After eight years working in the Indiana public schools as a speech-language pathologist (SLP), Ashley Whitaker decided to focus on helping children diagnosed with autism.
“Speech is one the first symptoms people recognize in individuals with autism,” Whitaker told Autism Business News.
She found a mentor in Janine Shapiro, a speech-language pathologist who had gone through the steps of becoming a board-certified behavior analyst, and conducted applied behavior analysis (ABA) sessions at Lighthouse Autism Center.
Whitaker joined Shapiro at Lighthouse. While Shapiro later left the Mishawaka, Indiana-based autism therapy provider, Whitaker today is one of four Lighthouse clinician’s dual-certified in SLP and behavior analysis.
Lighthouse says the dual expertise, what they call Fusion Therapy, is not just providing more efficient patient care, but serves as a recruiting tool to talented clinicians.
“It is definitely a differentiator from a recruiting perspective,” Maggie Gendel, a Lighthouse spokesperson, who notes the company lets clinicians pursue dual certification on company time, told ABN.
But other providers do not quite see the Lighthouse model as the future of autism therapy. Providers cannot bill for both speech and ABA therapy if they are done at the same time. And SLPs come from different educational backgrounds than behavior analysts.
“We made the decision early to focus on what we know well, ABA only, and haven’t altered much,” Krista Boe, chief clinical officer of Acorn Health, an autism therapy provider headquartered in Coral Gables, Florida, told ABN.
An integrated approach
Providers mostly agree that incorporating speech expertise into ABA generally helps children diagnosed with autism.
“The complements that speech-language pathology provides to ABA is high, because some of the hallmarks of autism spectrum disorder are deficits or differences in communication and socialization repertoires,” Adam Hahs, chief science officer of Hopebridge, an autism therapy provider based in Indianapolis, told ABN.
For example, Hahs said, there are autism assessments regarding verbal behavior that benefit from a speech pathologist’s involvement.
“In general, a lot of kids need both services so parents prefer it to be under one roof,” Brett Blevins, the CEO of Commonwealth, an autism care provider in Florence, Kentucky, told ABN.
Commonwealth has two dual-certified clinicians on staff, Blevins said. And though Acorn Health and Hopebridge do not have dual-certified personnel, they each employ multiple SLPs.
Lighthouse has co-treat sessions where a child will work with a dual-certified clinician, or have an SLP and behavior analyst both in the room. The sessions are intended to accelerate a child’s speech, language and vocabulary goals.
In these sessions, Whitaker said, ABA and speech therapy tend to naturally overlap.
“I often don’t know when I’m wearing my speech-language pathology hat versus when I’m wearing my behavior analysis hat,” she said.
Getting certified
But if ABA and SLP intersect in helping a child with autism, certification in each starts at different points.
“The educational backgrounds for behavior analysts and speech-language pathologists are quite distinct,” Hahs said. “SLPs generally have more developmental factors influencing speech and language deficits, while behavior analysts orient to the environment factors.”
Also, becoming an SLP “tends to be more competitive and rigorous” than behavior analysis, Hahs said.
SLPs are credentialed by the American-Speech-Language-Hearing Association, an 89-year-old nonprofit in Rockville, Maryland. The steps include a master’s in speech-language pathology, a clinical practicum of 375 hours, passage of an exam and a nine-month supervised fellowship.
“All of my colleagues would definitely agree that it is easier to start with your speech degree, and then go back to school to become a behavior analyst,” Whitaker said.
Still, the behavior analysis requirements also take time to meet. As decided by the Behavior Analysis Certification Board, a Littleton, Colorado nonprofit that started in 1998, aspiring behavior analysts must attain a master’s degree, pass an exam and complete 2,000 hours of fieldwork.
Requirements can also change, Whitaker said, such as if credits from a prior master’s count toward the behavior analysis master’s.
Lighthouse has let SLPs use work hours toward completing their ABA fieldwork, and even classes, Gendel of Lighthouse said.
The company would appear to be an outlier.
Nikia Dower, a dual-certified SLP and behavior analyst in Nokesville, Virginia, runs a nonprofit, Speech Pathology and Behavior Analysis (SPABA), that tracks the number of people dual-certified in SLP and behavior analysis. Dower put the present count at a mere 502 clinicians. Many, like Dower herself, are sole practitioners, and do not work for a larger provider that may offer an integrated SLP/ABA program.
Sari Risen, a SPABA member and clinician at Action Potential Services in Toronto, called the Lighthouse Fusion program a “distinct minority,” in part because of “the time-consuming credentialing process.”
The money motive
Changes in federal and state law the last 20 years require most private health insurers and state Medicaid programs to reimburse for ABA. But providers cannot bill extra for an ABA session that incorporates speech therapy. Nor can they add an SLP billing code to an ABA session.
“Speech therapy and ABA are very distinct services with different billing codes, billing descriptions, reimbursements and coding rules,” said Ashley Marshall, a speech language pathologist at Hopebridge.
So, while Whitaker may wear two hats at once, she can only charge for one service.
“The SLPs actually are donating their time,” Whitaker said. “We’re not billing for speech.”
The reimbursement rules have deterred companies like Commonwealth from a fusion model.
“We have two staff members that are dual certified but they only work for us as behavior analysts,” Blevins said. “As a provider, there really isn’t a financial motive for covering the costs of a staffer to do both.”
In regards to financial motive, Whitaker and Gendel of Lighthouse described the fusion program as a long-term investment in the company’s clinical model. Whitaker said that she has become a stronger clinician through the fusion program, and that Lighthouse is beginning to see better patient outcomes.
“It is something that we’ve been really fortunate we can do,” Whitaker said. “We understand that this is not always capable of being done at all companies.”
*Editor’s note (Oct. 14, 2024): This story was updated to correct language in a quote from Adam Hahs. It was also updated to correct a comment coming from Sari Risen; a previous version of this story said the comment came from Nikia Dower.