Applied Behavior Analysis and the treatment of Autism Spectrum DisorderThe Clinical Supervisor Certification Board (BACB) has published a practice guidelines document: Health Plan Coverage of Applied Behavior Analysis Treatment for Autism Spectrum Disorder. These guidelines were created “so that individuals diagnosed with autism spectrum disorder receive applied behavior analysis (ABA) treatment consistent with the best available scientific evidence and expert clinical opinion.”
In addition to the information on this FAQ page, these BACB guidelines are a useful resource. Download the guidelines here.
What is Applied Behavior Analysis (ABA)?
The simplest way to describe ABA in a broad sense is that it is a science of human behavior, using experimentally derived principals of behavior to improve socially significant behaviors. Specifically, behaviors are assessed within the context of their functional relationship with their environment. For example, how does my behavior change my environment — the things and people around me — to such a degree that the same behavior is more or less likely in the future? To that end, there is also an emphasis on positive reinforcement.
Over the past half-century, thousands of research studies have shown the effectiveness of ABA to improve a variety of behaviors, both increasing positive behaviors such as language, social, play and leisure skills, self-help skills, and academics, as well as decreasing severe behaviors such as aggression, self-injury and repetitive behaviors. This is true across a range of ages, from toddlers to senior citizens, and in nearly every conceivable setting, from schools and homes to institutions, hospitals, and in community settings such as restaurants and public transportation. These are just within the area of developmental disabilities.
Behavior Analyst Certification Board practice guidelines describe ABA as follows:
ABA is the design, implementation, and evaluation of environmental modifications to produce socially significant improvement in human behavior. ABA includes the use of direct observation, measurement and functional analysis of the relations between environment and behavior. ABA uses changes in environmental events, including antecedent stimuli and consequences, to produce practical and significant changes in behavior. These relevant environmental events are usually identified through a variety of specialized assessment methods. ABA is based on the fact that an individual’s behavior is determined by past and current environmental events in conjunction with organic variables such as their genetic endowment and ongoing physiological variables. ABA focuses on treating behavioral difficulties by changing the individual’s environment rather than focusing on variables that are, at least presently, beyond our direct access.
The successful remediation of core deficits of autism spectrum disorder, and the development or restoration of abilities, documented in hundreds of peer-reviewed studies published over the past 50 years, has made ABA the standard of care for the treatment of ASD.
For more detailed information about Applied Behavior Analysis, go to the Methodology page.
What is Autism Spectrum Disorder (ASD)?
What is the purpose of ABA therapy and how will it help my child?
How many hours of therapy per week should we schedule?
Particularly for individuals with autism, it is often critical for well-trained instructors to provide an intensive program with frequent, deliberate and precisely delivered learning opportunities.
Individual needs vary, and the amount of intervention may differ based on factors such as current levels of performance and interfering behaviors. However, particularly for young children, the research literature consistently indicates that at least 25-30 hours per week of intensive behavior analytic intervention, or more, may be necessary. Moreover, the prevalent notion that any intensive intervention can achieve meaningful outcomes for children with autism spectrum disorder has not been supported by empirical evidence. Only intensive behavior analytic intervention, competently delivered, has reliably resulted in large improvements in communication, intellectual functioning, and adaptive skills (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005).
A variety of research literature addresses this issue (Anderson, Avery, DiPietro, Edwards, & Christian, 1987; Birnbrauer & Leach, 1993; Fenske, Zalenski, Krantz, & McClannahan, 1985; Lovaas, 1987; McEachin, Smith & Lovaas, 1993; Perry, Cohen & De Carlo, 1995; Smith, 1999). In particular, A comparison of intensive behavior analytic and eclectic treatments for young children with autism (Howard, et al, 2005) is exceptionally informative.
How long are therapy sessions?
Most sessions are scheduled for 2-3 hours, though that can vary. Individual families, organizations and Kadiant employees are free to arrange mutually convenient therapeutic schedules. Several factors should be considered when scheduling therapy sessions.
First, in most cases, scheduling concerns include accommodating an intensive program, to include many hours each week (in some cases, more than 30). Consequently, scheduling longer sessions on a daily basis may be necessary.
Second, for many of the individuals we serve, we identify a variety of skills to target for intervention, including both skills acquisition (e.g., language, social skills, cognitive, academic, daily living) and behavior reduction (e.g., aggression, self-injury, “tantrums”). Several hours may be necessary to efficiently address this range of targets.
Third, as described in Methodology, a state-of-the-art program generally includes instruction in a variety of stimulus and motivational conditions, often including alternating both discrete trial instruction and naturalistic teaching strategies multiple times during each session. Moreover, for many individuals with disabilities, acquiring new skills requires repeated practice in these variable conditions. As a result, meeting these needs often requires several hours.
Some Kadiant services are provided on-site. We generally prefer to serve individuals in their environments: home, school, and community. Accordingly, there are often logistical scheduling concerns, some of which relate to commutes to and from family homes, schools, and/or organizations. For more remote sites, longer sessions may be necessary.
Lastly, an individual’s age, developmental level and/or interfering behavior may all affect the optimum session duration. This should be determined on an individual and ongoing basis.
What does an ABA program look like?
What are the ABA methods used by Kadiant?
How should ABA programs be supervised and/or supported?
A quality ABA program must be directed by professionals with advanced and formal training and experience in behavior analysis. The best predictor of how well an individual’s skills training and behavior reduction needs will be met is the extent to which his or her instructors have access to credentialed ABA professionals, such as Board Certified Clinical Supervisors (BCBA’s), and integrate their assistance into services.
BCBA’s hold at least a master’s degree, have met the requirements of the Behavior Analysis Certification Board, Inc. for specified coursework in behavior analysis and supervised hours of practical experience, and have passed a national credentialing examination, which must be maintained with continuing education, including ethical practices.
The need for this type of ongoing support and supervision is crucial as a mechanism to make necessary adjustments in an appropriate and timely manner. It is critical that an individual’s treatment team understand that all programming is temporary — including strategies for both skills acquisitions objectives and behavior reduction objectives. Treatment package strategies will need to be adjusted regularly. When aspects of treatment are effective, prompts and/or supports may need to be systematically faded to promote generalization to other settings, people, and motivational conditions. In other words, when a plan is working, more independence should be promoted. Conversely, when aspects of treatment are ineffective, a plan may need to be adjusted. In either case, behavioral professionals provide support and monitoring on a regular and ongoing basis to respond to those needs.
The amount of BCBA supervision will vary for each individual, but 1-2 hours of supervision for every 10 hours of direct treatment is the general standard of care in Applied Behavior Analysis. Direct supervision activities (involving contact with client and/or caregiver) generally constitute roughly 50% of supervision activities, while indirect case management activities constitute the remainder. Both direct and indirect supervision activities are crucial to produce successful treatment outcomes.
Supervision activities may include a variety of the following:
- Conducting assessments and writing reports
- Developing treatment goals and protocols
- Summarizing & analyzing data | adjusting treatment accordingly
- Direct observations
- Meeting with & evaluating team performance
- Monitoring treatment integrity
- Training family & consulting with other professionals
- Evaluating risk/crisis management
- Progress reporting
- Developing & overseeing transition/discharge
What kind of support and supervision will my child receive during their ABA program?
Do Kadiant Behavioral Technicians work on weekends and/or evenings?
Kadiant is open for business from 8 a.m. – 6 p.m. Monday through Friday. There may be times where services are scheduled outside of these business hours on an individual, case by case basis.
How many Behavioral Technicians should be on my treatment team?
Depending largely on the total number of scheduled therapy hours, each team consists of about 1-3 Behavior Technicians, a Case Manager/BCBA, and a Masters or Doctoral level Board Certified Clinical Supervisor (BCBA) Supervisor.
At least once every month, the Board Certified Clinical Supervisor supporting or supervising the program does the following: (1) observes the implementation of intervention related to each targeted skill and behavior reduction target (some observations will be on site, while others will be remote, such as through the use of recorded sessions, Catalyst videos, and or webcasts); (2) reviews all performance data; (3) schedules and hosts a team meeting (some of which may be remote, using video conferencing software) to review observations and data review, discuss programming with team, educational, and/or family members, and make adjustments to the individual’s treatment/IEP plan; and (4) make written adjustments to the program based on the observations, data, and team meeting.
How is your team trained before meeting with my child?
What credentials does your team have to work with my child?
Can I get behavioral support without an intensive behavior analytic intervention program?
Yes. Sometimes, individuals with fewer or less impactful impairments (e.g., Asperger’s, ADHD, etc.), need well-designed intervention programs, but not a team of Behavioral Technicians for delivery. In these cases, we can offer a range of services, including — on the least intrusive end of the spectrum — a Functional Behavioral Assessment (including direct observations, data collection, interviews with parents/teachers, etc.), development of a Behavior Intervention Plan (BIP) based on that assessment, and subsequent training for parents and/or staff on the accurate implementation of that plan.
On the more intensive end of the services spectrum, Kadiant can provide several hours of intensive behavior analytic intervention on an ongoing basis. It is important to understand that “behavior therapy” must be delivered precisely, not only by trained therapists, but also by parent, caregivers, instructors or teachers, and facility staff.
Does Kadiant accept Medicaid for ABA services?
The critical question for Medicaid and private insurance is not whether we accept these forms of health care coverage, but whether they reimburse behavioral services. Individuals with a Medicaid waiver, such as the NOW/COMP waiver, can often access some funding for behavioral services, sometimes even including intensive behavior analytic services. Parents should consult their Medicaid waiver support coordinator about whether their plan provides for such funding.
In at least some cases, self-directed waiver programs can provide funding for intensive behavior analytic services. Do not make changes to your Medicaid waiver program without consulting your Support Coordinator to verify benefits.
Does Kadiant accept private insurance for ABA services?
Benefits coverage for intensive behavior analytic services under private insurance policies varies even more widely than Medicaid. Each family should consult with their provider regarding their individual plan(s) to verify coverage of ABA services. Such coverage must be verified before intensive behavior analytic services can begin.
Those who plan to fund their programs through private insurance carriers are ultimately responsible for any charges their carriers do not reimburse, including the total amount, if the insurance carrier does not reimburse.
How do we get started?
For details about our intake process, please click here.
Can I hire my own therapists?
- Some families do choose to directly hire one or more independent contractors to supplement their treatment teams. In some cases, this can be a cost-efficient way to add to the quantity of therapy. Your supervising BCBA can speak with you about the pros and cons of such an option, though there are certainly aspects of programming related to quality (and how to monitor and maintain treatment integrity) that must be considered.Sometimes, families can recruit an independent therapist locally (e.g., a neighborhood student, a student or friend from church). Obviously, one advantage is avoiding overhead costs; so hourly rates may be less expensive. However, independent contractors rarely maintain adequate risk protection, such as liability insurance or workers’ compensation insurance, so injuries during therapy could represent substantial risks. Also, independent therapists will almost certainly need some training (preferably from the supervising BCBA) and more oversight. Again, your supervising BCBA can discuss the advantages and disadvantages of including independent ABA therapists on your treatment team.
References in Literature
Anderson, S. R., Avery, D. L., DiPietro, E. K., Edwards, G. L., & Christian, W. P. (1987). Intensive home-based early intervention with autistic children. Education and Treatment of Children, 10, 352-366.
Anderson, S. R., & Romanczyk, R. G. (1999). Early intervention for young children with autism: Continuum-based behavioral models. Journal of the Association for Persons with Severe Handicaps, 24, 162-173.
Birnbrauer, J. S., & Leach, D. J. (1993). The Murdoch Early Intervention Program after 2 years. Behaviour Change, 10 (2), 63-74.
Fenske, E. C., Zalenski, S., Krantz, P. J., & McClannahan, L. E. (1985). Age at intervention and treatment outcome for autistic children in a comprehensive intervention program. Analysis and Intervention in Developmental Disabilities, 5, 49-58.
Green, G. (1996). Early behavioral intervention for autism: What does research tell us? In C. Maurice (Ed.), G. Green, & S. Luce (Co-Eds.), Behavioral intervention for young children with autism: A manual for parents and professionals (pp. 29-44). Austin, TX: PRO-ED.
Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Research in Developmental Disabilities, 26, 359-383.
Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.
McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Long-term outcome for children with autism who received early intensive behavioral treatment. American Journal on Mental Retardation, 97, 359-372.
Perry, R., Cohen, I., & De Carlo, R. (1995). Case study: Deterioration, autism, and recovery in two siblings. Journal of the American Academy of Child and Adolescent Psychiatry. 34, 232 – 237.
Smith, T. (1999). Outcome of early intervention for children with autism. Clinical Psychology: Science and Practice, 6, 33-49.
Early Intensive Applied Behavior Analytic Intervention for Autism:
Gina Green, PhD, BCBA