Autism Intervention for Underserved Populations: An Example from the Province of New Brunswick
By David Celiberti, PhD, BCBA-D, ASAT Executive Director
I recently had the good fortune of interviewing Dr. Paul McDonnell, Professor Emeritus from the University of New Brunswick in Fredericton, Canada. This interview focuses on the provision of autism intervention services in a low population Canadian province with limited resources, and highlights efforts to reach segments of the provincial population that have traditionally been underserved.
Q: Dr. McDonnell, in order to put your journey in context, I would like to share with our readers how intervention services evolved in your province. As you know, there are many sections of the United States that are rural. Please share with our readers some details about your province and its demographics.
A: In terms of population, the Province of New Brunswick is one of Canada’s smaller provinces (population of about 750,000). Therefore, when it came to offering evidence-based intensive intervention for children with autism, there were financial constraints imposed by the relatively small tax base. Furthermore, 50% of our population lives outside of urban areas much like many of the more rural states in the United States.
We also have a significant population of children of First Nations families to serve. There are about 15 nations of Mi’kmaq and Maliseet Indians in this province. Lastly, we faced the extra challenge of offering intervention services in both French and English, as we are an officially bilingual province. The goal, of course, is to ensure an equally high quality of services in both languages and we were constantly challenged by the fact that the vast majority of educational materials and assessment tools were available only in English. Fortunately, that situation has slowly improved over the past 10 years.
Q: Please share some details about your career path and how you became involved in autism treatment.
A: For many years, I was a professor in psychology at the University of New Brunswick specializing in developmental and child psychology. However, earlier in my career (1964-65), I provided psychological services at a child and adolescent psychiatric clinic in Toronto where I was often working with children with autism spectrum disorder. My time in the Toronto clinic made me aware of the enormous lack of services available for this population despite the very real potential for help through applied behavior analysis (ABA). An early retirement package from the university afforded me the opportunity to change directions and I decided to set up a private practice and focus a lot of my energy supporting parents of children with autism in their quest for better services.
Q: What was autism treatment like twenty years ago? What led to the development of the programme at UNB?
A: 20 years ago in New Brunswick, there were no treatment services for preschoolers, but we did have Early Intervention workers who visited families weekly or bi-weekly and made recommendations largely based on developmental approaches. At that time, school aged-children were being included in the schools but the province’s Department of Education was committed to a policy of full inclusion for all children with special needs. This mostly meant that children were in class with their peers (regardless of their abilities) and while they may have had an educational assistant, they had little in the way of a meaningful curriculum. While this approach to full inclusion was not ideal from our point of view, it was dramatically better than what had existed previously. I do recall that in the 1970s, children with autism spectrum disorders were largely excluded from school, and parents had to provide their own education. In some centres, this was facilitated by schools operated by the association known at that time as the “Canadian Association for the Mentally Retarded.” Today that association has morphed into the “Association for Community Living.” Although parents and professionals began advocating, actively, for evidence-based services early in the 1990s, it took until 2003 for the government to commit to funding preschool services for all children on the spectrum. We are now entering our 10th year with funded intervention services for preschoolers with autism and our 8th year with ABA-based services within the schools.
Q: What were some of the values and core tenets of the initial group of parents and providers that spearheaded this effort?
A: The group of parents and professionals that advocated for services was committed to several core principles:
- We wanted to be sure that adequate training was provided to front-line therapists and their supervisors so that treatments offered would, in fact, be evidence-based and that standards for service would be put in place.
- We recognized the need to provide as many hours of treatment as possible and certainly, based on the research, we knew that the minimum was 30 hours for most children.
- We saw the need to have standards set for diagnostic assessments and some way for assessments to be expedited so that families were not kept waiting unduly. A timely and accurate diagnosis is essential for families to be fully informed and for the intervention teams to have a benchmark and a set of initial target behaviors.
- We saw the need to extend treatment through the school system in some manner and that transition to the schools from the preschool services should be as seamless as possible.
- We recognized that we had to ensure that the quality of services was equitable across Anglophone and Francophone populations as well as across rural and urban families. As a result, we advocated that a province-wide system be established that would provide training and ultimately, intervention.
- We were committed to the idea that parents also need training and need to be as well educated as possible in order for them to support and participate in intervention programmes for their children.
- A final principle was that we wanted to ensure that we had a multi-disciplinary approach so that we would have the support of all professions that are involved in interventions with children with autism while still maintaining our commitment to evidence-based interventions.
Q: I understand that the programme was launched in 2003. What did it involve?
A: In December 2003, the provincial government’s Department of Family and Community Services announced that funding would be provided for intensive behavioral interventions for preschool children with autism spectrum disorders including children from the First Nations whose funding generally is provided by Federal sources. They also agreed to fund a comprehensive province wide training programme. The University of New Brunswick’s College of Extended Learning won a contract from the province to offer training to front line therapists, which we called Autism Support Workers (or ASWs) as well as Clinical Supervisors (CSs) who were to be drawn from the ranks of health and educational professionals (viz., Occupational Therapists, Psychologists, Speech Language Pathologists, etc.). The Clinical Supervisors are responsible for writing individualized programme plans for children with autism and for supervising the implementation of the therapy plan by the Autism Support Workers.
The contract was awarded to the university in February 2004 and we were to be up and running by June. Thus, we had about four months to implement this comprehensive training programme and needed to find a way to provide trained staff to over 200 children. The reality of life at that point in time was that there were almost no professionals within our province that specialized in applied behavior analysis or had developed expertise in clinical supervision. Further, there were only a handful of front-line therapists with any experience. With this in mind, our biggest challenge initially was to find qualified instructors. In the end we were fortunate to be able to hire two complete teams of about six instructors each to serve our two language populations. The teams each were staffed with Psychologists, Occupational Therapists, Speech Pathologists, and Educators all of whom had experience with behavioural interventions. Two professionals flew in from Montreal and the rest either lived in the province or moved here. While none of these people had BACB certification, all had had extensive experience with autism interventions and most were skilled in behavioral theory and techniques. Today in New Brunswick, there are 13 professionals with BCBA certification and several more will become certified in the next year. Since 2004, the Autism Intervention Training Program at the University of New Brunswick has trained over 1000 people in evidence based intervention methods, especially applied behaviour analysis. The Province now funds 20 treatment hours per week of intensive behavioural intervention for all children diagnosed with any level of ASD and services are available throughout the province with waiting times under a year.
Q: Please tell our readers more about what the training involved.
A: For the past 10 years, most of the people trained in autism intervention services were trained through the Autism Spectrum Disorder Intervention Training Programme at the university. The province provided free instruction for students accepted into the training programme for both preschool and school based staff. Courses were 50% lecture and 50% practicum. The number of hours of instruction was 168 for Autism Support Workers and 299 for our Clinical Supervisors and the training was spread out over seven to eight months. The curriculum incorporated face-to-face teaching with web-based training and a hands-on practicum. The use of webbased technologies allows students in more rural areas to remain at home at least for some of the course work. The guiding design principle of this blended model is to provide an instructionally sound, flexible, user-friendly teaching and learning solution. The curriculum was compiled initially by team members in a series of educational sessions and has been overseen by a curriculum advisory committee at the university. In the past two years, the administration of funding for both preschool and school-based services has been taken over by the Department of Education. In addition to taking over the funding, the Department of Education has developed its own curriculum, which in many ways parallels the curriculum developed by the university. The department plans to provide core training for all preschool workers and educational assistants.
In addition, there will be advanced training for clinical supervisors and resource teachers. Meanwhile, the University of New Brunswick has re-configured into an open access programme and has developed a Bachelor’s level option in applied behaviour analysis.
Q: Given the mandate to serve both French speaking and English speaking individuals, please share the path that your group undertook to adequately meet the needs of Francophones.
A: Francophone and Anglophone instructors worked jointly to prepare details of lecture topics and practicum sessions. We specifically selected most of the topics from the BACB Task List but also included some topics and strategies specific to autism interventions not included on that list (e.g., ethics, developmental theory, Picture Exchange Communication System, visual schedules, etc.). We quickly discovered that there were very few resources with which to teach ABA available in the French language. While we had journal articles, texts, and video productions available in English almost none of this material was available in French. This posed a major problem for us in our attempt to provide the same quality of programme for both language groups. We could not assign a common textbook so we put together a course pack of key articles under a license agreement with a Canadian copyright licensing agency, which included translation of some key materials. Fortunately, well-known books by Maurice, Green, and Luce and Leaf and McEachin have been translated into French. In addition, Dr. Barbara D’Entremont and I applied for and received a grant in 2006 from Ronald McDonald House Charities to produce a set of five teaching videos in both languages. These videos were intended to give the very basic, core principles of some key intervention strategies (e.g., reinforcement, generalization) and were intended to provide some useful visual supports for our training programme.
Today, these teaching videos are freely available online for anyone to view (“Autism Intervention Training” video series: https://vimeo.com/41718685). Clearly, the lack of literature and media materials in French and in many other languages significantly limits the spread of knowledge about behavioral interventions. Another important part of the curriculum was to bring in at least two internationally known speakers each year to address a critical topic within our curriculum or one in which our local teachers did not have adequate expertise. In addition, the visiting speakers became part of our continuing education programme.
Q: What were some other lessons learned?
A: We wanted to attract students who were already experienced working with children either as a health professional or as an educator. The amount of time required for an educational leave of absence is one of the main considerations in attracting professionals who already have heavy time and financial commitments. If you want to attract mature students to a programme, even a free programme, it has to be possible for them to arrange for time off, and, not be too burdensome in terms of lost income. Therefore, while more hours of instruction would be desirable, we realized we had to strike a balance in order to develop a bank of trained therapists within the province in a reasonable time frame.
In order to reach out to potential students in the more remote regions, we opted to make use of audio and video conferencing and the instructional web-based tools, Web CT and Blackboard. PowerPoint lectures were set up on Web CT as PDF files which students could download in advance of videoconference lectures. Assignments, tests, and resource materials were also provided on Web CT. For example, students in the clinical supervisor course do on-line assignments in small groups that are monitored by our faculty. Practica were offered in various locations around the province to reduce travel time for students as much as possible. The combination of free tuition, web based training, different venues for practica, and a bilingual delivery has resulted in successful training of over 900 professionals in a 10-year period.
Q: Tell me a bit more about the present state of autism interventions in the province.
A: One of the nice features of the programme was that all children are provided with a thorough developmental assessment at the start of therapy. In addition, the province has 6 private agencies that are approved by the government and are responsible for delivering preschool treatment services around the province in whichever language is required. All regions are covered and one of the agencies was designated responsibility for any children who for some reason could not be included by the agency that was physically closest. At the present time there are no significant waiting lists (e.g., not more than four to six months after diagnosis) and all preschool-aged children are accepted so long as there is a diagnosis that places them on the spectrum. Children in the preschool programme can continue with therapy (if needed) until they enter the school system. Transition to the elementary schools is done with collaboration between the preschool therapists and the school staff. Preschool therapists attend school with the child for the first month or so and in some cases, longer if needed. In some cases, children can remain for some additional time in the preschool programme if that is deemed the best placement. Perhaps the greatest weakness of the programme from our point of view is that the number of hours currently funded is 20 hours per week and we would like to see that increased to 30 hours per week. We would also like greater flexibility in determining the number of hours allocated based on clinical factors.
It should also be mentioned that the Department of Health in New Brunswick has provided base funding for a network of eight resource centres across the province. These centres provide material and social support to families in each region. Among their services, they offer workshops, provide support groups for teens and adults, parent support groups, organize recreational activities, and a drop-in centre. They also provide books, videos, and many other teaching materials. What were some of your outcomes? The programme currently serves about 620 preschool children (approximately 425 are Anglophone and 195 are francophone) plus about 1780 students in Anglophone K-12 and 560 in the Francophone K-12 streams.
In the past 10 years the College of Extended Learning at the University of New Brunswick has trained about 380 autism support workers (front line therapist) plus 75 clinical supervisors for the preschool intervention programmes. In the last 8 years we have also trained about 430 educational assistants and about 125 resource teachers on a contract with the Province’s Department of Education. In addition, workshops and programmes have been offered to about 300 parents. Further, the College of Extended Learning has been offering similar training in the province of Saskatchewan.
The figure below shows the steady increase in enrollment in our preschool intervention programme. This represents approximately a 45% increase. It is always interesting to speculate on the causes of this dramatic increase.
We do know that a number of factors are involved including a greater willingness among professionals to diagnose ASD when treatment services are available and accessible. Similarly, more families seek a diagnosis when they know there are services are available. In addition, there has been some immigration into the province and retention of families because of the accessible services.
Q: What is next?
A: As is true in most other jurisdictions, we have a long way to go to provide the quality and level of service that is needed. The following is a short list of goals that we have now:
- To provide a range of residential and vocational services staffed with behaviorally trained supervisors and therapists
- To increase the hours of intervention for children in pre-school intervention programmes;
- To provide comprehensive parent training for Anglophone, Francophone, and First Nations families
- To follow up initial developmental assessments with periodic re-assessments and provide an ongoing evaluation of outcomes
- To provide funding for after-school hours and summer intervention programmes for those who need this service
- To increase the number of opportunities for continuing education for graduates from our autism intervention-training programme
Q: How can readers learn more about the UNB programme?
A: For more information on our training programmes, please visit “Autism Support Training Programmes:” www.unb.ca/cel/programs/alphabetical-listing.html.
Q: Finally, I understand that an Association for Behavior Analysis International (ABAI) affiliate chapter was created. What was that process like and have you had the opportunity to meet other behavior analysts outside of the field of autism treatment?
A: During the past two years, a group of us who are ardent supporters of ABA have seen the need to create a chapter of ABAI within the Canadian Atlantic Provinces. This perceived need was galvanized into action by Sheila Bulmer who, at the time, was an Autism Project Coordinator with the Atlantic Provinces Special Education Authority or APSEA. The move towards an Atlantic Provinces Association was seen as a way to bring a high standard of training and expertise to the whole region. Efforts were made to form an association and complete the application to ABAI to form a chapter. This was brought to a successful conclusion in February of this year with ABAI extending approval to our association to become a chapter. Your question is well taken, as one of the first benefits for me personally was the opportunity I have had to meet with behaviour analysts who work in fields other than autism. These include OB consultants and professors involved in research at regional universities. We had our first business meeting at ABAI in Chicago and attended the Expo and a leadership seminar. Our membership currently stands at about 18 but we think that our potential will be about 60 members. At this point we are working to develop our web site and we have already developed a Facebook page. There is also a link on the ABAI web site to our Facebook page as well as our membership application form. We even have developed a logo that represents the four Atlantic Provinces:
Thank you Dr. McDonnell for a wonderfully informative interview! Please click here for a review of the training videos.
Citation for this article:
Celiberti, D. (2014). Autism intervention for underserved populations: An example from the province of New Brunswick. Science in Autism Treatment, 11(3), 2-9.