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Applied Behavior Analysis (ABA) in Schools and in Clinics: Similarities and Differences

 

Contributed by:

Dr. Cathy Pratt, BCBA-D, Director, Indiana Resource Center for Autism
Pennie Gregory, MA, Assistant Director, MSD of Wayne Township
Laura Kuhn, MA, Autism Specialist, West Central Indiana Special Services Cooperative
Michele Trivedi, MHA, Parent of Adult on the Autism Spectrum, Manager, The Arc of Indiana Insurance Advocacy Resource Center

 

At times, parents choose to send their children to an ABA clinical program. Fortunately, Indiana has many options statewide from which parents can choose. Other parents choose to educate their child via the public school program. Still other families will choose a combination of programming. Having options and choices for family members who only want the best for their child is important. At times, family members may not understand what choice is best for their child, or what the differences are between a school program and clinical/medical ABA therapy program. This article hopes to clarify these differences so parents can make informed choices.

Purpose

Clinical/Medical ABA Therapy

To treat, ameliorate, manage or prevent the signs, symptoms and effects of the neurological condition of an autism spectrum disorder as defined by the DSM 5. Goal is to prepare children for less restrictive settings and with important lifelong skills.

 

Educational Programming

To provide a free and appropriate public education (FAPE) in the least restrictive environment (LRE) driven by a child’s individualized education program (IEP). Program goals can address academic, communication, social, behavioral, life and emotional skills. Ultimate outcome is to assist in preparing students for post-school outcomes.

 

Location: Where are services provided?

Clinical/Medical ABA Therapy

Can be provided and practiced in a hospital, home, clinic or community setting (including but not limited to schools, daycare, stores, car, a church, relatives home, etc.).

 

Educational Programming

Programming provided in a school building or in community settings.

 

Diagnostic Criteria: How do they qualify?

Clinical/Medical ABA Therapy

Must be diagnosed with an autism spectrum disorder by a medical provider. ABA may be prescribed by a treating clinician or psychologists. Family works with ABA center on developing a treatment plan that is submitted to insurance or Medicaid.

 

Educational Programming

Multi-disciplinary assessment must be completed by a school team to determine educational eligibility and to decide what disability category the child will be served under. Evaluation results are reviewed by the case conference team, of which the parent is a member. Medical diagnosis may be considered as part of overall evaluation process.

 

Providers: Who provides the services?

Clinical/Medical ABA Therapy

Certified BCBA (Board Certified Behavior Analyst) or BCBA-D (Board Certified Behavior Analyst-Doctorate) directs and oversees programming. A registered behavior technician (RBT) often carries out the direct hands on work under the direction of the BCBA.

 

Educational Programming

Licensed and certified teachers, occupational therapists, speech language pathologists, social workers, physical therapists, other related services staff, and unlicensed staff (paraprofessionals) conduct programming. Some schools employ BCBAs and RBTs, but are not required to do so.

 

Required Training and Certification or Registration

Clinical/Medical ABA Therapy

The Behavior Analyst Certification Board (BACB) https://www.bacb.com/ outlines requirements for training, certification, re-certification, and continuing education. BCBAs are not licensed in Indiana. BCBAs are required to have a least a Master’s degree, must complete specific coursework, complete a specific number of hours of supervision, and pass a national exam. Individual centers may develop additional training expectations for staff around ethics and such. Every two years, the BACB requires 32 hours of continuing education units, including 4 around ethics for all BCBAs. Registered Behavior Technicians (RBT) must complete a specific training program and pass a national exam, complete on-going education and must be specifically supervised by an assigned BCBA who is responsible for their performance. While a bachelor’s degree is not required, some providers do require that RBTs have a bachelor’s degree.

 

Educational Programming

Teachers complete college coursework on topics around curriculum, use of evidence-based practices, classroom management and individualizing instruction. Course work may address applied behavior analysis (tools and not intensive early intervention). Some teachers pursue becoming a BCBA. This is not a requirement in the state. Teachers are licensed by the state. The professional standards board for the state determines the type and amount of ongoing professional development staff are required to complete. Teachers must have at least a bachelor’s degree and must complete course work, field experiences, student teaching, and pass state licensure exams. Course work is mapped to the Council for Exceptional Children professional standards and includes evidence-based practices for supporting students with or at risk for a variety of disabilities.

 

Caseloads

Clinical/Medical ABA Therapy

Caseloads are limited by BACB standards (must be less than 20 for those needing intensive intervention); quality providers have typical caseload of less than 10 intensive intervention cases and may have stricter caseloads than the BACB standards.

 

Educational Programming

Classroom sizes will vary depending on whether the student is in special or general education, and the intensity of need. For students with more significant disabilities, class sizes may be smaller. There is no guidance or laws mandating caseloads.

 

Intervention Goals

Clinical/Medical ABA Therapy

Goals address characteristics identified in the DSM 5 criteria. Typical intervention goals will include language and communication, daily living skills, play skills and specific parenting and community goals.

Very few ABA programs are approved as education providers. This means they cannot offer course work that applies toward graduation.

 

Educational Programming

Goals are aligned with state standards and address all aspects of a child, including cognitive skills, executive functioning, communication, behavioral goals, and social skills, sensory and other goals as needed. Students gather credits that are necessary to graduate and be eligible for post-high school options (e.g., trade school, college, university). The child’s educational team, including family members, determine educational goals via the Individual Education Program (IEP) process.

Required Ethical Code

Clinical/Medical ABA Therapy

All must follow BACB Ethical Guidelines and provider organization policies. Although pursued by parents and providers, there is no licensure at this time in the state. Providers must also follow medical ethics and clinical community standard of care. When organization policies conflict with BACB ethics code or medical ethics, the provider/center must address and resolve. Fiduciary duty to the patient is paramount.

 

Educational Programming

Must adhere to school and state policies, practices and guidelines as set for by professional licensing board, the individual school district board, and federal and state legislation.

 

Standards of Care

Clinical/Medical ABA Therapy

Must abide by the professional and community standards of medical care as defined by the BACB, and relevant medical societies (pediatric, psychology, neurology, psychiatry, etc.).  Licensure of BCBAs is not currently required in Indiana; it is required in 30 states.

 

Educational Programming

Teachers are licensed in education and are required to follow federal and state level policies and standards. Teachers are evaluated by administration.

 

Accountability

Clinical/Medical ABA Therapy

Clinically significant progress as documented by daily data compiled and charted by supervising BCBA and plotted to demonstrate significant progress. Children assessed semi-annually to document progress as demonstrated using standardized developmental instruments.

Educational Programming

Educational staff members are required to collect data on IEP goals and to document progress. Behavior data collected for students who have a behavior implementation plan. Every three years, students are re-evaluated by a multi-disciplinary team using standardized instruments to assess progress, eligibility and future needs. In addition, in Indiana students are part of statewide testing.

IEP meetings are required annually.

 

Timeframe

Clinical/Medical ABA Therapy

ABA Centers only provide treatment during the day. Home based providers are available that can provide intervention during evening and weekend hours.

 

Educational Programming

Educational programming ends at the age of 22. At age 14, a transition plan is developed to help a child move to adult services upon graduation. Programming is only provided during the school day. Schools work collaboratively with families to help them identify strategies for home.

 

Funding

Clinical/Medical ABA Therapy

ABA programs are funded through private insurance and Medicaid because ABA is considered a medical necessity. Treatment plans are reviewed every 6 months to determine ongoing eligibility for funding. In Indiana, insurance only covers ABA for students on the autism spectrum. Clinical programs vary in cost since they vary in number of hours provided and are based on individual need. Programs are typically funded at a higher level than schools. This facilitates a better staffing pattern and more individualized treatment.

 

Educational Programming

Public education is supported via federal, state and local funds. Some districts pursue referendums, and Medicaid to supplement costs.

 

Entrance Criteria

Clinical/Medical ABA Therapy

Children receiving ABA treatment require a diagnosis of ASD from a qualified medical professional and an evaluation by the ABA center to determine level of care (e.g., 40 hour, 20 hour, 10-hour weekly treatment program). This information is submitted to the insurance provider for Prior Authorization (PA). Once approval is provided, treatment can commence. Insurance companies typically require authorization of treatment every 6 months.

 

Educational Programming

Public Education can turn no child away.