Everyone these days knows someone who has a child with autism, as Autism is diagnosed in 1 in 68 children (CDC, 2012). In fact, if you don’t have a child with autism, you probably have a neighbor or relative whose family is challenged with Autism or similar developmental disability.
New on the Horizon in Hawaii: Health Insurance Funding for ABA Treatment
Have you heard about the recent addition of Applied Behavior Analysis or ABA to many insurance plans in Hawaii? Since health insurers in Hawaii began covering it in fully funded insurance plans starting January 1, 2016, to the minimum required $25,000 per year, many families are just now seeking out this medically necessary treatment for their child with autism since. All federal plans will begin to cover ABA starting January 1, 2017. Medicaid (Quest Program in Hawaii) also covers ABA treatment and has no fiscal cap, meaning that those kids who require 30-40 hours a week (ie) children who are non-verbal or have limited communication skills, or more severe behaviors to ameliorate, can receive intensive treatment without the barrier of a funding cap. In addition, under the Early and Periodic Screening, Treatment and Diagnosis (EPSTD) program, Medicaid will provide a trial of ABA to children who “may benefit” from ABA, such as children up to age 21 with Down Syndrome, or other developmental disabilities. Parents should be advised that funding caps, along with a plethora of other provisions sometimes required by health insurers, may violate Mental Health Parity and Addiction Act of 2008 (MHPAEA).
What is ABA therapy like?
ABA is the science of behavior, but what does ABA look like in action? Well, it can look different depending on the child or adolescent. An early learner (a non-verbal child or one with limited communication skills) would spend most his/her session time engaging in pairing and mand training using naturally occurring activities such as play, with a Registered Behavior Technician (RBT). “Pairing” is the process of pairing oneself with positive reinforcement. We need our learners to understand that we are the givers of “all good things”, so they will see is as valuable to them, and be more likely to engage in behaviors which lead to reinforcement, like asking for the things he/she wants access to, such as trampoline, juice, cookie, etc. Pairing may need to take place for as long as a month or so depending on the child’s learning history. Mand training uses the child’s motivation to get the child to echo a speech sound or whole word, sign language or a tablet device with photos, in order for the RBT to deliver the reinforcer. They learn very quickly “If I talk, then I get!”. A typically developing 3-year-old asks for over 800-1000 things per day. Your therapists should be aiming for this frequency of manding, even if it is being built and expanded over time.
For another child, a school-age child who has social deficits, minor language deficits and maybe behavioral challenges, ABA may contain some fluency-based programs to increase speed of responding- we call this Precision Teaching. In addition, some social skills training, language acquisition programming, and behavior reduction protocols along with play skill targets may be worked on.
For other children who may have not developed an adequate language repertoire, and are older, say 10-18 years old, they may be in need of learning “life skills” so that they can achieve more independence from caregivers. Targets are more geared to skills for life. These may include self-care (washing, bathing, dressing), menstruation care, toileting, light meal preparation, leisure activities, along with functional language acquisition, and perhaps inappropriate behavior reduction.
It is important to remember that each child’s program should look different. Each procedure for skill acquisition or behavior reduction should be written out, step by step, with specific definitions and specific criteria for mastery of the skill.
Hallmarks of ABA
All ABA programs should maintain graphs of a child’s progress in each skill acquisition or behavior reduction program. Some provider agencies use Excel type graphs, with grids like graph paper, which don’t account for time. The use of standard celeration charts is emerging in the field of ABA, and provide information to quantify time just like EKG charts do. One of the hallmarks of ABA is visually displayed data, and Precision teaching not only provides a daily visual display of the child’s learning, as well as uses performance standards which refer to the specific frequency ranges indicating fluent behavior. If something is not fluent, it is likely difficult and requires a lot of effort, and is not very fun for us. If something is fluent, we usually enjoy doing it a lot more, and we are confident in demonstrating that skill.
Being a Smart Consumer of ABA
ABA is a wonderful, life-changing evidence-based treatment, however the road to ABA services may not be an easy one for parents to navigate. The first step is calling a few agencies, and asking them a few questions over the phone, perhaps in an interview style. This will help you choose a provider to first evaluate your child’s skills and develop a treatment plan.
How does one become a “smart consumer” of ABA you might ask? Parents are their child’s best advocate and knowledge is key! Parents should be given resources to learn about ABA, such as online video training, books, and also parent training provided by the supervisor, always a Board Certified Behavior Analyst (BCBA). Parent training (or even “family training”) is essential to give parents the tools they need to generalize the skills their child learns in ABA, to implement behavior reduction procedures consistently across settings and home, and to promote generalization across caregivers.
Parents should do their homework and interview potential ABA provider agencies in order to be smart consumers of ABA. Questions they should ask include: How long has the agency been providing ABA in Hawaii? How many BCBAs on staff? How many RBTs on staff? What is staff turnover like? What generally is the number of clients on a supervisor’s caseload (should no more than 10 as recommended by the BACB (see http://bacb.com/asd-practice-guidelines/)? How many technicians (RBTs) will be assigned to work with my child (more than 1 is recommended to promote generalization, and in full-time 40 hours/week cases 3-4 RBTs may be necessary). What is your policy on staff illness? ie) does the company cancel the session, or assign a substitute- and how familiar is that substitute with the program? What is your policy on session cancellations or lateness by the parent? Is there a cancellation fee? What type of parent training do you offer? How much parent training do you offer? Be sure to ask about parent training options while you are on the wait list.
Other things to consider are home-based ABA vs clinic-based ABA. Parents are usually required to be present during sessions in the home, whereas with clinic-based sessions, parents can drop off and pick up and run errands during therapy, or also stay to observe the session for parent training. Clinic-based ABA requires transportation to the clinic, whereas for home-based it does not. For home-based ABA, you should consider the impact on your family life, space issues, privacy issues, time commitment required to be present for therapy sessions, and your willingness to convert your home into a therapy center. You might also inquire about program materials parent are required to purchase (ie) toys, reinforcers, program supplies, curriculum items, which may be costly. Clinic-based ABA usually includes all of the toys, reinforcers, and materials necessary for a child’s program. A great article on the benefits of clinic-based ABA can be found at https://abcgrouphawaii.com/benefits-of-aba/
If your child is non-verbal, he may not possess the prerequisite skills to benefit from school, therefore the clinical recommendations may be 40 hours a week. You will also want to inquire about the provider’s ability to provide fulltime ABA (8 hours a day/5 days a week; 40 hours/week), and maintain adequate staff (at least 3-4 RBTs assigned).
Curriculum should also be inquired about. Researcher advise against the use of “cook book” ie) you get the colors, shapes and numbers program whether you need it or not type approaches to programming, and suggest an individualized approach based on the clinical assessment for developing ABA programs for each child.
The triumphs of ABA quickly leave parents with overwhelming confirmation that they made the right choice in choosing an ABA provider for their child. Sometimes the results are not achieved as quickly, however the graphs indicate that the child is making progress. ABA is done with fidelity should produce pretty immediate results and changes. Sometimes, a parent instinct raises a red flag. Something tells them that something is not right, or not working for the family, and parents may want to seek a “second-opinion” assessment from a different provider, to ensure that another board certified determine if the current program, intensity, goals/objectives and progress are clinically appropriate or not.
Speedbumps on the ABA Road
A few speedbumps exist now that many more kids in Hawaii can receive ABA due to insurance funding. Training newly hired staff as Registered Behavior Technicians (RBTs) is the first step for provider agencies, since there is not a steady pool of RBTs in Hawaii yet. Credentialing with health insurance companies and background checks can also cause a little bit of a delay from intake assessment to starting treatment sessions.
Choosing an ABA Provider in Hawaii
So you want to find out about ABA treatment in Hawaii? Visit the Autism Speaks resource directory: https://www.autismspeaks.org/directory
You may also want to call your health insurance company and confirm that ABA is a benefit in your plan. The health insurance company should be able to give you a complete list of the providers who they are in-network with.
If you are told that the company you work for does not offer ABA treatment as a benefit, you can ask if your company is a “self-funded” company, which are ERISA companies not obligated to follow the state mandate. Included in this link is a list to reference the self-funded companies who choose to cover ABA treatment. If your company does not cover ABA as a self-funded company, this link also includes a tool kit for parents who would like to approach their HR department and request that a rider for ABA be added. Autism Speaks attorneys can also help with advocacy efforts. https://www.autismspeaks.org/sites/default/files/docs/erisa_tool_kit.pdf Amy Smith Wiech, PhD, BCBA-D, LBA is a licensed Board Certified Behavior Analyst (BCBA-D) with over 25 years’ experience with children and young adults on the spectrum. She founded ABC Group: Autism Behavior Consulting Group, a kama’aina clinic-based ABA treatment center, located in Aiea. ABC Group is home to over 12 BCBAs and over 30 RBTs all committed to ameliorating the deficits associated with Autism. ABC Group offers several free parent orientation sessions per month, which provides a short training session on ABA at no cost, and an opportunity to find out about the programs and services available at ABC Group!