ABA has a lot to offer when it comes to understanding and helping people, and positively impacting the world around us. Our science is evidence based, it works, and our practitioners care deeply about the people we support.

Many people have demonstrated significant improvements in quality of life as a result of ABA services, but some have been hurt in the evolution of our practice.

The former in no way justifies the latter, but understanding and addressing the issues at hand in a vacuum has problematic implications looking forward.

The purpose of this article is to provide context for some common critiques of ABA and strategies for overcoming them.

WERE/ARE THE VALUES OF ABA PRACTITIONERS COMPARABLY WORSE, BY TODAY’S STANDARDS, THAN OTHERS?

As times change, healthcare and educational standards change with it. What we consider as “best practices” and socially acceptable practices change over time. Some therapeutic or medical procedures, language, and ideology that once prevailed are no longer acceptable.

Across all aspects of life (religion, medicine, education, parenting) normalization was a common goal, punishment was an accepted practice, and the concept of patient-centered care, at least as interpreted by today’s standards, was relatively foreign.

The actions and belief systems being called into question today are part of a broader cultural ideology from a time and mentality that’s fading from popular culture. These things are not, and were not, specific to ABA.

One could look to psychiatry, medicine, psychology for analogues in healthcare. In education, teachers, principles, psychologists, and others were all part of the same value system. It wasn’t uncommon in schools for educators and administrators to implore behavior analysts to prioritize aversive procedures such as extinction, time out, and punishment procedures, where those same behavior analysts sometimes advocated instead for reinforcement based procedures. In fact, this was an important part of positive behavior support’s history.

I strongly encourage behavior analysts who’ve only started practicing in the last 10 years or so to speak to parents and a variety of professionals if they question this claim. (Be sure to approach this systematically!)

“TODAY’S ABA”

Dr. Hanley provided context for “Today’s ABA” in his post “A Perspective on Today’s ABA From Greg Hanley” (linked below). He elaborated on that in a Behavioral Observations podcast (Session 160, also linked below).

I thought Dr. Hanley very nicely characterized the evolution we’re seeing in collective ideologies, values, and practices.

That said, I believe the manner in which some members of our community have carried that forward may prove counterproductive.

My concern is with the rebranding of our discipline around this terminology, and how some who embrace this rebranding contextualize it relative to our practice and history in the broader context.

The defining characteristics of ‘Today’s ABA’ aren’t the product of some cladogenesis, or some sudden shift away from yesterday’s practices by today’s enlightened professionals. They also aren’t specific to ABA, despite anti-ABA propaganda embraced and perpetuated by some people in and outside of our field, that would suggest otherwise. They are the result of our science and practitioners knowing more and therefore doing better. That’s an ongoing learning process and part of any discipline’s evolution.

These changes may be due in part to advances in evidence based science/research, change in collective societal values, and feedback from various stakeholder communities.

Messaging to suggest values or standards now being called into question were specific to ABA are misleading, and have adverse implications.

Specifically, impacts are erosion of trust in our science, our discipline, and our colleagues, and subsequently steers prospective beneficiaries of ABA services away from effective, validated, evidence-based services that can positively impact their quality of life.

FURTHER CONSIDERATIONS OF ALTERNATIVE TERMINOLOGY FOR A DISCIPLINE DISTINCT FROM ABA

For those embracing the concept of a new ABA as a means to address the segment of autistic adults who harbor anti-ABA sentiment due to personal experiences, consider how this approach may seem insincere. It might present as a public relations stunt to disassociate from outdated and hurtful practices, and draw effort and attention away from more actionable alternatives.

Treating “Today’s ABA” as some terminus rather than just where we are in our discipline’s timeline risks drawing focus away from “tomorrow’s ABA” and the wonderful science yet to come that will make what we’re doing today appear as going the way of the dinosaurs.

Johnston, Jacobson, Green, & Mulick (2006) discuss what I see as a comparable ‘campaign’: Positive Behavior Support (PBS). They also discuss some of its movement’s implications – pros and cons – which can apply here as well.

There is still work to do and there always will be. Surface level rebranding efforts don’t equate to real action, and even risk dismantling and therefore minimizing the collective historical and potential future impact of behavior analysis for the short term gain to any one generation of practitioners and businesses.

Science and practice are ever changing and improving. When tomorrow comes (i.e. as we learn and improve), today’s ABA will inevitably become yesterday’s ABA.

There will always be stragglers. Those who fall into this category won’t realize it. Nobody says “hit me up if you want 80’s style therapy”. People will inevitably assume they are offering the highest quality and most current practices. It would make sense that over time, the newly adopted language will lose its meaning.

NECESSARY ACTION

In my view, we need to play the long game, and the long game ain’t always easy. We need to accept responsibility when applicable, learn, and improve. As the saying goes, ‘when you know better, you do better’.

Quality will be demonstrated by engaging in practices that are based on the best and most current scientific evidence and also prioritizing and reporting out on measures that align with client/patient standards. The prevailing community of autism service providers have evolved with our culture’s predominant ideology to prioritize concepts of patient-centered, value-based, and compassionate care, (regardless whether they use that terminology), but we’ll continue to do even better as we learn more. “The proof is in the pudding”.

This doesn’t mean we don’t focus on our ‘brand’ and effective marketing of our science and discipline. Just that we are more thoughtful in doing so. Perhaps a greater shift in emphasis to patient-centered outcomes. Not at the expense of, but in addition to other clinical outcomes.

Consider your website’s landing page highlighting “clients meet x percent of their treatment goals and report a 5 out of 5 on their experience and satisfaction with our team! Their parents report the same!”.

I believe that keeping ethics and client/patient values, experience, and satisfaction as guiding beacons for our research and practice, and central to all that we do and all that we are, is bound to best reflect our sincerity and achieve the best long term outcomes all around.

SUMMARY

As I reflect back knowing what I do now, there are extinction bursts I would have avoided, autistic client voices (including those who were non-verbal) I would have weighed so much more heavily, and treatment plans I would have approached differently. I don’t say this lightly. I remember, and so I’m confident my clients do too.

But there are also people who I know have good memories. People who are doing things now, it was said they’d never do. People living safer and healthier lives and having opportunities and successes they’d have otherwise not had. Autistic adults and parents I’ve spoken to who praise their therapists from years ago.

I have memories of schools whose policies and practices I was able to help shift toward more appetitive and reinforcement based practices. I did this working with, not against, district educators and administrators.

This isn’t justification for any outdated, hurtful practices. It’s a basis for a more balanced historical context.

Brandon Herscovitch, Ph.D., LABA, BCBA-D

Partners Behavioral Health supports ABA practice leaders and advocates for our discipline.

REFERENCES

Johnston JM, Foxx RM, Jacobson JW, Green G, Mulick JA. Positive behavior support and applied behavior analysis. Behav Anal. 2006 Spring;29(1):51-74. doi: 10.1007/BF03392117. PMID: 22478452; PMCID: PMC2223172.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223172

The post Some context for anti-ABA sentiment, “Today’s ABA”, and action steps forward appeared first on Partners Behavioral Health.

Autism is heterogeneous, and for some autistic people, aspects of their autism experience are disabling. 

Anti-disability narrative, efforts to distance autism from disability, and perpetuating use of the term disability in a pejorative manner, can have unintended and undesirable consequences for some people. It can:

• Lead to others minimizing or invalidating the experience and needs of those who identify with that aspect of their autism experience. 
• Create barriers to accessing supports or services for those with disabilities.
• Build unproductive or problematic stigma around disability.
• Shame those who identify with disability, which has other implications for health and wellbeing. 

For others who either by legal or medical definitions or based on their own experiences do identify with autism as a disability, it’s important we respect, validate, and support them and their autism experience, even if it’s not reflective of others’. Similarly, those who have different experiences deserve the same respect and validation.

A label of disability affords certain rights and protections to people who need them. A great deal of time and effort has been invested in improving rights and protections for people with disabilities, and it would be sad to create additional barriers or strip autistic people who share those needs of those rights and protections.

There is no shame in disability. Let’s not make it a bad word.

Brandon Herscovitch, Ph.D., LABA, BCBA-D

Partners Behavioral Health can help with your clinical and business standards, compliance, and outcomes. We can help you scale an ethical ABA practice you’re proud about.

The post An anti-disability narrative around autism can be harmful appeared first on Partners Behavioral Health.

I want to emphasize this paper is not at all in opposition to caregiver involvement. Clearly there is value in parent or caregiver training and participation. It is in response to Parent Training as a Condition of Insurance Authorization.

The basis of the paper is as follows:

Parent training is an important and valuable practice in ABA and supporting your child with autism. “We wholeheartedly support parental involvement and parent training, [but] predicating service authorizations on a required level of involvement or requiring reports of parental involvement can be highly discriminatory and [can pose] unnecessary restrictions on access to care for the autism population.”

The full position paper is accessible here: https://partnersaba.com/product-and-service-packages/statement-on-parent-training-as-a-condition-of-insurance-authorization

Brandon Herscovitch, Ph.D., LABA, BCBA-D

Partners Behavioral Health supports ABA advocacy efforts and can help with your ABA business standards, compliance, and outcomes needs.

The post Parent training as a condition of insurance authorization appeared first on Partners Behavioral Health.

Brandon Herscovitch, Ph.D., LABA, BCBA-D

The post ABA, autism, and being “indistinguishable from one’s peers”? appeared first on Partners Behavioral Health.

Where this all started

Earlier this year, the AMA Medical Student Section did submit draft resolution 706 to the AMA House of Delegates, entitled “Removal of AMA Support for Applied Behavior Analysis”.

Addressing misinformation and misrepresentations

Some have been inaccurately conflating the Medical Student’s draft resolution with the AMA’s position. This resolution was not in fact representative of AMA’s position, does not represent the views of all stakeholders in the autism community, and was based on some inaccurate and outdated information about ABA. 

Important revisions

The committee responsible for reviewing the proposed resolution (Reference Committee G) prior to consideration by the AMA House of Delegates made meaningful edits prior to submission.

The outcomes

The resolution that was ultimately submitted by Reference Committee G and adopted by the AMA House of Delegates now broadens language from ABA to evidence based practice, and from the term autism to neurodivergent. I perceive these changes as positive, as they expand evidence based options to more people. The actions taken by the AMA are positive, progressive, and are in continued support of ABA and evidence based practices for autism.

Brandon Herscovitch, Ph.D., LABA, BCBA-D

Partners Behavioral Health can help with your ABA business standards, compliance, and outcomes needs.

The post Correcting Misinformation About ABA and the AMA appeared first on Partners Behavioral Health.

The implications of masking are not inconsequential, and adversely impact mental health, having been tied to things like anxiety, depression, and suicidal ideation.

It’s imperative we have a long game to foster a culture that values, not just tolerates, individuality, empowers personal growth, and ensures equitable opportunities.

But until that happens, I think we have other important questions to ask.

I’m curious to learn what others, and particularly autistic people who do experience this, feel about where the line is between masking autistic traits and acquiring skills to navigate their social environment in a way that will increase their likelihood of accessing their desired outcomes, personally or professionally. 

How do we best empower individuals in being self reflective and autonomous in identifying and balancing the implications of doing one over the other?

Please feel free to leave your thoughts in the comments if you’d like.

The post Autistic masking appeared first on Partners Behavioral Health.

In this article I discuss how our ability to more effectively advocate for autism and applied behavior analysis (ABA) services can be related to broad scale awareness, acceptance, and accurate perception and representation of both ABA and autism, which can of course be impacted by coverage in media, TV, and movies. Specifically, as related to a more representative sample of the autism community, including, but not limited to those commonly represented in the entertainment industry and media to date, as well as those segments of the autism community whose experiences are woefully underrepresented. In this article I provide some background about advocacy in our community, some associated financial information, various types of advocacy in which we can engage, and some actionable steps we can take moving forward. 

Advocacy

Advocacy may involve various different strategies, but generally involves educating people about specific issues, often to generate some kind of desirable change with respect to those issues. There are different matters in any professional field that require advocacy to move the field forward. With this in mind, different professional organizations have different purposes. It’s important to understand the different types of entities and what they do to help advocate for our field and their members. 

Professional Advocacy Organizations in Applied Behavior Analysis

Our field’s principal professional associations include Association for Professional Behavior Analysts (APBA) and  Association for Behavior Analysis International (ABAI). Nationally, our primary trade associations are Council of Autism Service Providers (CASP) and National Coalition for Access to Autism Services (NCAAS). Professional associations are based on an individual practitioner/professional membership model (APBA and ABAI), whereas trade associations are based on an organizational/company membership model (CASP and NCAAS). The former typically focuses more on the profession, and the latter more so on the industry. Both have their place, and their interests may often align, but they do sometimes have different priorities. ABAI’s primary focuses have been on scientific and scholarly issues related to ABA and their involvement in public policy issues has been a touchy subject to say the least. Some information on this history may be found here. The other three organizations listed are focused primarily on professional practice and public policy related matters.

Given the structure of the laws and regulations impacting the practice of ABA, a lot of the advocacy that needs to occur is at the state level. While some of the national organizations may be central in state based advocacy and progress, having state based organizations with a central focus on their own regional interests is essential. Using Massachusetts as an example, its primary trade association is Massachusetts Coalition for ABA providers (MassCAP), and its primary professional associations are Berkshire Association for Behavior Analysis and Therapy (BABAT), and Massachusetts Association for Applied Behavior Analysis (MassABA).

Non-Exhaustive Overview of Activities and Accomplishments by National ABA Advocacy Organizations Related to Professional Practice Issues 

APBA, CASP, and NCAAS have dedicated groups of professionals supporting and helping to advocate for and advance the professional practice of applied behavior analysis, with several of these groups having full time staff dedicated to these particular advocacy issues. All three of these associations allocate a significant percentage of their overall resources and funds to these practice and policy based issues, Together, these organizations represent and advocate for the interests of tens and tens of thousands of providers of ABA services, autistic children and adults, and their families, whose services are funded by commercial insurers, Medicaid, and TRICARE, among other funders. 

APBA, CASP, and NCAAS have successfully advocated for change in laws, regulations, and policies that positively impact commercial insurance, Medicaid, and Tricare funded ABA services in many states. They engage with pivotal people and departments in various public and private organizations, including but not limited to, public and private funders, legislators, and regulators throughout the country. Their successful contributions include impacting favorable changes related to licensure, insurance laws, mental health parity, EPSDT, data reporting, funding and service cap issues, among other important matters with respect to ABA services in the healthcare sector. Furthermore, these organizations have hired specialized consultants and allocated funds in various ways to support their respective advocacy efforts.

ABAI submitted the initial applications for implementation of the ABA CPT Codes covering associated costs. They currently have an ABA billing Codes Commission. They, along with BACB, APBA, and Autism Speaks were involved with the subsequent amendments of those codes. Currently, BACB, Autism Speaks, APBA and CASP are members of the ABA Coding Coalition, advocating for appropriate implementation of the CPT codes for ABA services and related policies, and are key contributors in covering the associated costs for that endeavor. 

The Cost of Effective Advocacy Campaigns

There are many elements of effective advocacy and they pretty much all require resources, and specifically money. A lot of money. In considering advocacy efforts related to insurance, Medicaid, and Tricare Funded ABA/Autism Services, as well as perception and support of the field more broadly, it’s important to consider this in the context of funds available to organizations representing the interests of not only ABA providers and organizations, but also those of funders who may have different priorities and interest. 

The table below provides financial information for America’s Health Insurance Plans (AHIP), which is the health insurance industry’s main advocacy group representing the collective interests of its members, as well as for APBA,CASP, NCAAS, and ABAI. These data are from Form 990s filed with the IRS for fiscal year 2019 where possible, or 2018 when 2019 data were not available. 

Let me first review some key terms related to the interpretation of these data. Annual revenue refers to the total amount of money the organization makes in sales (products, services, memberships, events, grants, donations) for the year. Net assets are essentially the net worth of the organization including both liquid and fixed assets, after subtracting liabilities. Liquid assets are commonly cash and things that can quickly be relatively quickly and easily converted to cash, like receivables. Fixed assets generally have a net life of over a year, and typically take longer to be converted into cash, like buildings, equipment, among other things. Liabilities are fundamentally what the company owes.

Health insurance trade association 

Organization (filing year)                         Annual revenue                         Net Assets at Year End

AHIP (2019)                                                    $68,697,325.00                             $6,690,684.00

Applied behavior analysis professional associations 

Organization (filing year)                        Annual revenue                          Net Assets at Year End

APBA (2019)                                                   $761,505.00                                    $415,619.00

ABAI (2018)                                                    $5,144,042.00                                 $10,955,088.00

Autism/ABA trade associations

Organization (filing year)                         Annual revenue                          Net Assets at Year End

CASP (2019)                                                    $668,608.00                                 $300,160.00

NCAAS (2018)                                                 $351,600.00                                 $135,371.00

Needless to say, having adequate revenue and assets is critical to the stability and sustainability of an organization. With that said, these data illustrate how the health insurance industry is much better funded to advocate for their interests related to ABA services. These data also suggest to me that we need to allocate the funds which are being spent on professional associations in our field to our professional practice and policy focused associations.

Lobbying

Lobbying may be one element of an effective advocacy effort, and involves attempts to influence specific legislation or policies at the regional, state, or federal levels. Lobbying is a means by which to influence legislation. It can be done by individual companies as well as collectively as industries. When done collectively as an industry it allows people and companies with shared interests, in this case anyone and everyone invested in autism and ABA, to pool their resources and influence laws and the government in a manner that serves their collective interest. A challenge is that it requires significant financial and social capital often beyond the scope of many individuals or even smaller organizations.  

In 2021 AHIP spent over $11 million on professional lobbying for their members’ interests. According to Becker’s Healthcare report, the following were professional lobbying expenditures to congress and federal agencies from January through June 2021. Note, this is over a 6 month, not a 12 month period, of 2021. 

• Blue Cross Blue Shield Association (Chicago) — $12,018,300 (6 months in 2021)
• America’s Health Insurance Plans (Washington, D.C.) — $6,410,000 (6 months in 2021)
• Cigna Corp. (Bloomfield, Conn.) — $4,310,000 (6 months in 2021)

Compare this to advocacy funds spent on professional lobbying as defined by and reported on the most recent IRS tax filings by professional ABA organizations listed here, which was limited to $220,200.00 spent by NCAAS in 2018. It should be noted, however, that although the above table indicates correctly that APBA and CASP did not spend any money on political campaigns or professional lobbyists, and that NCAAS contributed a couple hundred thousand, all these groups allocated an enormous amount of their available, but unfortunately very limited resources to try to influence public policies and advocacy efforts affecting their constituents, well beyond the numbers listed in their 990s. In fact, year over year APBA, CASP, and NCAAS have allocated a significant majority of their resources toward professional practice advocacy efforts. 

The Influence of Public Perception and Media Coverage on the Field of ABA 

Public relations and public perception are an important part of advocating for our field. However, production of commercial grade ads can be very costly, northward of $100,000.00. Production of television shows can be in the millions. Air time for these ads and shows can be even more than that. Perhaps we need to look at this strategically and try to get on board with the Science and Entertainment Exchange as one element of our field’s collective advocacy effort.

Some science organizations have relationships or contacts with news outlets allowing for exciting research, books, and programs to be highlighted through those mediums. Unfortunately, despite the meaningful and groundbreaking work we do, our field has very little coverage on social media, television, and the entertainment industry in general, and that which it does have sometimes misrepresents or unfavorably represents our field. 

Our ability to effectively advocate for autism and ABA are related to broad scale acceptance and accurate perception and representation of both autism and ABA, which can of course be impacted by coverage in media, TV, and movies. With this in mind, do you know what the following films and TV shows have in common?

Doctor Strange, Avengers, Thor, Battleship, Apollo 18, TRON: Legacy, Mental, Green Lantern, Ant-man, House, Big Bang Theory, Criminal Minds, Covert Affairs, The Good Wife, Bones, Heroes, Contagion, Eureka, Known Universe, Priest, Prometheus, Blackhat, Castle, Fringe, Terra Nova, Lie to Me, I, Predator, Caprica, The Lost Future.

The answer: They are all projects associated with The Science and Entertainment Exchange.

Why is that relevant?

“The Science & Entertainment Exchange (The Exchange) is a program of the National Academy of Sciences (NAS) that connects entertainment industry professionals with top scientists and engineers to create a synergy between accurate science and engaging storylines in both film and TV programming….. The goal of The Exchange is to use the vehicle of popular entertainment media to deliver sometimes subtle, but nevertheless powerful, messages about science.”

In order to maximize advocacy efforts and outcomes, powerful and accurate messaging about our science and the diverse experiences and priorities of those we serve is much needed.

I’ve reached out to The Exchange but to no avail. If any readers have network connections that extend to or can influence pertinent decisions makers there, hit me up!

Concluding Comments

We need to make sure those engaging in advocacy efforts supporting our field, and specifically our professional practice, have our support. This should not be an afterthought. If you can have this ideology and even funding mechanisms built into your organization’s philosophy and structure, all the better.

If you don’t have a state trade association that currently engages in lobbying or other advocacy efforts and would like help setting one up, Partners Behavioral Health can help with that.

Brandon Herscovitch, Ph.D., LABA, BCBA-D

Partners Behavioral Health can help with your clinical and business standards, compliance, and outcomes. We can help you scale an ethical ABA practice you’re proud about.  

References

https://www.opensecrets.org/federal-lobbying/clients/summary?cycle=2021&id=D000021819

https://www.modernhealthcare.com/politics-policy/healthcare-industry-launched-lobbying-blitz-ahead-year-end-spending-deal#:~:text=The%20insurance%20 industry%20trade%20 association,%24790%2C000%20from%20the%20previous%20year.

https://www.beckershospitalreview.com/finance/top-20-healthcare-lobbyists-by-2021-spending-through-june.html

https://www.investopedia.com/investing/which-industry-spends-most-lobbying-antm-so

https://khn.org/news/cpi-health-lobbying

https://publicintegrity.org/health/lobbyists-swarm-capitol-to-influence-health-reform

https://www.propublica.org/article/insurance-lobby-has-sturdy-bridges-to-democrats

https://www.washingtonpost.com/opinions/2019/10/22/insurance-companies-arent-doctors-so-why-do-we-keep-letting-them-practice-medicine

https://psychiatry.org/membership/join-apa/general-members

https://jezebel.com/health-insurers-are-idiots-possibly-evil-321003

https://www.irs.gov/pub/irs-pdf/p557.pdf

https://www.charitynavigator.org/index.cfm?bay=content.view&cpid=1559

https://lda.senate.gov/system/public

https://www.beckershospitalreview.com/finance/top-20-healthcare-lobbyists-by-2021-spending-through-june.html

http://scienceandentertainmentexchange.org/about/

https://masscapaba.org

https://babat.org

https://www.massaba.net

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Partners Behavioral Health is dedicated to helping ABA companies with both their individual business and collective advocacy efforts (i.e. trade associations and trade organizations) – our team members track records speaks for itself.

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Partners Behavioral Health can help with your clinical and business standards, compliance, and outcomes. We can help you scale an ethical ABA practice you’re proud about.

The post Shifting values in autism awareness and acceptance appeared first on Partners Behavioral Health.

Brandon Herscovitch, Ph.D., LABA, BCBA-D

Partners Behavioral Health can help with your clinical and business standards, compliance, and outcomes. We can help you scale an ethical ABA practice you’re proud about.

The post Addressing Inequities and ‘Isms’ in Applied Behavior Analysis: A Call for Change appeared first on Partners Behavioral Health.