How Does Senate Bill 946 Affect Individuals with Autism in California?

Senate Bill 946, passed by the State Assembly and the State Senate on September 9th, 2011 and signed by then Governor Brown and filed with the Secretary of State on October 9th, 2011 is a monumental step for individuals with Autism and Pervasive Developmental Disorder (PDD) in California. The new law took effect on July 1st, 2012.

Previous to this bill signing, individuals with autism could get necessary services in one of three ways. First, families or caregivers could pay out-of-pocket. Only a small segment of the population could afford this as estimated costs for monthly services ranged from $3,000 to $12,000. The second way to get services was to request them from your local school district. This has proven to be very challenging as the school districts have been unfamiliar with the unique service type and more recently are financially challenged. Last was the option of regional centers. There are 21 in the state of California at present and each one has taken a slightly different approach to providing services for Individuals with Autism and Pervasive Developmental Disorder. In addition, the budget crisis in California in the early 2010’s has greatly affected most regional center’s abilities to provide services. Thus, using a regional center then for services for an individual with Autism or PDD depending on where one lived and the policies of that regional center, could also prove challenging.

As a result of SB 946 over the last few years, individuals with Pervasive Developmental Disorders or Autism are entitled to use their medical insurance to obtain services. Specifically, as of July 1, 2012 individuals in the state of California can now use their medical insurance to obtain services Pervasive Developmental Disorders or Autism. This applies to the following medical service providers: Every health care service plan contract that provides hospital, medical, or surgical coverage. It appears that SB 946 does not apply to a medical insurance plan that does not provide behavioral health or mental health services, a health care service plan in the Medi-Cal program, a health care service plan in the Healthy Families Program, or health care benefit plan or contract entered into with the Board of Administration of the Public Employees’ Retirement System.

It is important to note that SB 946 specifically states that there is no intention of the bill to alter the responsibilities that have typically fallen under an Individual Educational Plan (IEP) under the Individuals with Disabilities Education Act (IDEA and its amendments and reauthorizations) or in and Individual Program Plan (IPP) under Title 17. We interpret this to mean that SB 946 does not mean that school systems will no longer have to provide services or will have to alter the services they provide to individuals with Pervasive Developmental Disorders or Autism because the bill now requires that medical insurance will now also cover services. In addition, we feel that the same conclusion can be reached that SB 946 will not eliminate, reduce, or alter regional center’s responsibilities to provide services to Pervasive Developmental Disorders or Autism under Title 17.

What treatments are covered? The following is what SB 946 is referring to when it is talking about services. Specifically, “Behavioral Health Treatment” means professional services and treatment programs, including Applied Behavior Analysis and evidence-based behavior intervention programs. Other than Applied Behavior Analysis, no specific mention of another treatment approach is made.

What is required of the treatment programs? The treatment programs must include all of the following criteria to be eligible for coverage. First, the treatment has to be prescribed by a physician or licensed psychologist. Second, the treatment follows a treatment plan prescribed (developed by) a qualified Autism service provider and administered by a qualified Autism service provider, a qualified autism service professional supervised and employed by the qualified autism service provider, or a qualified autism service paraprofessional supervised and employed by a qualified autism service provider. Third, the plan developed by a qualified Autism service provider has measurable goals that are specified to a timeline and that are unique to the individual being treated. The treatment plan has to be reviewed no less that once every six months, modified when appropriate, and describes the individual with Autism’s impairments that will be treated; develops an intervention plan that specifies the service type (i.e., techniques and methodology), the number of hours required, the level of parent participation to achieve those goals, and the frequency of progress evaluation and progress reporting. Fourth, discontinues intensive intervention services when goals have been achieved or are no longer appropriate. Last, the treatment is not used as a means of or a reimbursement for a respite program, day care, or educational services and cannot be used as a means to reimburse a parent for participating in the program.

What is a qualified Autism service professional? SB 946 specifies the following criteria must be met to be considered a qualified Autism service professional. First, this person provides behavioral health treatment (e.g., treatment for individuals with Autism). Second, if they do not meet the criteria to be a qualified Autism provider, that the person is employed and supervised by a qualified autism service provider (e.g., an agency or clinic). Third, that individual provides treatment that follows a treatment plan developed and approved by the qualified autism service provider. Third, is a behavioral service provider approved as a vendor by a California regional center to provide services as BCBA-D, BCBA, BCaBA, a Behavior Management Assistant, a Behavior Management Consultant, or a Behavior Management Program as defined in Section 54342 of Title 17 of the California Code of Regulations. We interpret this to mean that one of the criteria to be considered a qualified Autism professional is to have met the vendor requirements of a California regional center. Fourth, that the individual has training and experience in providing services for pervasive developmental disorder or autism.

SB 946 also provided for an Autism Advisory Task Force. The purpose of the task force was to submit a report to the Governor and specified members of the Legislature by December 31, 2012. The report developed recommendations regarding behavioral health treatment that is medically necessary for the treatment of individuals with autism or pervasive developmental disorder.

What are the Changes to the Diagnosis of Autism with the DSM-V?

The first change with the new edition of the DSM is to combine the formerly separate diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not-otherwise-specified into one group with the name of Autism Spectrum Disorder. The stated reason for this was that of reliability and validity. That is, the DSM IV could, to the satisfaction of the committee, distinguish individuals with autism from typically developing individuals. Further, the committee stated that because autism is described by a common set of behaviors that it is best represented as a single disorder. Finally, the committee stated that a single spectrum disorder represents the current state of knowledge regarding the disorder and how it appears clinically to clinicians.

The second change is the combining of the three domains that appeared in DSM-IV (Qualitative impairments in social interaction, Qualitative impairments in communication, and restricted repetitive stereotyped patterns of behavior) into two domains (Social Communication Deficits and Fixed Interests and Repetitive Behaviors). The following rationale were provided: 1) deficits in communication and social behaviors are inseparable and; 2) delays in language are neither unique to autism (i.e., they appear in other disorders), nor are they universal (i.e., not all individuals with autism have them); 3) The changes improved specificity of the diagnosis while not compromising the sensitivity; 4) Increased sensitivity across severity levels of autism; 5) Secondary analyses of data sets support the combination of categories.

The third change is a change in the criteria within the social/communication domain were merged and streamlined to clarify diagnostic requirements. The following rationale was provided. In the previous version of the DSM several criteria measured the same symptom thus giving greater importance to that symptom (social/communication) and the merging of these criteria requires a new approach to them. Secondary data analyses were conducted to determine the most sensitive and specific symptom clusters to facilitate diagnosis for a range of ages and language levels.

Next, there is a new requirement of two symptoms from repetitive behavior and fixated interests be identified. It was also proposed that this change will increase specificity while not decreasing sensitivity. In addition, there is a requirement for multiple sources of information (clinical observations and parent/caregiver report).

These changes represent the current iteration of the DSM-V diagnosis of autism.

When You Start an ABA program, What Should You Reasonably Expect from Your Service Provider?

The following are things that you should expect as a parent when you begin treatment for your child with Autism.

You and your child have a right to a therapeutic environment.  This means that the teaching environment set up to help your child is one in which socially significant learning occurs.  As a client, your child also has the right to services from an agency in which their number one goal is the personal welfare of your child (e.g., safety, treatment efficacy, advocacy). This means that all energy put into the program is to help your child become more independent and lead a better life.

It is also your child’s right to have a treatment program supervised by a competent behavior analyst. Unfortunately, as the rates of autism have increased, so have the number of treatment programs allegedly providing assistance to children with autism.  Furthermore, in many locations, the demand presently outweighs the supply for trained, experienced behavior analysts. It is imperative that the credentials and qualifications of your service provider be credible.

Your child has a right to be provided with a program that teaches functional skills. Functional skills are skills that a child can use in their everyday life and that furthers their independence (tying shoes, initiating conversation, engaging in cooperative play, etc.). There is little benefit in taking the time and dedication to teach a child something that cannot be incorporated or used in their everyday life.

Assessment and ongoing evaluation are crucial components of any ABA program, and should be expected.  This includes setting up a program based on the individual needs of a child and continuing a program based on the ongoing needs of a child. These needs will continually change, therefore ongoing assessments and modifications are imperative, necessary, and a right.

Parent and caregiver trainings should be included in the ABA program. These typically include meetings between parents or caregivers and their service provider in which valuable ABA strategies are discussed, demonstrated, and implemented. The focus of these meetings is to educate parents about various but individualized ABA based techniques they can implement with their child to address challenging behaviors, reinforce desirable behaviors, and promote generalization of progress.

Lastly, and perhaps most importantly, a child with autism has the right to the most effective treatment procedures available. In this case – scientifically validated treatment programs which today have only been shown to be based on ABA principles and techniques.

Parent Tips To Determining Why Behavior Problems Happen

A helpful way to effectively tackle a child’s problem behavior is to figure out why it is happening in the first place.  To implement an intervention without this important information may produce no results or even make the challenging behavior far worse than it was before implementing the tactic you’ve chosen.

To figure out a behavior’s possible function, first we have to look at the antecedent—whatever it is that happened right before the behavior. And secondly, we also have to pay attention to the consequence that happens while or after the behavior happened.  This relationship between antecedent àbehavior ß consequence over time may contribute to why a child does the problem behavior.

There are four likely reason “why” a behavior may happen: for access, to escape/avoid, for attention, and for self-stimulation.

  1. Access

A problem behavior can be strengthened or reinforced when it produces a consequence that increases the chance of the problem behavior from happening again over time.

Example

A child is told he cannot have his tablet to play video games on which results in the child engaging in tantrum behaviors.  The parent does not want to deal with the tantrums so the child is given the tablet.  In this example, tantrums after being told “NO, you can’t have ____” resulted in the child getting what he cannot have.

A B C
Told no tablet/video games Tantrums Got tablet video games

 

  1. Escape/Avoidance

A problem behavior can be strengthened or reinforced when it produces a removal of something a person does not like (Escape).  The same strengthening of the behavior may also happen if the behavior prevents something that a person does not like from happening at all (Avoidance). Providing the behavior with either consequence may strengthen the behavior over time.

Example 1 (Escape)

A child is asked by his parent if there is homework for the day.  The child says yes and with her parent, starts working on the homework.  As the work becomes more difficult, the child starts complaining to the parent.  The parent instructs the child to continue working, but the child just continues complaining and eventually starts throwing pencils towards the wall. Unsure about what to do, the parent takes the homework off the table and tells the child that she doesn’t need to work on it anymore.

A B C
Instruction to continue with school-work Continual complaints, throwing pencil at wall School-work removed

 

Example 2 (Avoidance)

Upon getting home, the parent asks the child if there is homework for the day.  The child replies, “No homework today, yay!”  There is homework for that day.

A B C
Parent asks about homework Lies about having no homework Homework avoided
  1. Attention

A problem behavior can be strengthened or reinforced when it produces any response from another person that leads to the likelihood on the problem behavior from happening again over time.

Example

A family is having dinner at the table.  The elder child starts playing with her food and manages to flick a pea from her plate across the table with her fork.  The younger child starts laughing at his sibling being funny.  The elder child then repeats the behavior which makes the younger child laugh hysterically.  The parent asks the elder child to stop, but to no avail—peas scattered all over the dining table.

A B C
Other people at the table Flicking pea across the table (elder child) Younger child laughing

 

  1. Self-stimulatory

A problem behavior can also be reinforced automatically by the pleasant sensations the action produces. Parents can have an idea if a problem behavior may function for self-stimulation if the child performs the behavior regardless whether the child is around individuals or—and most especially—if the child is all alone.

Example

A child watching a video on her tablet “rewinds” the video to a specific scene, watches the clip for a few seconds, then rewinds the video once again to watch the same scene.  This chain of behaviors may repeat for an indefinite length of time.

A B C
End of favorite clip (and “desire” to watch again Rewinds video to the beginning of favorite scene Watching favorite scene again

Although there are now many tools that we can use to figure out the specific function of a behavior, parents and caregivers can still use A-B-C data analysis to help them find out the function(s) of a problem behavior to help determine the best tactic to use in addressing the behavioral difficulty.   For complex or intense problem behaviors that can pose a hazard to a child’s and others’ safety, it is highly advised that parents/caregiver seek assistance from a qualified behavior analyst.