The rate of autism diagnoses has skyrocketed in the last decade, shooting from 1 in 68 to 1 in 36, according to the CDC. Applied behavioral analysis (ABA) therapy has become one of the most notable behavioral approaches to autism treatment, but there’s no one-size-fits-all modality.
Clinicians providing ABA therapy meet children with autism where they are – often literally. The one-on-one therapy is offered to children with autism inside clinics, inside their homes, within their communities and, in rarer cases, via telehealth.
ABA encourages desired behaviors, like initiating conversation with others, and discourages undesired behaviors, according to the CDC.
“It really is the science of learning,” Kathleen Stengel, CEO of NeurAbilities Healthcare, told Behavioral Health Business.
Voorhees, New Jersey-based NeurAbilities offers diagnostic and treatment services, including ABA, to children and adults with neurological, neuropsychological, behavioral, developmental and learning challenges.
ABA is often only one of several therapies used to treat children. San Diego-based provider Cortica views ABA as “one essential piece” of its holistic program that focuses on treating the whole child. The company also views its ABA program as “neurodiversity affirming,” meaning that it avoids altering a child’s characteristics unless there is danger to the child or others.
“We are really intentional about delivering care in the setting in which the child is most likely to benefit from it,” Suzanne Goh, co-founder and chief medical officer of Cortica, told BHB. “That means we offer services in multiple settings: in-center, in-home, in-community and in schools. We also offer telehealth because sometimes that is a wonderful way for families, especially caregivers, to receive ABA services, and in particular, caregiver coaching.”
Just one modality or care setting is not enough for NeurAbilities, which requires patients to receive ABA therapy in multiple locations to promote generalization of skills.
“In our agency, we look at how they learn in the home, the school, the clinic and the community,” Stengel said. “We provide skill remediation packages to try and get communication occurring across those environments. Then we constantly look at the data to analyze what’s the next level of trajectory.”
Different locations, different benefits
A clinician showing up at a family’s doorstep for ABA treatment is one of the most important modalities, according to Goh.
“So much of a child’s experiences take place in the home and most of their most important relationships are very much based in the home,” she said. “In-home service allows for empowerment of caregivers in a really effective way, but also for a child to practice skills in the setting in which they will be used.”
Skills that are perhaps best suited to in-home ABA therapy include self-care skills and daily living skills.
But a challenge for providers: Home-based ABA has an increased likelihood of cancellations, according to Sara Litvak, CEO of the Behavioral Health Center of Excellence Accreditation. Caregivers may have something come up that prevents them from being available at home, and clinicians are not as easily able to step in for a co-worker.
It may also feel intrusive to some families.
“If a parent is not comfortable, then you lose some of that effect and parents’ involvement,” Litvak told BHB.
Los Angeles-based Behavioral Health Center of Excellence Accreditation is an international accrediting body for organizations providing autism and ABA care.
Meanwhile, the structured, more controlled environment of a clinic creates different benefits and may be a better fit for a child whose home is not suitable for ABA.
In-center therapies can reduce the sensory stimuli to which a child is exposed, provide more materials to support learning, foster socialization with groups of other children and also allow for collaboration between professionals.
“Having the clinical staff in-center where they can distribute their time more efficiently allows an opportunity for the therapists to develop,” said Stengel. “There’s a direct correlation between how the therapist develops and how the child makes progress.”
Clinics sometimes offer more safety measures, like safety equipment or padded walls, which may be a better fit for children with extreme behaviors like aggression or self-injury.
In-center services may also have lower turnover rates.
“In clinic-based locations, you have that community,” Litvak said. “When you’re driving to homes, it’s a little bit more isolating as a clinician.”
Skills learned through in-home or in-center ABA therapy can later be applied to a wide variety of community settings. This can mean offering therapy at schools, playgrounds, beaches, sporting events, or many other locations.
“For example, if mom needs to go to the grocery store, oftentimes the kid and the therapist will come to the grocery store and they’ll practice behaving appropriately at the grocery store,” Litvak said.
These out-of-the-box locations allow for skills garnered at other locations to be generalized in a real-world environment.
School-based ABA is especially important because of how much time children spend in that particular setting.
“If we can create consistency between how a child is supported in school and in other settings like home, center or community that can be really, really important and help us progress,” Goh said. “Eventually, we want a child to be able to access a whole range of enriching experiences in the community.”
The specific needs of a child usually determine which modality is preferable in any given circumstance. Though in some instances, providers may let their bottom line get in the way of what’s best for the patient.
“Sometimes I do see organizations making decisions based on better margins or what’s the better financial model,” Litvak said. “It really should [stem] from patient outcome. What you don’t want is, if you have a hammer for everything to look like a nail.”
In cases where a provider only offers one location of care, clinicians should refer patients who are better suited to a different modality to another practice, Litvak said.
NeurAbilities determines the type and level of care necessary through an assessment, which takes the whole child and family into consideration.
“Every child gets something different,” Stengel said. “There’s not one treatment path. But there’s general consensus on making sure we identify the needs and address them.”
The frequency of one location over another differs from provider to provider. Cortica most frequently provides in-home services, while the bulk of NeurAbilities’s services are rendered in-center.
The rise of telehealth services
The rise of telehealth has extended to ABA services. Digital services are used primarily to train caregivers, although in some cases it may be the best fit for a child to receive direct ABA therapy through digital means.
“There are some children who engage really well through a screen, and, sometimes, it’s an even better way for them to engage with other people,” Goh said. ”For children with that profile, virtual direct ABA services can be very effective. It has to be delivered really carefully.”
For both Cortica and NeurAbilities, telehealth makes up only about 5% of the companies’ ABA services.
“It’s very rare,” Neil Hattangadi, CEO and co-founder of Cortica, told BHB. “It’s only in accordance with the health plan and a treatment plan that’s submitted to the health plan ahead of time.”
Cost for providers
Crucially, differences in costs between different settings of care are insignificant, according to Hattangadi.
Services rendered in-center have the overhead of the facility’s physical footprint, while in-home services require paying for gas and clinicians’ drive time. For Cortica, cost differences between the two types end as a wash.
“It’s completely a clinical decision based on what’s appropriate for that child,” Hattangadi said.
For NeurAbilities, offering multiple locations of care leads to better financial outcomes in the long term, in addition to more comprehensive care for patients.
“It’s probably cheaper to do only center-based but you end up having a higher turnover of patients,” Stengel said. “You also end up having reduced hours later on when they get alternative services. From a financial perspective, hybrid actually helps us with being able to cross-collaborate across different environments to fully utilize the services to remediate some of the deficits. So it might be a little bit more expensive, but the delta is not worth the clinical outcomes.”