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.

Sunday, March 22, 2009

Using the Word “Retard”

It is disappointing for me whenever I hear someone use the word “retard” as an insult. I am sure this is not a unique experience amongst hub bloggers. Nor are we likely to be the only ones who feel this way. The Special Olympics has even come out with an r-word petition.

But in some ways… maybe many ways, this isn’t going to change things. I am prepared to argue that the use of word “retard” as a pejorative is most common (although
grown ups make this sort of error too) among teens. I want to focus on that in this post. In my view, there are rather unique motivation factors that influence teen behavior and make this behavior particularly likely.

There seems to almost be a mystique attached to teenage verbal misbehavior by our culture. References are made to hormonal imbalances and changing brain structures as if layman’s appeals to the medical model are somehow a sufficient answer in and of themselves.

In contrast I tend to look at the fact that teens are by definition at a point of transition. The simple and often direct contingencies of behavior management that have governed their lives up till this point are being faded and more cognitive or delayed rule-based-behavior contingencies are replacing them. Concepts, memes, and ideals become increasingly important. As these shifts take over, the teens become more able to discriminate contradictions, exceptions, and inconsistencies.

However, until these discriminations are firm, there will be uncertainty as to what constitutes acceptable limits of a given contingency. The teens will, as we say “test the boundaries”. Moreover, if a teacher or caregiver adds in a simple contingency to counter this, there may well be an inadvertent counter contingency. This happens all the time with swearing. It is punished when emitted in front of a teacher, but reinforced in the presence of peers. This reinforcing aspect is possibly increased by aggression reinforcers, based on a time when emitting the same word was punished. In other words, the more it is punished in one situation the more reinforcing it is in another.

I have spent a fair amount of time working with teens both with and without disabilities. It seemed the more I discouraged the use of this term the more the teens employed it. Some used it, I think; to get a reaction out of me. So, I made a classic mistake. I increased the severity of my reaction. Whereas before, I gave a verbal reprimand, I now gave written write-ups. This did eliminate the behavior around me, but it continued when I was not around. I wonder in the end, if my actions made a lick of difference in this regard.

Upon reflection maybe there was another strategy. Maybe instead of punishment I could have employed a specific explanation illustrating the rule based contingencies that controlled my own behavior. In other words, I could explain why I chose not to use the word “retard” as a pejorative. This may or may not result in a shift in the contingencies.

Ultimately, if I am correct about the managing contingencies, then strategies where the use of the word “retard” is turned into the equivalent of a swear word, will only increase the usage of this expression.

There is yet another strategy too. I think it is inevitable that many teens are going to at one point or another emit comments that are rude, cruel, or derogatory toward an entire classification of people. Perhaps then, another strategy is to tolerate the misbehavior to degree. This does not imply acceptance, it implies that we understand that this is likely to be an age specific misbehavior that will be intrinsically countered as maturation occurs. If this is true, then our duty is then to provide appropriate models of the verbal behavior employed by adults in our society.

Sunday, March 08, 2009

A Review of Insidevaccines’ “Scary Stats IV: Polio”.

I would like to take this opportunity to review “Scary Stats IV: Polio”. This is my third review of an article from the Insidevaccines blog. Some might wonder why I am reviewing a science issue not related to autism. Well, as said before, Insidevaccines is sometimes described as a model of good science. They are quoted on occasion by those advocating a vaccine etiology theory of autism.

I was very interested to see how well this claim held up. Vaccines are by no means perfect, they do cause injury, and it is possible that they cause at least some cases of autism. Any clarity on vaccine science, even if it points toward an uncomfortable truth, is a good thing. However, one will not find that at Insidevaccines. The first two articles I reviewed had rather remarkable errors of logic and science, this one was no different.

The worst problem in the article is the graph of polio over the years that appears early in the article. It correlates polio with DDT and other chemicals. This is cherry picking on an absolutely epic level. The authors at Insidevaccines state that the discussion will not address the relationship between DDT and polio. The authors give their rationale for using this graph as being that it begins earlier and gives a more accurate picture of the pattern and extent of disease notifications prior to the Salk vaccine. Further, Insidevaccines links to the same or similar graph stretching back further into the 1800s and based on general historical commentary to produce the data points.

The source of the graph is a New Age site promoting a range of metaphysical ideas and alternative medicine, complete with advertising tours for sacred places of power. However, what is interesting is that the site author does not even get simple ideas like incidence correct. Further still, the site author doesn’t mention how s/he obtained the data for the first half of the 20th century.

So, this is what Insidevaccines leaves us; a graph the veracity of which we cannot check, which attempts to correlate DDT and other chemicals to Polio. I argue that their choice was an inappropriate and ill served their readership. That they did not address the argument for DDT as a cause of polio is no excuse. In the realm of science, even in the realm of popular science you present what you mean. If the authors at Insidevaccines do not agree with the DDT argument then they should have created their own graph. Or if they did agree they should have offered their support for this idea. By leaving it as is, their actions do lend themselves to charitable description.

The authors write (references removed):

“Depending on whether you consult the CDC data compiled for parents or the CDC data compiled for medical professionals,
the fatality rate for paralytic polio is between either 2-5% or 5-10%."

If one journeys to the source one will see that the CDC is providing a general rate and then a rate for a specific age group.

“The actual historical data from the peak years: 19,794 avg. acute cases in 1941-1950, which is 0.6% of the total average births for the US from 1941-1950”

Actually, based on the sources the authors’ provide, they miscalculated here. It should be 1.0% of the total average births.

“In 1951-1954, an avg. 16,316 paralytic cases (notice that this data conveniently stops at the time of the definition change and the introduction of the Salk vaccine, thus implying that subsequent reduction in incidence is due to the vaccine. Unfortunately for this hypothesis, the Salk vaccine was shown to have very little positive effect, prompting the switch to the Sabin vaccine)”

A lesser effect is not the same as “little positive effect”. In fact in the field trials, the Salk vaccine was found to be over at least 60% effective for all subtypes of polio and often more than 90% effective (Smith, 1990).

“Based on Table 1
, using the hypothetical birth cohort of 3,803,295 infants as stated in the article, we get 1,179 paralytic cases per year, with an estimated 23 (2%) to 118 (10%) deaths. For 60,974 cases of polio, using CDC metrics of 200:1 inapparent:paralytic (leaving aside how they can project an estimate for an inapparent infection), we would get 3,048 cases of paralytic polio, resulting in 61 (2%) to 305 (10%) deaths, rather than 723.”

The Insidevaccines authors are taking a rate from a single age group and trying to apply it across ages. This comparison has no validity.

“So, what can we conclude from these discrepancies and contradictions? The data doesn’t support the headlines. The numbers presented by vaccine defenders do not stand up to scrutiny.”

Actually it is the poor mathematical practice used by Insidevaccines that is the problem here.

“Our analysis above shows that data are not consistent within an individual publication, or from one publication to the next.”

Offering different rates based on age cohorts or via total should not be a problem for a careful reader. The authors at Insidevaccines have failed to exercise this concept.

“Sometimes, they do not even correlate with numbers from the CDC, an organization whose primary objective appears to be the defense of vaccines!”

This is a ridiculous claim. One does not have to like the CDC or even think they are good people, to recognize this claim as absurd.

“Is their work just sloppy, erroneous, or intentionally misleading? Are they so focused on marketing the vaccines that they are unwilling to critically parse the data? Perhaps they think parents aren’t paying attention.”

Insidevaccines has made basic errors in mathematics, reasonable comparison, data checking, and graphical presentation. Are they prepared to argue that they are paying attention?

In the first article I reviewed from Insidevaccines the authors note that many who advocate for vaccines want nothing to do selective or delayed vaccinators. The authors challenge this stance, as delayed or selective vaccinators may be allies who advocate for certain vaccines. In response, I wrote a number of concerns I think should be addressed before any collaboration was considered. I would like to add a few more.

I think potential allies:

Should accurately quote science

Should not pull graphical shenanigans

Should not mis-compare data

There is room for disagreement and debate in the world of vaccines and autism. Any site that offers science or criticism that illuminates the issue is a blessing. Unfortunately, it is clear that this role will not be fulfilled by Insidevaccines.


Smith, Jane S. (1990). Patenting the Sun: Polio and the Salk Vaccine.