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Clinical Standards For Autism Treatment See Major Update

Clinical Standards For Autism Treatment See Major Update

A child participates in an applied behavior analysis session. (Francine Orr/Los Angeles Times/TNS)

For the first time in a decade, there are new guidelines for the most widely-used autism treatment.

The Council of Autism Service Providers, or CASP, a nonprofit trade group representing hundreds of autism service providers, recently released the third edition of the Applied Behavior Analysis (ABA) Practice Guidelines for the Treatment of Autism Spectrum Disorder. The document is intended to provide ABA standards of care for insurers, regulatory bodies, consumers, practitioners and other stakeholders.

“ABA is a highly effective treatment for autism. But it has to be correctly implemented at the highest quality,” said Lorri Unumb, chief executive officer of CASP. “These guidelines are key to achieving that.”

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The latest edition reflects a myriad of changes in the industry since the second edition was published in 2014, according to Unumb. That includes the widespread use of state licensure for behavior analysts, the establishment of medical billing codes for ABA and the expansion of ABA insurance coverage mandates.

The updated guidelines address everything from training and certification for ABA practitioners to staffing and delivery models, treatment implementation, outcome measures and relevant state and federal policies. Additions in the new version include defining “medical necessity” in the context of ABA, addressing the use of telehealth, greater detail on collaboration, coordination of care, transition and discharge planning.

Unumb said the guidelines are often relied on by regulators and insurers use them to understand what ABA should look like when authorizing services. Likewise, people with autism and their families can use the information to identify quality providers, she said.

At the same time, the guidelines help ABA providers across the country ensure consistency in their offerings.

“Just like a heart catheterization shouldn’t look different in North Dakota than it looks in New York, ABA should not look different from state to state — at least not on the basis of differing geography,” said Unumb, though she noted the inherent challenge in this given that ABA is meant to be highly individualized.

ABA can be provided at various levels of intensity based on medical necessity, the guidelines indicate. The duration of treatment can range from months to years or across the lifespan and services can be provided in clinics, homes, community settings or elsewhere.

The 88-page document is the culmination of a three-year process to incorporate the latest scientific evidence and clinical opinion, CASP officials said.

“We collected input from over 60 behavior analysts, extensively reviewed the latest research since version 2.0, and carefully deliberated on every word,” said Dr. Jane Howard, who chaired the steering committee and is co-founder of Therapeutic Pathways, an autism treatment center with multiple locations in California.

This is the first time that CASP has released the guidelines. They were first published by the Behavior Analyst Certification Board in 2012 and revised in 2014 before they were transferred to the trade group in 2020.

The use of ABA has been controversial in recent years with some self-advocates reporting negative experiences and raising concerns that the treatment teaches people to hide their autism traits. But, proponents of the approach say that it can help reduce challenging behaviors and improve quality of life.

“These guidelines don’t change our fundamental concerns about the philosophy behind ABA, the evidence base for ABA, how it is practiced and its effect on autistic people,” said Zoe Gross, director of advocacy at the Autistic Self Advocacy Network, which opposes ABA.

Unumb said that the clinical practice guidelines are not intended to address those issues, but noted that “the third edition does place a strong emphasis on shared decision-making and collaboration with consumers and caregivers.”

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