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  • 1. Applied Behavior Analysis:Medically Necessary Treatment forAutism Spectrum DisordersWest Virginia Autism InsuranceStakeholders RoundtableJuly 13, 2012Stonewall Resort1

2. What is Autism? What is AutismSpectrum Disorder Autism spectrum disorder (ASD) and autism are both general terms for a group of complex neurodevelopmental disorders. These disorders are characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors.2 3. What is Autism SpectrumDisorder? (ASD) Itincludes: autistic disorder, Rett syndrome, childhood disintegrative disorder, pervasive developmental disorder-nototherwise specified (PDD-NOS) and Asperger Syndrome 3 4. What is Autism? What isAutism Spectrum Disorder ASDcan be associated with: intellectual disability, difficulties in motor coordination attention physical health issues such as: sleep and gastrointestinal disturbances.4 5. What is Autism? What is AutismSpectrum Disorder Autismappears to have its roots in very early neurodevelopment. However, the most obvious signs of autism and symptoms of autism tend to emerge between 18 months and 3 years of age.5 6. A national public health crisis Autism statistics from the U.S. Centers forDisease Control and Prevention (CDC)identify around 1 in 88 American children ason the autism spectruma ten-fold increase inprevalence in 40 years. An estimated 1 out of 54 boys and 1 in 252girls are diagnosed with autism in the UnitedStates.6 7. What is Autism? What isAutism Spectrum Disorder By way of comparison, more children arediagnosed with autism each year than withjuvenile diabetes, AIDS or cancer, combined. ASD affects over 2 million individuals in theU.S. and tens of millions worldwide.7 8. Applied behavior analysis(ABA) Behavior analysis: A natural science approach to understanding and changingbehavior; focus is on interactions between behavior andenvironment A distinct discipline with theoretical, experimental, and appliedbranches and specific research methods, scientific journals,and scholarly/professional organizations Applied behavior analysis (ABA): Application ofscientific principles of behavior (e.g., positivereinforcement) to improve socially significant behaviorto a meaningful degree Many applications in addition to ASD treatment Based on the work of many researchers and practitioners over40+ years8 9. ABA in practice An approach comprising many evidence-based techniques or procedures for changing behavior Stresses positive reinforcement and scientific evaluations of effectiveness Highly individualized Flexible and dynamic; intervention is adjusted continuously based on data Delivered in a range of settings: homes, hospitals, clinics, schools, workplaces, community, etc. Effective for improving functioning and reducing problematic behaviors in people of all ages, with and without disabilities, when implemented by professionals with bona fide training and experience in the discipline 9 10. ABA in practice ABA is a distinct profession; not the same as clinicalpsychology, developmental psychology, educationalpsychology, counseling, special education, occupationaltherapy, etc. The internationally accepted credentialing program forprofessional practitioners of ABA is managed by thenonprofit Behavior Analyst Certification Board, Inc.(BACB; see Accredited by the National Council for Certifying Agencies,Institute for Credentialing Excellence BACB-certified behavior analysts are recognized as qualifiedproviders in autism insurance laws, Medicaid laws, and otherlaws and regulations in many states, and by the U.S.Department of Defense TRICARE health plan under its ABAbenefit for military children with ASD. 10 11. ABA: Evidence-basedtreatment for ASD Hundreds of published studies document the effectiveness of many specific, focused ABA techniques for building a wide range of important skills and reducing problem behaviors in people with ASD of all ages, in a variety of settings. At least 11 controlled between-groups studies show that multiple ABA techniques combined into early comprehensive, intensive treatment programs can produce large improvements in symptoms and skill deficits in many young children with ASD when treatment is directed by qualified professional behavior analysts.11 12. ABA: Medically necessarytreatment for ASD Asa neurological disorder, ASD is clearly a medical condition. It is diagnosed by a physician or a licensed psychologist. TheCDC (Centers for Disease Control and Prevention) identifies autism as a: "national public health crisis."12 13. ABA: Medically necessarytreatment for ASD A number of other government and national healthorganizations recognize ASD as a medical condition,including: -The U.S. Surgeon General -National Institutes of Health -National Institute of Child Health andHuman Development -American Academy of PediatricsALL of these organizations recognize andrecommend ABA as the only proven methodfor treating ASD.13 14. ABA: Medically necessarytreatment for ASD On March 27, 2012, Florida Federal Judge Joan Lenard held that applied behavior analysis is medically necessary and not experimental as defined under Florida statutory and administrative law and federal law.14 15. ABA: Medically necessarytreatment for ASD Plaintiffshave established through theirexpert witnesses that there exists in thescientific and medical peer-reviewedliterature a plethora of meta-analyses, studiesand articles that clearly establish ABA as aneffective and significant treatment to preventdisability and to restore children to their bestpossible functional level and restore theirdevelopmental skills. Florida Federal Judge, Joan Lenard15 16. ABA: Medically necessarytreatment for ASD The treatment for all other neurological disorders (such as traumatic brain injury, seizure disorders, ALS, Parkinsons Disease) is considered medically necessary. As a neurological disorder, ASD is no different.16 17. ABA: Medically necessarytreatment for ASD Medically necessary treatments ameliorate or managesymptoms, improve functioning, and/or prevent deterioration. ASDs are neurodevelopmental conditions that manifest inbehavioral symptoms, i.e., behavioral abnormalities in threecore domains: social interaction, communication, and interestsand activities. ABA treatment has proved effective for ameliorating those coresymptoms as well as building other skills that enhancefunctioning and health in people with ASD, such asHygiene and self-care skillsPersonal safety skillsEating a healthy dietSleepingCooperating with medical and dental procedures 17 18. ABA: Medically necessarytreatment for ASD ABA interventions have also proved effective for decreasing behaviors that directly jeopardize the health and welfare of people with ASD, such as Self-injurious behaviors Property destruction Pica (ingesting inedible items) Aggression Elopement Obsessive behaviors Hyperactivity Fearful behaviors 18 19. Summary Contemporary ABA intervention for ASD rests onmore than 40+ years of scientific research. At present, no other approach to ASD interventionhas comparable scientific support Best available scientific evidence indicates thatcompetently directed and delivered early intensiveABA intervention is especially effective forameliorating and preventing symptoms of ASD.19 20. Summary ABA intervention is now deemed medicallynecessary for people with ASD by many publicand private health plans around the U.S. Health insurance coverage of ABAintervention for ASD provided by professionalscredentialed by the Behavior AnalystCertification Board can save millions in health care and other costs over time.20 21. For more information on ABA forASD, please see (Autism Speaks) (Cambridge Centerfor Behavioral Studies) (Association ofProfessional Behavior Analysts) (Association for Sciencein Autism Treatment)21 22. For qualifications to practiceABA, please see Behavior Analyst Certification Board Association of Professional Behavior Analysts Association for Behavior Analysis AutismSpecial Interest Group Consumer Guidelines - 22 23. AcknowledgementWe would like to express our sincere thanksto Gina Green, PhD, BCBA-D, ExecutiveDirector of the Association of ProfessionalBehavior Analysts, for permission toredistribute her materials.23 24. ReferencesAssociation for Science in Autism Treatment - reviews of evidence on autism treatments, J.M. (2003). Efficacy of behavioral interventions for reducing problem behavior in persons with autism: A quantitative synthesis of single-subject research. Research in Developmental Disabilities, 24, 120-138.Cuvo, A. J., Reagan, A. L., Ackerlund, J., Huckfeldt, R., & Kelly, C. (2010). Training children with autism spectrum disorders to be compliant with a physical exam. Research in Autism Spectrum Disorders, 4, 168-185.Dawson, G.(2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorders. Development and Psychopathology, 20, 775-803.Eldevik, S., Hastings, R.P., Hughes, J.C., Jahr, E., Eikeseth, S., & Cross, S. (2009). Meta-analysis of early intensive behavioral intervention for children with autism. Journal of Clinical Child and Adolescent Psychology.Ganz, M.L. (2007). The lifetime distribution of the incremental societal costs of autism. Archives of Pediatric and Adolescent Medicine, 161, 343-349.Gillis, J.M., Natof, T.H., Lockshin, S. B., & Romanczyk, R.G. (2009). Fear of routine physical exams in children with autism spectrum disorders: Prevalence and intervention effectiveness. Focus on Autism and Other Developmental Disabilities, 24, 156-168. 24 25. ReferencesGreen, G. (2008). Single-case research methods for evaluating treatments for ASD. In S.C. Luce, D. S. Mandell, C. Mazefsky, & W. Seibert (Eds.), Autism in Pennsylvania: ASymposium Issue of the Speakers Journal of Pennsylvania Policy (pp. 119-132).Harrisburg, PA: Legislative Office for Research Liaison, Pennsylvania House ofRepresentatives.Green, G. (in press). Early intensive behavior analytic intervention for autism spectrumdisorders. In E. Mayville & J.Mulick (Eds.), Behavioral foundations of effective autismtreatment. Sloan PublishingHall, L.J. (1997). Effective behavioural strategies for the defining characteristics ofautism. Behaviour Change, 14, 139-154.Jacobson, J.W., Mulick, J.A., & Green, G. (1998). Cost-benefit estimates for earlyintensive behavioral intervention for young children with autism: General model andsingle state case. Behavioral Interventions, 13, 201-226.Kodak, T., & Piazza, C. (in press). Assessment and treatment of feeding and sleepingdisorders in children diagnosed with developmental disabilities. Child and AdolescentPsychiatry Clinic of North America.LeBlanc, L. A., Carr, J. E., Crossett, S. E., Bennett, C. M., & Detweiler, D. D. (2005).Intensive outpatient behavioral treatment of primary urinary incontinence of childrenwith autism. Focus on Autism and Other Developmental Disabilities, 20, 98-105.25 26. ReferencesLilienfeld, S.O. (2005). Scientifically unsupported and supported interventions for childhood psychopathology: A summary. Pediatrics, 115, 761-764.Mandell, D.S. (2007). Psychiatric hospitalization among children with autism spectrum disorders. Journal of Autism and Developmental Disorders, available at www.springerlink.comMotiwala, S.S., Gupta, S., & Lilly, M.D. (2006). The cost-effectiveness of expanding intensive behavioural intervention to all autistic children in Ontario. Healthcare Policy, 1, 135-151.Myers, S.M., Johnson, C.P, & The Council on Children with Disabilities (2007). Management of children with autism spectrum disorders. Pediatrics, 120 (5), 1162- 1182.National Autism Center (2009). National Standards Project Findings and Conclusions. Randolph, MA: Author.New York State Department of Health Early Intervention Program (1999). Clinical Practice Guideline: Autism/Pervasive Developmental Disorders-- Assessment and Intervention for Young Children (Age 0-3 Years). Health Education Services, P.O. Box 7126, Albany, NY 12224 (1999 Publication No. 4216). 26 27. ReferencesPerrin, C. J., Perrin, S. H., Hill, E. A., & DiNovi, K. (2008). Brief functional analysis andtreatment of elopement in preschoolers with autism. Behavioral Interventions, 23, 8795.Piazza, C. C., Hanley, G. P., Bowman, L. G., Ruyter, J. M., Lindauer, S. E., & Saiontz, D.M. (1997). Functional analysis and treatment of elopement. Journal of AppliedBehavior Analysis, 30, 653672.Piazza, C. C., Fisher, W. W., Hanley, G. P., LeBlanc, L. A., Worsdell, A. S., Lindauer, S.E., et al. (1998). Treatment of pica through multiple analyses of its reinforcingfunctions. Journal of Applied Behavior Analysis, 31, 165-189.Reichow, B. & Wolery, M. (2009). Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA Young Autism Project model. Journal of Autism and Developmental Disorders, 39, 23-41.Rogers, S. J. & Vismara, L. A. (2008) Evidence-based comprehensive treatments for early autism. Journal of Clinical Child & Adolescent Psychology, 37, 8 38.Simera, N., & Cuvo, A. J. (2009). Training vision screening behavior to children withdevelopmental disabilities. Research in Autism Spectrum Disorders, 3, 409-420.27 28. ReferencesSmith, T. (1999). Outcome of early intervention for children with autism. Clinical Psychology: Science and Practice, 6, 33-49.U.S. Department of Defense. (2007, July). Report and plan on services to militarydependent children with autism. Washington, DC: Author.U.S. Surgeon General s Report on Mental Health Autism, S., Richdale, A., & Matthews, J. (2005). Behavioural treatment to reduce sleepproblems in children with autism or fragile X syndrome. Developmental Medicine &Child Neurology, 47, 94-104.Wolery, M., Barton, E.E., & Hine, J.F. (2005). Evolution of applied behavior analysis in the treatment of individuals with autism. Exceptionality, 13, 11-23.Zachor, D.A., Ben-Itzchak, E., Rabinovich, A., & Lahat, E. (2007). Change in autism coresymptoms with intervention. Research in Autism Spectrum Disorders, 1, 304-317. 28