1. Applied Behavior Analysis:
Medically Necessary Treatment for
Autism Spectrum Disorders
West Virginia Autism Insurance
Stakeholders Roundtable
July 13, 2012
Stonewall Resort
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2. What is Autism? What is Autism
Spectrum 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.
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3. What is Autism Spectrum
Disorder? (ASD)
 Itincludes:
 autistic disorder,
 Rett syndrome,
 childhood disintegrative disorder,
 pervasive developmental disorder-not
otherwise specified (PDD-NOS) and
 Asperger Syndrome
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4. What is Autism? What is
Autism Spectrum Disorder
 ASD can be associated with:
 intellectual disability,
 difficulties in motor coordination
 attention
 physical health issues such as:
sleep and
gastrointestinal disturbances.
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5. What is Autism? What is Autism
Spectrum 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.
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6. A national public health crisis
 Autism statistics from the U.S. Centers for
Disease Control and Prevention (CDC)
identify around 1 in 88 American children as
on the autism spectrum–a ten-fold increase in
prevalence in 40 years.
 An estimated 1 out of 54 boys and 1 in 252
girls are diagnosed with autism in the United
States.
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7. What is Autism? What is
Autism Spectrum Disorder
 By way of comparison, more children are
diagnosed with autism each year than with
juvenile diabetes, AIDS or cancer, combined.
 ASD affects over 2 million individuals in the
U.S. and tens of millions worldwide.
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8. Applied behavior analysis
(ABA)
• Behavior analysis:
• A natural science approach to understanding and changing
behavior; focus is on interactions between behavior and
environment
• A distinct discipline with theoretical, experimental, and applied
branches and specific research methods, scientific journals,
and scholarly/professional organizations
• Applied behavior analysis (ABA): Application of
scientific principles of behavior (e.g., positive
reinforcement) to improve socially significant behavior
to a meaningful degree
• Many applications in addition to ASD treatment
• Based on the work of many researchers and practitioners over
40+ years
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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
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10. ABA in practice
• ABA is a distinct profession; not the same as clinical
psychology, developmental psychology, educational
psychology, counseling, special education, occupational
therapy, etc.
• The internationally accepted credentialing program for
professional practitioners of ABA is managed by the
nonprofit Behavior Analyst Certification Board, Inc.
(BACB; see www.BACB.com)
• Accredited by the National Council for Certifying Agencies,
Institute for Credentialing Excellence
• BACB-certified behavior analysts are recognized as qualified
providers in autism insurance laws, Medicaid laws, and other
laws and regulations in many states, and by the U.S.
Department of Defense TRICARE health plan under its ABA
benefit for military children with ASD.
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11. ABA: Evidence-based
treatment 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.
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12. ABA: Medically necessary
treatment 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."
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13. ABA: Medically necessary
treatment for ASD
 A number of other government and national health
organizations recognize ASD as a medical condition,
including:
 -The U.S. Surgeon General
 -National Institutes of Health
 -National Institute of Child Health and
Human Development
 -American Academy of Pediatrics
ALL of these organizations recognize and
recommend ABA as the only proven method
for treating ASD.
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14. ABA: Medically necessary
treatment 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.
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15. ABA: Medically necessary
treatment for ASD
 “Plaintiffshave established through their
expert witnesses that there exists in the
scientific and medical peer-reviewed
literature a plethora of meta-analyses, studies
and articles that clearly establish ABA as an
effective and significant treatment to prevent
disability and to restore children to their best
possible functional level and restore their
developmental skills.” Florida Federal Judge, Joan Lenard
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16. ABA: Medically necessary
treatment for ASD
 The treatment for all other neurological
disorders (such as traumatic brain injury,
seizure disorders, ALS, Parkinson's Disease)
is considered medically necessary. As a
neurological disorder, ASD is no different.
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17. ABA: Medically necessary
treatment for ASD
• Medically necessary treatments ameliorate or manage
symptoms, improve functioning, and/or prevent deterioration.
• ASDs are neurodevelopmental conditions that manifest in
behavioral symptoms, i.e., behavioral abnormalities in three
core domains: social interaction, communication, and interests
and activities.
• ABA treatment has proved effective for ameliorating those core
symptoms as well as building other skills that enhance
functioning and health in people with ASD, such as
• Hygiene and self-care skills
• Personal safety skills
• Eating a healthy diet
• Sleeping
• Cooperating with medical and dental procedures
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18. ABA: Medically necessary
treatment 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
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19. Summary
• Contemporary ABA intervention for ASD rests on
more than 40+ years of scientific research.
• At present, no other approach to ASD intervention
has comparable scientific support
• Best available scientific evidence indicates that
competently directed and delivered early intensive
ABA intervention is especially effective for
ameliorating and preventing symptoms of ASD.
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20. Summary
• ABA intervention is now deemed medically
necessary for people with ASD by many public
and private health plans around the U.S.
• Health insurance coverage of ABA
intervention for ASD provided by professionals
credentialed by the Behavior Analyst
Certification Board
can save millions in health care and other
costs over time.
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21. For more information on ABA for
ASD, please see…
 www.autismspeaks.org/whattodo/what_is_ab
a.php (Autism Speaks)
 www.behavior.org/autism (Cambridge Center
for Behavioral Studies)
 www.apbahome.net (Association of
Professional Behavior Analysts)
 www.asatonline.org (Association for Science
in Autism Treatment)
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22. For qualifications to practice
ABA, please see…
 Behavior Analyst Certification Board --
www.BACB.com
 Association of Professional Behavior Analysts --
www.APBAhome.net
 Association for Behavior Analysis Autism
Special Interest Group Consumer Guidelines -
http://www.autismsig.org
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23. Acknowledgement
We would like to express our sincere thanks
to Gina Green, PhD, BCBA-D, Executive
Director of the Association of Professional
Behavior Analysts, for permission to
redistribute her materials.
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24. References
Association for Science in Autism Treatment - reviews of evidence on autism treatments
http://www.asatonline.org/resources/autismtreatments.htm
Campbell, 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.
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25. References
Green, 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: A
Symposium Issue of the Speaker’s Journal of Pennsylvania Policy (pp. 119-132).
Harrisburg, PA: Legislative Office for Research Liaison, Pennsylvania House of
Representatives.
Green, G. (in press). Early intensive behavior analytic intervention for autism spectrum
disorders. In E. Mayville & J.Mulick (Eds.), Behavioral foundations of effective autism
treatment. Sloan Publishing
Hall, L.J. (1997). Effective behavioural strategies for the defining characteristics of
autism. Behaviour Change, 14, 139-154.
Jacobson, J.W., Mulick, J.A., & Green, G. (1998). Cost-benefit estimates for early
intensive behavioral intervention for young children with autism: General model and
single state case. Behavioral Interventions, 13, 201-226.
Kodak, T., & Piazza, C. (in press). Assessment and treatment of feeding and sleeping
disorders in children diagnosed with developmental disabilities. Child and Adolescent
Psychiatry 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 children
with autism. Focus on Autism and Other Developmental Disabilities, 20, 98-105.
25

26. References
Lilienfeld, 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.com
Motiwala, 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. References
Perrin, C. J., Perrin, S. H., Hill, E. A., & DiNovi, K. (2008). Brief functional analysis and
treatment of elopement in preschoolers with autism. Behavioral Interventions, 23, 87–
95.
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 Applied
Behavior Analysis, 30, 653–672.
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 reinforcing
functions. 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 with
developmental disabilities. Research in Autism Spectrum Disorders, 3, 409-420.
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28. References
Smith, 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 military
dependent children with autism. Washington, DC: Author.
U.S. Surgeon General ‘s Report on Mental Health – Autism Section:
www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html#autism
Weiskop, S., Richdale, A., & Matthews, J. (2005). Behavioural treatment to reduce sleep
problems 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 core
symptoms with intervention. Research in Autism Spectrum Disorders, 1, 304-317.
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