Dear Mr. Philpott.
Thank you for sharing information on the importance of evidence-based intervention for children with autism. We commend Tricare for funding interventions based on the science of applied behavior analysis (ABA) for children of military families. However, we were concerned to read that ABA does not currently meet Tricare’s requirements for evidence-based coverage as part of the basic benefit, and that the current funding scheme is considered a “demonstration” because, as stated by Navy Capt. Edward Simmer, Chief Clinical Officer of the Tricare Health Plan, “the effectiveness of applied behavioral techniques for autism remains unproven.”
The effectiveness of ABA-based interventions in ASDs has been well documented through 5 decades of research by using a variety of research methods, including single-subject designs, randomized controlled clinical trials, meta analyses, and cost benefit analyses. This body of published work in peer-reviewed journal is based on the collective scientific efforts of hundreds of researchers. Children who receive early intensive behavioral treatment based on the principles of ABA have been shown to make substantial and sustained gains in IQ, language, academic performance, and adaptive behavior, and their outcomes have been significantly better than those of children in control groups (including no treatment, low intensity treatment, or non-ABA treatment groups; see Eldevik et al, 2009).
It is important to note that ABA isn’t one type of treatment for autism, and is not simply a set of techniques. Rather, ABA is a comprehensive approach to treatment that encompasses many evidence-based teaching methods, in addition to ongoing data collection and data analysis to make treatment decisions (one such modification may involve the number of hours of therapy the child is receiving). An Applied Behavior Analytic approach to treatment should include the following essential components, which are described in the Behavior Analyst Certification Board’s Practice Guidelines for Healthcare Funders and Managers:
- A comprehensive developmental assessment to identify the person’s strengths and skill deficits at the outset of treatment
- The careful selection of treatment goals such that the person’s health, independence, and quality of life are improved
- The inclusion of the person and family in the treatment planning and treatment review process
- A carefully constructed and individualized treatment plan that uses positive reinforcement (and other procedures with strong scientific support) to teach new skills and strengthen adaptive and pro-social behavior
- A focus on establishing small units of behavior that gradually build toward larger functional life skills
- Treatment protocols that are implemented consistently across people and environments until discharge criteria are met
- The collection and analysis of data of skill development to inform clinical decision-making and revisions to the treatment plan
- Direct support and training for family, support workers, teachers, and other professionals who are part of the treatment team
These are the essential elements that define an applied behavior analytic approach to treatment, not a single technique (such as discrete trial teaching) or set of techniques. Sadly, misunderstandings and mischaracterizations of ABA have led to policy reform and government positions in many countries that prevent people with autism and related conditions from accessing effective interventions based on rigorous scientific research. We hope Tricare will take steps to fully appraise this body of research, and disseminate accurate information to the public about ABA. For more information on evidence-based, scientifically sound treatments for autism, we invite you to visit our website.
Sincerely,
Erin Leif, PhD, BCBA-D
Association for Science in Autism Treatment
References:
Eldevik, S., Hastings, R.P., Hughes, J.C., Erik, J., Svein, E., & Cross, S. (2009). Meta-Analysis of Early Intensive Behavioral Intervention for Children with Autism. Journal of Clinical Child & Adolescent Psychology, 38(3), 439-450.
