Saturday, March 28, 2009

Why I support ABA Insurance Billing Changes

I am aware there is some concern over proposals in various States to force insurance providers to cover ABA as it relates to autism. I am going to take what may be an unpopular position and argue in favor of such. I understand this may frustrate some of my fellow bloggers; and while this is unfortunate, I think most of our peers at the hub will at least hear my reasons. Maybe a question-answer format will best address this?

Q. Why support the proposals regarding Insurance support for ABA and autism?
A. All students have a right to an educational method that actually can successfully teach them. The idea of what constitutes appropriate goals of education is in debate. Regardless, the zeitgeist in the human service field is toward evidence based practice. This concept props up research based teaching and begins to fade pure theory based teaching.

Currently there are four methods of teaching relative to autism that have some level of support. One is ABA, also TEACCH, Occupational therapy, and speech therapy. That is it…. There is nothing else with an evidence base beyond quasi-experimental designs. I will advocate for any of these four, although speech and OT are often alreadt covered under insurance.

Q. But ABA has been called into question?
A. The groups designs have been questioned to a degree, not the single case designs, of which there are multiple examples and which are consistent and well designed for a number of techniques. ABA literature in autism has developed to the point where there are often multiple research based techniques available for teaching the same skill. This is not opinion, it is fact.

Q. So, why support the law if it only supports ABA?
A. I am all for allowing TEACCH to written in as well, but I am not going to pull my support for that reason. It is not personal; I would still support this proposal even if it was TEACCH that was being promoted.

Q. But ABA targets autistic behaviors, not just academics, right?
A. Yes it does…. so advocate for a focus on academics and what you believe to be more appropriate behavioral goals. I am not unsympathetic, but I will not pull my support for what would have to be a shift of the whole human service field. If you think that general eclectic or Floortime programs are somehow even one mote more respectful of inherent autistic differences then you are simply wrong. In fact I cannot think of any programs that can be considered exemplary in this regard, not even Montessori schools. If that changes I am happy to revise my opinion.

Q. This medicalizes autism, don’t you think?
A. Autism is already deeply medicalized. It is a billable code for many… many services. The services range from the evidence based to Jungian/Tibetan sand play therapy, under the guise of counseling for teens with autism.

Q. Well, then we shouldn’t feed further into the medicalization of autism, right?
A. Fine, so advocate that terms be changed to better fit the view of autism you wish to promote. The reality is some autistic students need tutoring or additional educational work, just like some typically developing students do. They still have a right to have substantiated practices used to educate them….again… just like their typically developing students do.

Q. Then why not put them into standard tutoring, just like their typically developing peers?
A. Do not confuse equality and equity. They are not the same thing.


As always, comments welcome below.

34 Comments:

Blogger Michelle Dawson said...

If I'm not mistaken, you've written that ABA "single case designs," and this kind of design in general, have never been "questioned" in the scientific literature.

Setting aside whether this is accurate, it does imply that it would generally (wherever possible, which would cover a lot of ground) be more efficient to replace much more expensive, difficult designs (like RCTs), which have been thoroughly questioned and will continue to be, with this level of remarkably unquestioned evidence.

Also, you wrote that it's an "unpopular" position to promote private insurance funding (rather than public education funding) of ABA services as "medically necessary" treatment for the illness of autism in the US. Can you show me evidence for this? I mistakenly saw this as a hugely popular position that has met little public dissent in the US. Many thanks.

11:34 AM  
Blogger Do'C said...

Q. This medicalizes autism, don’t you think?
A. Autism is already deeply medicalized. It is a billable code for many… many services. The services range from the evidence based to Jungian/Tibetan sand play therapy, under the guise of counseling for teens with autism.


This seems to be leaning towards arguing in favor two wrongs make a right fallacy.

Q. Well, then we shouldn’t feed further into the medicalization of autism, right?
A. Fine, so advocate that terms be changed to better fit the view of autism you wish to promote. The reality is some autistic students need tutoring or additional educational work, just like some typically developing students do. They still have a right to have substantiated practices used to educate them….again… just like their typically developing students do.


Agreed.

Q. Then why not put them into standard tutoring, just like their typically developing peers?
A. Do not confuse equality and equity. They are not the same thing.


Agreed.

Why is the provision of appropriate "human services" ("substantiated practices") an issue of health insurance vs. education? Without advocating alternate terms, I'd like to understand yours better with specific regard to the ethics of who should hold financial responsibility.

12:46 PM  
Blogger Interverbal said...

Hi Do’C,

“This seems to be leaning towards arguing in favor two wrongs make a right fallacy.”

Ah, but I am not arguing that because kitty litter therapy with counseling gets funded ABA should too. I am arguing that the medicalization of autism is already a done deal. The much more difficult issue is the question I put immediately below in my post. The question of whether this would on some level, feed into the medicalization of autism. As to that question, I am not entirely convinced my answer is correct. It is the weakest part of the argument I presented and I freely admit it. I will continue to put thought to it, but this is where I stand at the moment.

“Why is the provision of appropriate "human services" ("substantiated practices") an issue of health insurance vs. education? Without advocating alternate terms, I'd like to understand yours better with specific regard to the ethics of who should hold financial responsibility.”

Good…. Good question. It depends on the specific State proposal. In Utah, the proposal is relegated to pre-schoolers. Most pre-school special education programs that I know of here are ½ day. Very likely then, any ABA teaching will happen during the hours the child is not at pre-school. To me then, because it would happen out of school, I think that insurance companies should provide the funding. This issue pops up frequently in the special education use of OT and speech. A child may have speech concerns, but may not qualify for school based services in speech. And a child may have fine or gross motor difficulties including enough difficulties to be of clinical concern, but this does not necessarily qualify them for OT. In this gap, is where supplementary services outside of school have to provided.

3:02 PM  
Blogger Interverbal said...

Hi Michelle,

“If I'm not mistaken, you've written that ABA "single case designs," and this kind of design in general, have never been "questioned" in the scientific literature.”

Relative to ABA and autism there has never been a large scale decimation of single case design on a given issue. There are some critiques of individual articles though both within the ABA journals and on the web.

“Also, you wrote that it's an "unpopular" position to promote private insurance funding (rather than public education funding) of ABA services as "medically necessary" treatment for the illness of autism in the US. Can you show me evidence for this? I mistakenly saw this as a hugely popular position that has met little public dissent in the US. Many thanks.”

Leaving aside the mix of Canadian and American terms, this blog is part of the hub. It is to this group I wish to refer. I do not anticipate that my current post will be within the majority view of the hub. I could be wrong (wouldn’t be anywhere near the first time), but I would be surprised.

3:10 PM  
Blogger Michelle Dawson said...

Thanks. So you don't consider the autism literature to contain any substantial criticism of the collective ABA single subject designs. And you don't consider the literature in non-autism areas to be germane. That's clear enough.

But... could show me where I mixed up Canadian and American terms? I was using language from US documents I've read, particularly from the recent California class action (where autism is classified as a major mental illness), but apparently I've erred. If you have time to show me where, I'd appreciate it.

3:55 PM  
Blogger Do'C said...

"I am arguing that the medicalization of autism is already a done deal."

Please add comment from an ethical perspective: does a "done deal" ensure "done correctly"?

"Very likely then, any ABA teaching will happen during the hours the child is not at pre-school. To me then, because it would happen out of school, I think that insurance companies should provide the funding."

Regardless of the location where ABA teaching services are to be provided, do you think they are healthcare services or educational services? If that's too black and white, feel free to describe your perspective of the weight that should be given to each description.

Why shouldn't ABA teaching, outside of the typical school day, still be considered teaching even if provided at an accomodated time or location?

3:58 PM  
Blogger Interverbal said...

Hi Do'C,

"Please add comment from an ethical perspective: does a "done deal" ensure "done correctly"?"

In no way does "done deal" mean "done correctly", especially from an ethical perspective.

"Regardless of the location where ABA teaching services are to be provided, do you think they are healthcare services or educational services? If that's too black and white, feel free to describe your perspective of the weight that should be given to each description."

They are educational services.

"Why shouldn't ABA teaching, outside of the typical school day, still be considered teaching even if provided at an accomodated time or location?"

It can still be considered teaching, but it can't be required. This is because the current interpretation special education law will not allow for it. Schools are only required to provide for some educational benefit, not optimal educational benefit.

7:26 PM  
Blogger Interverbal said...

Hi Michelle,

"Thanks. So you don't consider the autism literature to contain any substantial criticism of the collective ABA single subject designs. And you don't consider the literature in non-autism areas to be germane. That's clear enough."

Correct.

"But... could show me where I mixed up Canadian and American terms?"

"medically necessary", is a Canadian law term. To my knowledge it has not been used in legal documents in the US. If this is incorrect, please consider my comment retracted.

7:32 PM  
Blogger Do'C said...

"medically necessary", is a Canadian law term. To my knowledge it has not been used in legal documents in the US.

LINK

They are educational services.

How do you propose that legislation of insurance coverage for "educational services" should address the definitions of "medical necessity" in current U.S. case law?

8:17 PM  
Blogger Autism Reality NB said...

Medicalizes autism?

Autism exists only as a medical diagnosis. It has no other meaning.

8:29 PM  
Blogger Do'C said...

How do you propose that legislation of insurance coverage for "educational services" should address the definitions of "medical necessity" in current U.S. case law?

Addendum:

To clarify, I don't equivocate "educational services" with academics. Case law semantics seems light on the inclusion of "educational services". Perhaps my question would be better worded as: How do you think private insurance providers should define "medical necessity"?

9:44 PM  
Blogger Michelle Dawson said...

In response to Interverbal, apart from the link Do'C provided (thanks!) try this site (there is information from various states, if you look around), and this recently filed complaint.

I also disagree with your stated positions, but you have given me insight into behaviour analytic standards, which I appreciate.

1:20 AM  
Blogger Michelle Dawson said...

Sorry, forgot Autism Speaks' "Model Autism Insurance Reform Bill" which you can find via this page.

1:28 AM  
Blogger David N. Andrews MEd (Distinction) said...

Someone with a law degree but without the brains to understand much: "Autism exists only as a medical diagnosis. It has no other meaning."

Wrong.

Firstly, educational psychologists can diagnose autism. Part of my training includes the making of this diagnosis.

Secondly, autism is a developmental issue, not a medical one; it is more appropriate to use educational methods to work with autistic people than to 'treat the autism' with medical methods.

9:54 AM  
Blogger Interverbal said...

Hi Do'C,

Thanks for the medical necessity link.

"How do you propose that legislation of insurance coverage for "educational services" should address the definitions of "medical necessity" in current U.S. case law?"

1. Autism is diagnosable as a DSM disorder.
2. Some additional educational/behavioral help or support may be prudent in given cases.
3. ABA (but not ABA alone) fulfills that niche with evidence to back it up.
4. It is clear from my knowledge of other cases that "medical necessity" is a broad term. A person may not die or physically/mentally weaken in the absence of a therapy considered to be medically necessary via law.

11:13 AM  
Blogger Interverbal said...

Hi Harold,

"Autism exists only as a medical diagnosis. It has no other meaning."

1. Autism was first used a describe a so called negative symptom of schizophrenia.
2. In the previous DSM (DSM-III), there were residual categories for autism for those persons who initially met full criteria, but later did not.
3. Some persons meeting criteria for autism and their allies refer to autism in a non-medicalized way.

11:21 AM  
Blogger Interverbal said...

Hi Do'C,

"How do you think private insurance providers should define "medical necessity"?"

Medical necessity: A formal, diagnosable physical, mental, or developmental condition for which technologies, therapies, treatments, or methods are reccomended by the diagnostician.

Note: I do not say how therapies etc, are established as appropriate.... I see that as a seperate issue.

11:31 AM  
Blogger Interverbal said...

Hi Michelle,

Please consider my statement concerning the mix of Canadian and US legal terms to be retracted.

"I also disagree with your stated positions, but you have given me insight into behaviour analytic standards, which I appreciate."

Disagreements are welcome Michelle; as always.

11:33 AM  
Blogger Michelle Dawson said...

In response to Mr Doherty, major behaviour analysts (e.g., Ivar Lovaas, Tristram Smith, Jack Michael) have denied that autism is a valid diagnosis. Instead, they have claimed that autism is a error of reification or a social construct.

Lovaas has written throughout his career that autism is not a valid or useful diagnosis, and that medical approaches to autism are largely or entirely ineffective (Lovaas, 1979; Lovaas, 1981; Lovaas & Smith, 1989; Lovaas, 2000; Lovaas, 2003).

Standards of autism diagnosis in the vast bulk of the ABA literature (the single subject designs) are largely very low or non-existent, which is consistent with the common behaviour analytic position that diagnosis is not useful or relevant (and may even hamper behaviour analytic interventions). This is inconsistent with a medical view of autism.

Other famous behaviour analysts (Nathan Azrin, Richard Foxx) have used "autism" to describe various behaviours found in any person, regardless of diagnosis (e.g., head-weaving and body-rocking are "autisms").

All of the above can be confirmed by reading the ABA literature.

12:29 PM  
Blogger Benjamin said...

Children with autism are primarily in need of an appropriate education to acquire the skills they will need to become functional adults. From my personal experience I know that Daily Life Therapy can provide the best education for most children with autism. Adults with autism need appropriate assistance to function at the level of typical adults in all areas. Behavioral psychology allows humans to understand nonhuman animals but has no place in educating humans. In the U.S., the proper implementation of IDEA should be pursued and not the use of private health insurance.

12:53 PM  
Blogger Interverbal said...

Hi Benjamin,

"From my personal experience I know that Daily Life Therapy can provide the best education for most children with autism."

I understand that this is from personal experience. However, I and others like me are looking for something a bit more here in terms of evidence.

"Behavioral psychology allows humans to understand nonhuman animals but has no place in educating humans."

No place in educating humans for efficacy reasons? No place in educating humans for ethical reasons? No place in educating humans for other reasons?

"In the U.S., the proper implementation of IDEA should be pursued and not the use of private health insurance."

That is sort of the point. The IDEA is used correctly as is. You can't make a district use any specific program even if it is best practice.

4:58 PM  
Blogger Benjamin said...

With my son's permission, I will try to provide some factual information and then later, with my needed substanital assistance, see if my son wishes to reply directly to you.

At our school district's initiative, my son was educated with the "Miller Method" for 3 years years (age 5-1/2 to 8-1/2), then at his parents' initiative but largely at the school district's expense, with ABA-type services for 5 years (age 8-1/2 to 13-1/2) and then with Daily Life Therapy for 9 years (age 13-1/2 to 22-1/2). Please note that ABA-type services were not available in our state until the late 1970s and then only at a residential school. As an adult since 1994, at my son's own initiative, he has arranged the substanital assistance he needs to function. My son has expressed that "best practice" in education should be on an individual basis, which is what the "I" in IDEA and in IEP stand for. Based on his own personal experience, school districts in the U.S. do not always take the initative to correctly implement IDEA, which is why this federal law includes "due process" that we had to pursue for nearly 14 years starting in 1980, but we never used our private health insurance for the education of our son.

Our son's personal experience includes physical contact with hundreds of persons with autism from many countries and states within the U.S. and therefore is based on substantial broad evidence, all with an "insider's" perspective of a person with a diagnosis of autism as a preschooler. His thoughts that "behavioral psychology...has no place in educating humans" have not been expressed before and I will try to see if my son wishes to comment further.

10:53 PM  
Blogger Benjamin said...

As my father stated, my personal experience is based on "substantial broad evidence." No place means absolutely no place, but since my experience and opinion are consistent with Daas Torah, one can find the details there. In closing, I recommend that parents pursue their rights under IDEA and leave private health insurance alone.

11:17 AM  
Blogger KeithABA said...

Well, there is some hope for the education system. In Michigan parents recently sued the school board and won so that ABA classrooms had to be created. Dr. John Esch and Dr. Barbara Esch have consulted and essesntially created these classrooms. The classes have been so successful that there is possiblity that the schoolboard will fund further classrooms. It proves that the education system could be the provider of ABA services.

On the other hand "Data on thousands of children in project Follow Through (Adams & Engelmann, 1996; Gersten, Keating, & Becker, 1988; Meyer, 1984; Meyer, Gersten, & Gutkin, 1983) showed that Direct Instruction and Applied Behavior Analysis fostered the highest achievement in reading and math—in contrast to so-called progressive, child-centered, "developmentally appropriate" curricula." (Kozloff, 2002)

It seems unlikely to me that with the combination of increased cost, and completely different methodology, that the schools will readily accept this sort of change.

12:52 PM  
Blogger Interverbal said...

Thank you Benjamin and Benjamin's son.

There are a number of points you both have mentioned that deserve some scrutiny. But perhaps another time as this is not the direction I want to take the current thread.

I do have a question for Benjamin. Were you assisting your son type his response (facilitating)?

6:36 PM  
Blogger Interverbal said...

Ditto Keith, although Michigan is a bit of an outlier anyway. It already had at least one famous public school ABA room that has been in existence for nearly a generation.

Really though, I just don't see ABA being forced upon the schools in a large way. Not only is it outside the current interpretation, it is against school culture to a degree.

Teachers often like short parsimonious theories. Ask your average teacher if they like Gardner's theory of Multiple Intelligences and you will probably get a "yes". Ask them if they apply that theory by teaching using multiple formats and you will probably get a "yes". Ask them if they remember all 8 current categories and you will probably get an embarrassed giggle.

And are Gardner’s 8 intelligences really better than Interverbal’s dynamic-synergistic 22 areas of cognitive ability? Probably not, but Gardner’s theory is much briefer. And in the world of day-trip seminars, that counts for something.

I think that if we really want to promote ABA in schools then what we should do is get BACB to offer some sort of teacher certification. Target teachers already in the business. Partner with local Universities and local school districts. Get the school districts to pay for this as continuing ed. Focus on evaluation of behavior, functional assessment/analysis, and current behavior strategies. Do-away with certain strategies (or teach them scrupulously and correctly) that tend to be mis-used or abused by teachers like token-economies, level systems, interminable use of primary reinforcers, and especially time-out from positive reinforcement.

And teach them not to abuse the social efficiency concept (the goal of education is to get you ready for a job), which can sometimes have a very pernicious flavor in special education and can start dumb-foundingly early in a child’s life. The goal itself is not a problem. The problem is when the goal is used to sort children into rigid compartments or seen as the only goal possible in special ed (an idea against the IDEA, as it were).

7:27 PM  
Blogger Interverbal said...

Also (tips hat towards Michelle), the topic of whether autism is a reification or not is worthy, but for my part, I will save it for another day.

7:29 PM  
Blogger Clay said...

I like what this guy has to say about it. Says it better than I could.

http://thiswayoflife.org/blog/?p=373

12:15 AM  
Blogger Benjamin said...

This is a genuine communication from an autistic, even if some people are not sure. I am sure that all the comments on this blog entry are genuine communications, but I am only sure that I am an autistic because I do not have any persecutory delusions.

3:37 PM  
Blogger Interverbal said...

Hi Benjamin or Benjamin's son was the case may be.

"This is a genuine communication from an autistic, even if some people are not sure."

The question was not whether this was authentic communication the question was whether Benjamin was facilitating for his son's message. This question continues.

"but I am only sure that I am an autistic because I do not have any persecutory delusions."

Why I do not question your diagnosis, I am not sure the reason you have offered is valid. I can think of at least 3-4 examples right off the top of my head where an autistic did indeed have persecutory delusion.

Thank you for your time,

11:06 PM  
Blogger Laura said...

As a BCBA I strongly support ABA Insurance coverage. Speech Therapy at an hour or week has not shown significant results with individuals with autism whereas ABA has. Part of the problem I think is the number of hours usually recommended for ABA, at least 20. But generally speaking, if OT and SLP and PT are traditionally covered why not ABA?

10:18 PM  
Anonymous Anonymous said...

www.rocktheboatforautism.org

We also have a facebook group... check us out! Rock the boat for Autism.

6 guys will be rowing in 3 Van Duyne row boats from Florida to New Jersey.... a total of 1500 miles to raise money for Autism Society of America!

4:17 PM  
Blogger Autism Reality NB said...

Interverbal

I have revisited this post and the comments. I thank you for the post itself which is balanced and non-ideological. I also thank you for your response to my comment which was also very balanced.

I understand that some persons, even some who have obtained a pervasive developmental disorder/autism spectrum disorder diagnosis, prefer to describe autism as a social construct rather than as a medical diagnosis. That does not mean though that their usage of the term in that context is proper usage.

As you have pointed out "autism" is set out in the PDD/ASD category of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. It is also set out in the mental disorders section of the International Statistical Classification of Diseases and Related Health Problems (ICD).

It is not a "social construct" problem when my severely autistic son bit himself, a behavior which we have reduced almost entirely using ABA methods. It is not a social construct when he has almost no language abilities oral, written or by communication technologies. Again, he has made gains in language and communication using ABA methods.

I understand the weakness of anecdotal evidence such as I have just provided. As a parent though I sought ABA intervention for my son based on the complete evidential basis of its effectiveness as related by a professor of psychology and clinical psychologist who actually works with autistic children, including severely autistic children like my son. The benefits gained for my son using ABA have been clear and substantial in helping him in everyday life. Of course on a personal level when you see the benefits of an approach in helping your own child your assessment of that approach is reinforced.

I thank your for your objective discussion of ABA as an autism intervention. No one can change the minds of those who have built careers opposing ABA interventions for autistic children but some parents who have newly diagnosed autistic children and who are surfing the net looking for guidance might see your comment.

Their autistic child might benefit as a result.

3:27 AM  
Blogger Ophidian said...

Thank you, Interverbal.

I agree with you that ABA should have at least the same amount of support and coverage as some clearly ineffective therapies for autism have: speech therapy for autistic kids presently covered by insurances, is one example.


For those, who doubt or just do not know if autism is diagnosis or not I would suggest reading "Handbook of Autism and Pervasive Developmental Disorders", vol. 1: Diagnosis, Development, Neurobiology, and Behavior Edited by Fred R. Volkmar et al.


Here I cite from the manual (p.5): "Clinicians and researchers have achieved consensus on the validity of autism as a diagnostic category and the many features central to its definition (Rutter, 1996). This has made possible the convergence of the two major diagnostic systems: the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) and the 10th edition of the International Classification of Diseases (ICD- 10; World Health Organization [WHO], 1992)."


And if one takes one step further and looks up DSM-IV (a manual published by the American Psychiatric Association (APA)
forall currently recognized mental health disorders), Code 299.00: Autistic disorder.

In ICD-10 Code F84.0 (chapter chapter V) refers to childhood autism.

8:55 AM  

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