Therapist explains importance of ABA treatment for kids on autism spectrum
Last week, the Ontario government announced it was revamping autism services in an effort to eliminate a waiting list with 23,000 names on it by giving money directly to parents.
One of the central issues for parents of children with autism is access to a long-term therapy called Applied Behaviour Analysis (ABA), which can cost more than $60,000 a year. Research has shown that it is the most effective treatment for the main characteristics of autism.
We asked Kendra Thomson, president-elect of the Ontario Association of Behaviour Analysis, about ABA. Thomson is an associate professor in the department of applied disability studies at Brock University, and a doctoral-level board-certified behaviour analyst.
Q What is ABA?
A The professional practice of ABA involves the design and delivery of interventions that are based on science and have been evaluated in experiments in order to help people develop new skills, such as learning to speak or dress, and to help reduce behaviour that interferes with quality of life, such as self-injury or aggression. ABA involves very close monitoring through direct data collection and the use of data to make treatment decisions on a daily basis.
ABA methods help people with autism spectrum disorders increase behaviours, such as on-task or social behaviours and teach new life skills, communications skills and social skills. The interventions help maintain behaviours, such as self-control. They also help “generalize,” or transfer behaviours from one situation to another — for example, to learn the skills necessary to complete an assignment in a resource room, then transfer those skills to completing an assignment in a classroom.
Q How many trained therapists are there in Ontario? Can they fulfil existing demand?
A There are approximately 650 board-certified behaviour analysts (BCBAs) in the province (certified by the Behaviour Analyst Certification Board). This is not a sufficient number to meet the needs of the demand for ABA services within the autism program. BCBAs also work in many other sectors, including developmental services, education, geriatrics and mental health. So the total number includes professionals working in other disciplines.
Q Parents say full-time ABA costs $60,000 a year or more. Why does ABA cost so much? A Intensive forms of ABA require teaching across the majority of a child’s waking hours. This intensity is required as children often need support in developing skills across many areas. Skills that typically develop in children with very little help may need to be broken down into very small steps and practised with support in order for children with autism spectrum to learn them. So the number of hours of intensive one-to-one intervention is part of the cost of IBI (Intensive Behavioural Intervention).
Equally important to the intensity of the program is the level and type of supervision within ABA and IBI programs. For example, most IBI programs involve a three-tier hierarchy of supervision: an instructor therapist, who is supervised weekly by a senior therapist or BCBA, and then a third level of supervision by a more experienced BCBA or BCBA-D. The job of the supervisors is to ensure that the intervention is being implemented as intended and that the child’s progress is monitored closely through continuous review of the data. This level of supervision, as well as the close monitoring of treatment implementation and data collection, has been supported by research to be a part of the reason why IBI is so effective.
Not all children require IBI or comprehensive ABA programming for many hours per week. Many children require far less support. Autism is a spectrum, so there is no one-size-fits-all support solution. Intervention decisions need to be based on careful assessment of what the person needs.
Q Is there any way to offer ABA at less cost?
A For some children and adolescents less intensive, group-based delivery of ABA is clinically appropriate. However, for other children intensive, comprehensive ABA is required in order to help them achieve best outcomes. For these children, who often have more autism symptoms or severe cognitive impairment, the evidence supports intensive, comprehensive ABA programming. For these children, access to two hours a week versus 36 hours a week is tantamount to giving them nothing. However, it is important to remember that for many children, or at different points of a child’s life, this level of intensive, comprehensive will not be necessary.
Q How will the new provincial system of payment affect the supply and demand for ABA providers?
A The new system will cause significant instability across all autism service providers, both public programs and private programs. Significant layoffs will occur, or are already occurring. As employment opportunities become less stable, behaviour analytic professionals at all levels will leave the field or province, or they will work in other populations, such as adult developmental services or geriatrics. This will further restrict the number of available practitioners and will likely result in a situation in which parents may have money for services but they can’t find people qualified to provide early intensive behavioural services. With such limited funds available, clinicians will have to make difficult ethical choices whether to provide services at suboptimal levels or to provide no service.