’s services, medical, education & employment and township trustee offices throughout Allen County, Indiana.

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:

Speak with your pediatrician or other medical provider about ABA. They can discuss whether ABA is right for your child.
Check whether your insurance company covers the cost of ABA therapy, and what your benefit is. We can help with this!
Ask your child’s doctor for recommendations.
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!

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

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:

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).
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.
A 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:

Why a behavior may be happening
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:

Determine if you are under a “self-insured” plan.
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.
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!).
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.

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.

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

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