Insurance, ABA, and Older Children
October 19, 2008 by Kristina Chew, PhD
Filed under Health
Legislation to provide for insurance coverage for autism treatment has been introduced, and even passed, in many states including my own state of New Jersey; here’s a number of previous posts on this topic. An Associated Press article quotes J.P. Wieske, a lobbyist for an insurance coalition, as saying that “‘This is the hottest trend in mandates we’ve seen in a long time…..It’s hard to fight them.’”
Notable in the Associated Press is mention of families with older children—-11, 12 (same age as my son) who are using ABA therapy. It’s noted that, while there are studies arguing for the benefits of ABA therapy in younger children, research supporting its efficacy for older children are “sparse.”
Some states require behavior therapy coverage up to age 18 or 21. But the scientific evidence for ABA is strongest for the youngest, ages 2 to 5. Some researchers have reported on individual children with autism who no longer appeared disabled when they reached school age.
The most rigorous studies, though, show mixed results. A study published in 2000 showed that preschoolers who got intensive behavior therapy had greater gains in IQ than children who didn’t get the therapy. But there was little difference in the two group’s language development or the intensity of behavior problems. And the children most severely affected by autism showed no comparative gain.
Another study in preschoolers, published in 2005, showed little difference between an intensive ABA-based program run by therapists and less-intensive therapy from parents; children in both groups improved.
When it comes to older children, the research is sparse, said Tristram Smith of the University of Rochester Medical Center in New York, who co-authored the 2000 autism study.
“You could make a decent case for the little kids up to 6 or 7 that (insurance mandates) would be appropriate,” Smith said. “I think it would be hard to make that case for older kids.”
Psychology professor Laura Schreibman of the University of California at San Diego also raises the problem of “‘fly-by-night’ behavior therapists could defraud insurers with ineffective therapy.”
The same questions remain: Are educational treatments like ABA better provided by public schools or private insurers, or by a mix of both? And, how to autistic teenagers and, too, adults—my son is always learning, and I know there’s no deadline for when we stop teaching him.
But to play devil’s advocate (somewhat)… Here in Canada, ABA therapy is not paid for by health insurance, but by the provincial governments. The current waiting list in our province is 2-3 years for coverage. That means that if your child is diagnosed at 3 (like our child), than he could be 6 years old before he starts to receive treatment, and I see this delay only getting longer as more children get diagnosed. Now, I realize that this is a different situation than exists in the US, but is it really fair that a child who is 11 years old, who started to receive funding before the current bottle-neck, continues to get treatment while my son loses what most experts agree are the most crucial years for ABA to work? I acknowledge that there are gains to be made in older children, but I am somewhat bitter that those gains are made at the expense of my child.
Dr. Schreibman states some concerns, which I share, but having read the text of many of the bills, for the most part they define the competencies and supervision of the service delivery and, in some cases, 6 month intervals of review of efficacy. Since she does not state who the “fly-by-night” behavioral service providers are, I can’t speak to the specific competencies that she refers to, or whether she has relevant specific information which have already passed such insurance mandates.
In my own biased statement of self-interest, we tried other interventions and educational strategies, and at least for most skills, those initially based in task analysis and a behavioral approach, and data analysis have been more efficient and effective for us as instructors and less stressful to Eleanor as a student. Because our health insurance has never covered it, nor has the school system very well (I remember some truly rudimentary and tortuous DTT there), for the most part, it has been out-of-pocket, and continues so. A change in our individual situation would be most welcome, but even if there are conditions that restrict our personal ability to access, I would not begrudge those younger children for whom this is a successful approach a more streamlined ability to avoid the roadblocks and headaches that we encountered.
@jen,
The early years of lots of intense teaching helped Charlie tremendously and the training I received in ABA has been something I’ve returned to, to help him through tough moments. I can see how parents of older children (myself included) still use ABA and other educational therapies; ABA has helped us deal with some challenging moments. Like Regan, I don’t at all begrudge families with younger children seeking this foundation—-the last thing we need to do is to feel that we families are set against each other.