DSM-III After 40 Years

In The Politics of Autism, I discuss evaluation and diagnosis.

Fred Volkmar at The Journal of Autism and Developmental Disorders:

Just over 40 years have now passed since the landmark 3rd edition of the American Psychiatric Association Diagnostic and Statistical Manual—DSM-III (American Psychiatric Association, 1980). Before DSM-III appeared, there was no official recognition of autism and both clinical work and research suffered as a result (American Psychiatric Association, 1980); In the first article in this section Rosen and colleagues (Rosen et al., 2021) summarize that the rational for autism’s official recognition rested on several important and distinctive lines of evidence and despite some problems with the definition it significantly advanced work in the area. As Rosen and colleagues discuss important issues and areas of diagnostic controversy remain even in the face of attempts to produce better revised definitions of the condition. These controversies have to do with issues like gender and cultural issues, the complexities of Asperger’s disorder, and the broader autism phenotype even while the most recent name change to Autism Spectrum Disorder has been well received. In the next article Fombonne and colleagues (Fombonne et al., 2021) note the important advances and challenges that have come with official recognition and epidemiological research. As they emphasize, challenges include culturally based work and continued surveillance studies of autism but compared to what we knew back in 1980 knowledge has advanced markedly. The quality of outcome studies began to increase in both number and sophistication. As Howlin reviews (Howlin, 2021), the evolving ways in which autism has been conceptualized have had significant importance in planning for adult services and evaluating changes in outcome. Similarly, as Vivanti and Messinger discuss (Vivanti & Messinger, 2021) the official diagnosis of the condition has led to a number of important attempts to develop psychological models and theories of autism that can both guide research and may also have important implications for clinical work. The growing consensus on best approaches to diagnosis of autism has also significantly advanced work in the area of genetics; this work, first begun in the 1970’s, has now emerged as one of the major areas of research interest in the condition and, as Thapar and Rutter discuss (Thapar & Rutter 2020), there have been important implications for understanding the heritability of autism and its diagnostic boundaries. Similarly work on the neuroscience of autism has been significantly advanced as we now understand much more about some important basic aspects of brain functioning in ASD and have seen autism emerge as, in many ways, the prototypic disorder for the study of the social brain (McPartland et al., 2021).

NC Governor Signs ABA Bill

In The Politics of Autism, I discuss the day-to-day challenges facing autistic people and their families.  In many states -- particularly those with large rural populations -- one problem is a shortage of behavior therapists.

AP reports:

Supporters of children and dults with autism said legislation signed into law on Monday by Gov. Roy Cooper creating a licensing process for treatment specialists should expand services and rein in their costs.

The bipartisan measure that Cooper signed at an outdoor Executive Mansion ceremony says behavior analysts can now operate independently, rather than under the supervision of psychologists, as has been required. North Carolina was the only state until now mandating such control, bill supporters say, leading to higher costs and less access to therapy for those autism spectrum disorder.

“It’s more about access to care and the fact that depending on your zip code, you can be without,” said Rep. Zack Hawkins, a Durham County Democrat who helped shepherd the Senate bill through the House with Majority Leader John Bell, a Republican. Hawkins has two sons with autism disorders.

The new law, which creates a state Behavior Analysis Board to issue licenses, charge fees and conduct investigations of licensees, “is going to impact so many lives in our state,” GOP Sen. Jim Perry of Lenoir County, a chief bill sponsor, said during the ceremony.

Children, their parents and licensure proponents huddled around Cooper as he signed the measure.

NC Bill on Psychologists and Behavior Analysts

In The Politics of Autism, I discuss the day-to-day challenges facing autistic people and their families.  In many states -- particularly those with large rural populations -- one problem is a shortage of behavior therapists.

Greg Childress at NC Policy Watch:

A bill to make treatment of people with autism more accessible in North Carolina is headed to Gov. Roy Cooper’s desk for his signature.

House Bill 91 removes the requirement that behavior analysts working in the state must be supervised by licensed psychologists. It was unanimously approved by the House on Monday. The bill also received unanimous support in the Senate.

Bill supporters and those who supported a companion bill, Senate Bill 103, say removing the restriction will make the state more attractive to behavior analysts.

There are only 62 psychologists to oversee the work of roughly 680 people who could provide care for the state’s 65,000 children with autism, according to State Sen. Jim Perry, a Republican from Kinston, who co-sponsored SB 103.

Rep. John Bell, a Republican from Goldsboro, co-sponsored HB 91.

Antivaxxers and the Dunning-Kruger Effect

 In The Politics of Autism, I analyze the discredited notion that vaccines cause autism. This bogus idea can hurt people by allowing disease to spread.  Trump has helped spread misinformation.

At Hospital and Health Care (Australia), Amy Sarcevic writes about antivaxxers:

Cognitive biases are a natural human tendency resulting from the mental shortcuts (‘heuristics’) we use subconsciously to process information and fill in blind spots in our knowledge.

The Dunning–Kruger effect — often referred to as ‘ignorance of one’s own ignorance’ — is a well-documented bias that has been known to psychologists since 1999.

David Dunning, psychology professor at the University of Michigan — who coined the term — said the effect is harmful, because people are often oblivious to its impact on their own thinking.

“The first rule of the Dunning–Kruger club is you don’t know you’re a member of the Dunning–Kruger club,” he said in a Vox interview.

Indeed, researchers from the University of Pennsylvania, Utah Valley University and Texas A&M University recently led a study into the psychology of anti-vaxxers. They found evidence that the Dunning–Kruger effect plays a key role in widely held beliefs about vaccinations — specifically the false claim that MMR jabs cause autism.

Testing 1300 people, they found that 62% of those that performed the worst on autism knowledge tests rated themselves as knowing ‘as much’ or ‘more’ than doctors about the causes of autism.

Professor Matthew Hornsey of the University of Queensland — well known for his research on anti-vaxxers — said that conspiracy theories are also to blame.

“Some people think it is commonplace for groups of powerful elites to band together and conduct elaborate hoaxes on the public. Vaccinating the public involves cooperation between government and Big Pharma, two institutions that people find notoriously hard to trust. With that mistrust comes the conspiracy theories. People join the dots and presume a sinister motive,” he said.

Looking for Autism Biomarkers

Uncertainty is the major theme of The Politics of Autism.  

 Brita Belli at Yale:

Five years ago, a Yale-led partnership launched a landmark study to identify the biomarkers, or biological indictors, of autism that could help diagnose, track, and assess treatments in patients.

Since then, the Autism Biomarkers Consortium for Clinical Trials has discovered the first two biomarkers for any psychiatric disorder to be accepted into the U.S. Food and Drug Administration’s (FDA) Biomarker Qualification Program, an advance that could lead to new treatments through drugs and other interventions.

The study recently received $39 million for a second phase in which researchers will seek to replicate the findings of the first phase and test a younger group of preschool-aged children. The next stage will begin in the new year.

“Everything we do to treat autism is currently based on clinical subjective decisions,” said James McPartland, professor in the Yale Child Study Center and of psychology, who has led the study for the past five years and will direct the renewal. “It’s not the same as making decisions based on biology.”

Autism affects 1 in 54 children in the U.S., including 1 in 34 boys, according to the Centers for Disease Control and Prevention.

In the initial study, the largest of its kind in this country, researchers tested nearly 400 children, 280 with autism and 119 with typical development. The participants were aged 6 to 11 and represented a wide range of IQs.

To identify the biomarkers, the researchers used one of the oldest methods of brain imaging — electroencephalography (EEG) — in which brain activity is measured through the placement of electrode sensors on the scalp, as well as eye tracking.

At three different times, scientists measured how the children responded to various cues. Both of the biomarkers they discovered were related to how children with autism responded to human faces; one involved the brain’s neural processing of a face, the other measured the child’s visual attention to people. “Children with autism showed slower than expected brain responses to faces and paid less attention to faces,” McPartland said.

They were the first two biomarkers for a neurodevelopmental disorder or psychiatric condition accepted to the FDA’s Center for Drug Evaluation and Research Biomarker Qualification Program. The researchers are now working with the FDA to develop methods for evaluating additional biomarkers for these types of disorders.

In the second phase, researchers will follow up with the same group of children evaluated during the first phase, who are now 11 to 16 years of age, to see whether the biomarkers have remained stable and whether they might predict subsequent outcomes in the child’s life. In addition, they will also evaluate these biomarkers in a group of younger children — ages 3 to 5 — both with and without autism.

McPartland, who is director of the Yale Developmental Disabilities Clinic, said this research offers new possibilities for treating autism. “These are considered intervention and drug development tools,” he said of the biomarkers. “The field doesn’t have a way of measuring how treatments affect autism except through clinical observation. We hope these will be sensitive biological measures to achieve this goal.”

In addition to the potential for drug companies and intervention developers to identify treatments for autism, McPartland said the biomarkers may offer clinicians a better understanding of how behavioral and therapeutic tools might benefit children with autism and which patients might benefit the most.

Shortage of School Psychologists in Texas

In The Politics of Autism, I write about special education and the Individuals with Disabilities Education Act.  Across the country, there are shortages of professionals in the field.

Laura Isenee at Houston Public Media:

In 2018, federal regulators ordered the state to stop capping the number of children who could receive services and to ensure all kids with special needs are identified.

Already, the Texas Education Agency has seen the number of students tested for special ed services soar by 56%, to 138,000 evaluations in 2018-19.

But no region in Texas has enough licensed school psychologists to meet national staffing recommendations and keep up with that kind of demand.

Statewide, there’s only one licensed school psychologist for about 2,800 students, though national guidelines say there should be about one for every 500-700 students.

The shortage leaves current school psychologists with heavy caseloads, according to Stephanie Barbre, who works in the Lubbock area and is the incoming president of the Texas Association of School Psychologists.

“The only ones that got somewhat close were in the Austin and San Antonio areas,” says Barbre, who’s crunched the numbers for a statewide journal.

She says it’s worst in East Texas where 31 districts don’t have any licensed school psychologist on staff.

...
Many advocates, psychologists and administrators say the key to the workforce shortage lies on college campuses, though again there are challenges. One issue: A master’s degree to become an LSSP [licenbsed specialist in school psychology] is longer than a typical master’s. It generally takes someone studying full-time three years to graduate. Another issue: Colleges often have small school psychology programs that don’t always get much promotion to undergraduates.

A Shortage in North Carolina

In The Politics of Autism, I discuss the day-to-day challenges facing autistic people and their families.  In many states -- particularly those with large rural populations -- one problem is a shortage of behavior therapists.

Sarah Ovaska-Few reports at North Carolina Health News:

North Carolina has a shortage of the highly-educated professionals that can develop and oversee the therapies, with just 327 board-certified behavioral analysts (BCBAs) in North Carolina, according to the Behavior Analyst Certification Board. BCBAs must have a masters-level education, undergo extensive training, and pass rigorous board exams to receive their certification. While the BCBAs create treatment plans, mostly registered technicians carry out the day-to-day work of implementing that plan for the child with autism. North Carolina has just 812 of these registered behavioral technicians.
,,,

The main barrier to recruitment has been because of North Carolina’s requirement that a psychologist oversees ABA therapies, a practice unique to North Carolina, said Lorri Unumb, Autism Speaks’ vice president for state government affairs.

Many BCBAs have undergone intensive training and find the oversight unnecessary and time consuming, Unumb said. It is also difficult to find psychologists who want to do that type of work.

Autism Speaks and other groups are pushing to have the state legislature remove the psychologist oversight, in hopes it will lead to more ABA providers.

“Until that issue gets fixed, you’re never going to have good access” to ABA therapies, Unumb said.

Podcast on The Politics of Autism

I did an interview on The Politics of Autism with Dr. Eugenio Duarte:

Autism as a condition has received much focused attention recently, but less attention has been paid to its politics. It is a condition that necessitates significant accommodations and interventions, which can be difficult for people with autism and their loved ones to obtain, depending on the state of autism public policy. Sociologist John J. Pitney argues that political science needs to more rigorously study autism policy and politics, as he outlines in his book The Politics of Autism: Navigating the Contested Spectrum (Rowman & Littlefield, 2015). In our interview, we explore the evolution of our understanding of autism, how public policy impacts the lives of autistic individuals, and suggestions for future research. For anyone with autism or their loves ones, this interview offers suggestions for meeting important needs and hope for a better future.

PODCAST HERE: https://player.fm/series/new-books-in-history-80804/john-j-pitney-the-politics-of-autism-navigating-the-contested-spectrum-rowman-and-littlefield-2015

Invitation to Take Part in an Autism Study

Hello,

My name is Katie Franke, and I am a doctoral candidate in school psychology at the University of South Carolina. If you are a caregiver of a teen with ASD (ages 13-18), I invite you and your teen to participate in an on-line research study of strengths and well-being. The online questionnaire (password: research) takes 20-30 minutes total to complete. A caregiver completes the first part, and the teen completes the second part. Participants can enter to win one of eight $25 Amazon.com gift cards!

Survey Link: https://www.surveymonkey.com/r/thoughtsandfeelings
Password: research
--
Kathleen B. Franke, M.A.
School Psychology Doctoral Candidate
University of South Carolina
1512 Pendleton Street
Columbia, SC 29208
kfranke@email.sc.edu 

ABA Licensing in Texas

In The Politics of Autism, I discuss the day-to-day challenges facing autistic people and their families.

Sebastian Herrera reports at the Houston Chronicle on SB 589 and House Bill 26, which would require licensing of behavior analysts in Texas:

Applied behavior analysis (ABA) stakeholders and supporters in the state now are attempting to regulate the practice with two bills in the Legislature that would require behavior analysts to be licensed. Supporters say it is crucial not only to protect vulnerable people from untrained analysts, but also because it could affect medical insurance coverage.

Senate Bill 589, by Sen. Eddie Lucio Jr., D-Brownsville,is scheduled for a Senate committee hearing Tuesday. It faces an uncertain reception, though no public opposition has surfaced.

"Right now, there's just no way for the state to regulate the profession," said Dorothea Lerman, director of the Center for Autism and Developmental Disabilities at the University of Houston Clear Lake and president of the Texas Association for Behavior Analysis."(The bill) is to protect the consumer, and the other reason is to protect our profession as well."

The TxABA Public Policy Group has raised about $20,000 to pay lobbyist Courtney Hoffman to represent them at the Legislature, said Kate Johnson-Patagoc, director of specialized services at the Texana.

Herrera reports in a more recent article:

SB 589 supporters also say licensure could lead some insurers who don't cover ABA treatment to change their policies. The federal government requires licensure for Medicaid reimbursements, according to Sen. Kelly Hancock, R-North Richland Hills, the chair of the Senate Business and Commerce Committee, which heard the bill.

Joseph McCoy, a psychologist from the Rio Grande Valley, was the sole person to testify against the bill. While McCoy supports licensure for behavior analysts, he believes the measure should be regulated by the Texas Board of Examiners of Psychologists because ABA treatment has psychology roots.

The bill currently lists the Texas Department of Licensing and Regulation as the proposed license regulator after a committee substitute amended that part of the legislation. The bill's original version proposed the Texas Medical Board as the regulator.
House Bill 26, by Rep. Ron Simmons, R-Carrollton, would also require licensure for behavior analysts. The bill is pending in a House committee.

The state currently spends about $7 million annually on autism programs.

Senators said SB 589 would be heard again next Tuesday. A licensure bill passed the full House in the last legislative session before getting stuck in the Senate. Backers hope a similar result won't happen this time.

Early Intervention and Lifelong Support

In The Politics of Autism, I discuss the day-to-day challenges facing autistic peopleand their families.

At Al Jazeera America, Dr. Sarah C. Bauer writes:

Children with autism benefit from explicit instruction on communication and social skills. It is easier to do this early, even before the age of 2, preferably as soon as families are concerned.

With early detection and intervention, I have seen many children’s communication, learning, social skills and behavior improve to the point that they can function well in a general education classroom. But the older children get, the harder these skills are to teach. Maladaptive behaviors can develop. The lack of early intervention can result in increasing communication problems, behavior problems and family stress, and older children cannot typically be as easily redirected and physically removed from volatile situations as young children.

In addition, we need to encourage and incentivize individuals to pursue vocations that support the millions of individuals with autism and their families. It is important to remember that individuals with autism benefit from services throughout their lives, not just when they are young. They rely on developmental pediatricians, child psychiatrists, psychologists, social workers, special education teachers, speech and language therapists, occupational therapists, community partners and behavior therapists, among others.

We know that early intervention can change the developmental trajectories for many children with autism. Now we need to be able to provide it to everyone who needs it.

In The Politics of Autism, I write:

Once parents get past all the red tape, they often find that providers are scarce. Rural states may be especially short on behavior analysts, who tend to prefer to work in large metropolitan areas that have greater educational and technological resources. If psychiatric help is necessary, it may be hard to get. There is a shortage of child psychiatrists, and insurers are of little help in finding them. When The New Haven Register called several doctors’ offices listed on Aetna’s website as “Psychiatry, child and adolescent,” they found none who actually treated pre-teen children. One doctor said of the rosters of providers issued by insurance companies, “Their lists are never correct.” More generally, psychiatrists are less likely than other physicians to accept insurance. A national survey found that barely half said they accepted private insurance and only 43 percent accepted Medicaid.   

Positive Signs

A couple of articles in Journal of the American Academy of Child and Adolescent Psychiatry find positive outcomes for a couple of different interventions.  The usual caveats apply.  Over the years, there have been many, many false starts.  Studies require replication before we can be really confident that they are onto something. (The failure to replicate studies and reproduce their findings is a big problem in psychology.)

That said...

Annette Estes and colleagues, "Long-Term Outcomes of Early Intervention in 6-Year-Old Children With Autism Spectrum Disorder." The abstract:

Objective
We prospectively examined evidence for the sustained effects of early intervention based on a follow-up study of 39 children with ASD who began participation in a randomized clinical trial testing the effectiveness of the Early Start Denver Model (ESDM) at age 18 to 30 months. The intervention, conducted at a high level of intensity in-home for 2 years, showed evidence of efficacy immediately posttreatment.
Method
This group of children was assessed at age 6 years, 2 years after the intervention ended, across multiple domains of functioning by clinicians naive to previous intervention group status.
Results
The ESDM group, on average, maintained gains made in early intervention during the 2-year follow-up period in overall intellectual ability, adaptive behavior, symptom severity, and challenging behavior. No group differences in core autism symptoms were found immediately posttreatment; however, 2 years later, the ESDM group demonstrated improved core autism symptoms and adaptive behavior as compared with the community-intervention-as-usual (COM) group. The 2 groups were not significantly different in terms of intellectual functioning at age 6 years. Both groups received equivalent intervention hours during the original study, but the ESDM group received fewer hours during the follow-up period.
Conclusion
These results provide evidence that gains from early intensive intervention are maintained 2 years later. Notably, core autism symptoms improved in the ESDM group over the follow-up period relative to the COM group. This improvement occurred at the same time that the ESDM group received significantly fewer services. This is the first study to examine the role of early ESDM behavioral intervention initiated at less than 30 months of age in altering the longer-term developmental course of autism.

Robin L. Gabriels and colleagues, "Randomized Controlled Trial of Therapeutic Horseback Riding in Children and Adolescents With Autism Spectrum Disorder." The abstract:

Objective
This study expands previous equine-assisted intervention research by evaluating the effectiveness of therapeutic horseback riding (THR) on self-regulation, socialization, communication, adaptive, and motor behaviors in children with autism spectrum disorder (ASD).
Method
Participants with ASD (aged 6–16 years; N = 127) were stratified by nonverbal IQ standard scores (≤85 or >85) and randomized to 1 of 2 groups for 10 weeks: THR intervention or a barn activity (BA) control group without horses that used similar methods. The fidelity of the THR intervention was monitored. Participants were evaluated within 1 month pre- and postintervention by raters blinded to intervention conditions and unblinded caregiver questionnaires. During the intervention, caregivers rated participants’ behaviors weekly.
Results
Intent-to-treat analysis conducted on the 116 participants who completed a baseline assessment (THR n = 58; BA control n = 58) revealed significant improvements in the THR group compared to the control on measures of irritability (primary outcome) (p = .02; effect size [ES] = 0.50) and hyperactivity (p = .01; ES = 0.53), beginning by week 5 of the intervention. Significant improvements in the THR group were also observed on a measure of social cognition (p = .05; ES = 0.41) and social communication (p = .003; ES = 0.63), along with the total number of words (p = .01; ES = 0.54) and new words (p = .01; ES = 0.54) spoken during a standardized language sample. Sensitivity analyses adjusting for age, IQ, and per protocol analyses produced consistent results.
Conclusion
This is the first large-scale, randomized, controlled trial demonstrating efficacy of THR for the ASD population, and findings are consistent with previous equine-assisted intervention studies.
Clinical trial registration information
Trial of Therapeutic Horseback Riding in Children and Adolescents With Autism Spectrum Disorder;http://clinicaltrials.gov; NCT02301195.

A Caution About Screening

Many posts have mentioned the many autistic children who go undiagnosed for a long time.  But overdiagnosis is also a potential problem.  At The Atlantic, psychologist Enrico Gnaulati discusses the problem of false positives:

What gets lost in the debate is an awareness of how the younger in age we assess for problems, the greater the potential a slow-to-mature kid will be given a false diagnosis. In fact, as we venture into more tender years to screen for autism, we need to be reminded that the period of greatest diagnostic uncertainty is probably toddlerhood. A 2007 study out of the University of North Carolina at Chapel Hill found that over 30 percent of children diagnosed as autistic at age two no longer fit the diagnosis at age four. Since ASD is still generally considered to be a life-long neuropsychiatric condition that is not shed as childhood unfolds, we have to wonder if a large percentage of toddlers get a diagnosis that is of questionable applicability in the first place.
...

Several years ago, Gary L. Freed, MD, chief of the Division of General Pediatrics at the University of Michigan, initiated a survey of physicians listed as pediatricians on state licensure files in eight states across the United States: Ohio, Wisconsin, Texas, Mississippi, Massachusetts, Maryland, Oregon, and Arizona. According to the survey, 39 percent of state-identified pediatricians hadn't completed a residency in pediatrics. And even for those who had, their training in pediatric mental health was minimal.

Currently, the American Academy of Pediatrics estimates that less than a quarter of pediatricians around the country have specialized training in child mental health beyond what they receive in a general pediatric residency. The latest data examining pediatricians who have launched themselves into practice reveals that 62 percent of them feel that mental health issues were not adequately covered in medical school. These figures hardly inspire widespread confidence as regards relying on pediatricians to accurately diagnose ASD.In a 2010 study, 45 percent of graduate students in child psychology had little exposure to coursework in child/adolescent lifespan development.

This brings me to my own cherished profession: child psychology. What does survey data tell us about the current training of child psychologists that speaks directly to their ability to separate out abnormalcy from normalcy?

Poring over the numbers of a 2010 study out of the University of Hartford in Connecticut, I discovered that 45 percent of graduate students in child psychology had either no exposure to, or had just an introductory-level exposure to, coursework in child/adolescent lifespan development. It is in these classes that emerging child psychologists learn about what is developmentally normal to expect in children.

It would appear that the education and training of a sizable percentage of pediatricians and child psychologists leaves them ill-equipped to tease apart the fine distinction between mild ASD and behaviors that fall within the broad swath of normal childhood development.

Governors Sign Insurance Bills in Rhode Island and Louisiana

Autism Speaks provides a couple of updates on insurance legislation in the states.

Rhode Island:

Gov. Lincoln Chafee has signed a pair of bills enabling Rhode Island families to access insurance coverage for Applied Behavior Analysis (ABA) as intended under the autism insurance reform bill he signed last year, and adds pharmacy, psychology and psychiatric care as eligible benefits.

The 2010 law required that ABA be provided and supervised by a state-licensed Board Certified Behavior Analyst (BCBA), despite the fact Rhode Island has no such licensing process. As a result, fanmilies have been unable to access coverage for ABA care.

The new bills signed by Chafee include SB.2559 which creates a five-member Applied Behavior Analyst Licensing Board within the state Department of Health so that practiioners can get licensed in Rhode Island. The second bill, SB.2560, adds pharmacy, psychology and psychiatric care as eligible benefits.

SB.2560 also enables licensed psychologists to provide ABA provided they have "equivalent experence" or the therapy falls within "their scope of practice." Both laws take effect immediately.

Louisiana:

Governor Bobby Jindal signed legislation today expanding Louisiana's 2008 autism insurance reform law by raising the age cap to 21 and eliminating the $144,000 cap on lifetime benefits. Families paying thousands of dollars a year in insurance premiums will be able strating in 2013 to continue coverage for the screening, diagnosis, testing and treatment of autism spectrum disorder (ASD) for individuals aged 16 through 20.

Sponsored in the Louisiana House of Representatives by Rep. Franklin Foil (R-Baton Rouge), the bill eliminates any ceiling on lifetime benefits. Under the 2008 law, coverage ended once lifetime claims reach $144,000. In addition, the new law eliminates the current requirement that treatments be supervised by a physician or psychologist. A $36,000 annual cap on benefits is retained, but coverage was expanded to include firms with 10 employees or less. The current threshold exempted business with 50 employees or less.

West Virginia and BACB

Previous posts described the attempt by West Virginia psychologists to claim jurisdiction over behavior analysts.  AP reports:

West Virginia does not appear to need its own regulatory board to oversee specialists who treat children with autism, given current national standards, a Tuesday report presented to lawmakers concluded.

The legislative audit found that the national Behavior Analyst Certification Board "provides adequate and sufficient protection to the public."

The findings arrive after the West Virginia Board of Examiners of Psychologists sought to claim jurisdiction over behavior analysts last year. The board dropped that attempt following a lawsuit and an outcry among parents of children diagnosed with these neurological conditions.

These specialists provide applied behavioral analysis, a treatment considered crucial by experts for many children with an autism spectrum disorder. These conditions are marked by problems with communication, behavior and social skills. The range includes a severe form called autistic disorder and the much milder Asperger's syndrome. Tuesday's report said the number of West Virginia schoolchildren diagnosed within the spectrum increased to 1,474 during the just-completed school year from 372 during 2001-2002.

"It is a distinct profession with distinct training that pulls from many difference degree programs in order for a certification to be specialized," Susannah Poe, the state's only behavior analysts who is also a licensed psychologist, told the House-Senate committees that received the report.
...
Welcoming the audit's conclusion, Poe blasted the psychology board for trying to force behavior analysis to work under the paid supervision of licensed psychologists.

"This current board of examiners filed an unprecedented and unnecessary emergency order that immediately restricted our professionals from engaging in the work that they had performed without complaint, without oversight or without any interest from the board," Poe said.

Concern About DSM-5

A number of posts have dealt with upcoming changes in DSM-5. Amanda Gray writes at The South Bend Tribune:

Those proposed changes could have large ramifications for local families, said Joshua Diehl, the University of Notre Dame psychology professor who eventually told Pierce with certainty that Wesley had autism.

"We've seen it coming since a couple of years back," Diehl said of the changes. "We began to see it as more research came out about the autism spectrum."
...

Some experts believe up to 40 percent of those currently considered autistic will be affected and might lose their diagnoses, which could affect insurance coverage and other services, according to The Associated Press.

Diehl said many of those diagnosed with specific types of autism would lose specialized services and environments they depend on.

"A lot of people embraced the Asperger's diagnosis culture," Diehl said. "They came out of it as bigger than the diagnosis itself. Autism carries a little more of a stigma with it -- Asperger's is a less stigmatizing diagnosis."

Another potential problem with the proposed changes is the damage they could do to the reputation of the psychology field as a whole, according to Diehl.

"In some ways, there is a danger to undermining the psychology profession," he said. "A lot of families have been struggling for years to find a diagnosis."

Understandably, the definitions needed to be upgraded, according to Diehl.

"The idea is that we created the autism spectrum, and we have a catch-all category (PDD-NOS) that wasn't exactly autism," he said. "Too many people were put in there -- it sort of became autism.

Important New Data

A data brief from the National Center for Health Statistics offers some important new information:

The median age when school-aged children with special health care needs (CSHCN) and autism spectrum disorder (ASD) were first identified as having ASD was 5 years.[Note: other studies have reached different conclusions.]

Percent distribution of child's age when parent or guardian was first told that child had

autism spectrum disorder among children aged 6–17 years with special health care needs and

autism spectrum disorder: United States, 2011

 

School-aged CSHCN identified as having ASD at a younger age (under age 5 years) were identified most often by generalists and psychologists, while those identified later (aged 5 years and over) were identified primarily by psychologists and psychiatrists.

Percent distribution of type of doctor or health care provider who first told parent or guardian that child had autism spectrum disorder, by child's age when parent or guardian was first told, among children aged 6–17 years with special health care needs and autism spectrum disorder: United States, 2011

 

Nine out of 10 school-aged CSHCN with ASD use one or more services to meet their developmental needs. Social skills training and speech or language therapy are the most common, each used by almost three-fifths of these children.

Percentage of children aged 6–17 years with special health care needs and autism spectrum disorder who currently use selected health care services, by age: United States, 2011

More than one-half of school-aged CSHCN with ASD use psychotropic medication.

Percentage of children aged 6–17 years with special health care needs and autism spectrum disorder who currently use selected medication types: United States, 2011

Michigan Mandate and Jobs for Behavior Analysts

An earlier post noted that the West Virginia mandate might enable the state to keep behavior analysts who received training in its institutions.  The same is true of Michigan.  Crain's Detroit Business reports:

With 15,400 school-age children and an additional 4,500 ages 2-5 diagnosed with autism, Michigan needs up to 600 more licensed psychologists who also are board-certified behavior analysts and as many as 7,000 licensed therapists to provide autism treatment, said Colleen Allen, executive director of the Autism Alliance of Michigan in Detroit.

...

"There will be some frustration in the beginning from parents because there are not enough qualified therapists in Michigan," said Dave Meador, one of the leading supporters of autism insurance reform and a member of the Autism Alliance.

"Our intention is to help organizations run job fairs to attract (licensed psychologists) back to Michigan," said Meador, who is also CFO of DTE Energy Co. in Detroit. "We have good behavioral colleges, but many graduates leave the state because there is no insurance for autism. This (law) will be a job creation mechanism." [emphasis added]

In Michigan, there are only 118 board-certified behavior analysts, and fewer who specialize in autism, compared with 2,000 in Florida. The Sunshine State is one of 30 that, like Michigan, now mandates autism insurance coverage, said James Todd, a psychology professor at Eastern Michigan University in Ypsilanti

MLive reports:

When passing the bill, State Rep. Lisa Brown, D-West Bloomfield, urged members to note the loss of talent Michigan was facing without the bills.

“I think most people know at least one person who has a family member with a child diagnosed with autism,” she saidwhen the legislation was approved on March 29. “We’ve heard from the schools. They graduate these wonderful, educated, ready-to-go-to-work kids and they have to move out of state because the jobs aren’t here because it’s not covered by insurance.”

Department of Psychology Professor and Chair Wayne Fuqua said he looks forward to seeing less than 90 percent of his behavior analysis graduate students leave the state.

He says he hopes the new legislation translates into WMU ramping up training capabilities, especially once the Great Lakes Center for Autism Treatment and Research center is completed in July. Residential Opportunities, Inc., and Western Michigan University began a $1.7-million renovation project on Portage Road for a new center for autism treatment to serve the 500 children with autism and their families in Kalamazoo County in January.

Licensing Legislation in Louisiana

The Louisiana chapter of the Autism Society reports:

Board Certified Behavioral Analysts Show Strong Opposition to Senate Bill 185:

Senate Bill 185: Louisiana State Board of Examiners of Psychologists (LSBEP) has introduced legislation known as S. B. 185, or the “Board Certified Behavioral Analyst Practice Act.” sponsored by Senator Dan Claitor. This bill would require behavior analysts to be licensed by the Louisiana State Board of Examiners of Psychologists (LSBEP). Clinical psychologists who make up the LSBEP would determine the requirements for the license and oversee the practice of applied behavior analysis (ABA).

Board Certified Behavioral Analysts (BCBA) feel that just as the practice of clinical psychologists is properly regulated by members of that profession. BACB credentials are already recognized in many laws and regulations around the U.S. that enable BCBAs and BCBAs (under the supervision of BCBAs) to practice and be reimbursed by many funding sources without interference from other professions.

BSBAs in Louisiana report that SB 185 will make it difficult for Louisiana to recruit or retain BCBAs. Currently, Louisiana has only 56 credentialed behavior analysts in the state.

One rule adopted recently by the Louisiana Board of Elementary and Secondary Education (LBESE) allows public schools to hire BCBAs as employees. The LSBEP was the only opponent to that rule, arguing that ABA is in the scope of practice of licensed psychologists so behavior analysts should be licensed as psychologists or supervised by psychologists or physicians.

Supporters of that rule argue that the practice of ABA is very different from the practice of clinical psychology, and they feel the supervision of behavior analysts by licensed psychologists is unnecessary and costly.

WAFB in Baton Rouge describes how the bill died:

Insurance Legislation in West Virginia and Louisiana

The State Journal reports that the West Virginia Legislature has passed a cleanup to its autism insurance mandate:

It was never a sure thing, but a bill to provide insurance coverage for applied behavioral therapy for autism spectrum disorders will be sent to Gov. Earl Ray Tomblin.

After a few questions in the House of Delegates March 10, the final day of the regular legislative session, members concurred with the amendments the Senate made to the bill.

House Bill 2693 passed during last year's legislative session to provide insurance coverage for children with the disorder. However that bill left a gap in coverage.

A bill introduced during this year's regular session, House Bill 4260, aimed to close that gap. It quickly and unanimously passed the House of Delegates, but stalled in the Senate.

A Thursday  release from Autism Speaks:

Autism Speaks, the world’s largest autism science and advocacy organization, today endorsed HB.771, which would amend Louisiana’s 2008 autism insurance reform law by raising the age cap to 21 and eliminating the $144,000 cap on lifetime benefits. Families paying thousands of dollars a year in insurance premiums would be able to continue coverage for the screening, diagnosis, testing and treatment of autism spectrum disorder (ASD) for individuals aged 16 through 20 if the legislation is enacted.

Sponsored in the Louisiana House of Representatives by Rep. Franklin Foil (R-Baton Rouge), the bill would eliminate any ceiling on lifetime benefits. Under current law, coverage ends once lifetime claims reach $144,000. In addition, the bill would eliminate the current requirement that treatments be supervised by a physician or psychologist.