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QUESTIONS FOR IN-HOME AUTISM TREATMENT PROVIDERS
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Autism and Behavioral Consultants
Revised November 8, 2000
David M. Small, Ph.D., Clinical Director
349 Winnebago Drive
Fond du Lac, WI 54935
920-921-1366
(Division of Counseling and Wellness Center, S.C.)
A. Therapy:
1. How would you characterize your therapeutic approach? We recognize the individuality of each child, and use the techniques of Applied Behavioral Analysis (ABA) to intensively intervene with children diagnosed with autistic spectrum disorders, including Autistic Disorder, Asperger's Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS). We use a one to one discrete trial format and supplement with other advanced behavioral techniques to maximize skill acquisition and promote generalization of newly acquired skills. Additional intervention techniques include the work of: Greenspan, Attwood, Bondy, Myles, Freeman and Davis, Koegel and Koegel, Miranda and Donnellan, and Carbone. We are attentive to Sensory Integration issues, and include techniques to help alleviate and improve functioning. We incorporate environmental designs to improve learning, literacy and language supports and utilize a developmental approach with each child.
2. How do you work with children who are nonverbal? It has been our clinical experience that assisting the child to develop functional means of communication greatly improves their quality of life and lowers the stress and frustration level of the children and their families. We aggressively work to establish a communication system that is understandable for the child, their family and others in the comunity. To reach this goal, we utilize multimodal strategies, including: Picture Exchange Communication System (PECS), Augmentative Communication devices, Sign Language, Errorless Learning, and the Dynamite/Dynavox. Where available, we consult with Speech and Occupational Therapy services to develop a comprehensive language based program that is synamic and individualized for the child.
3. How do you accommodate the child's sensory defensiveness? We develop an individualized treatment plan in consultation with Occupational and Physical Therapists to address sensory defensiveness in children that have been identified with this issue. Recently, we have added three master's prepared Occupational Therapists, and one bachelor's prepared O.T. to our staff. Through the use of a positive reinforcement system and recommendations for a "sensory diet" as indicated by the Occupational Therapists, we have in many cases reduced the sensory defensiveness of the children we serve. It has been our experience that most children with ASD will have sensory issues and we incorporate strategies to reduce and redirect problematic behaviors.
4. How do you deal with a child's aggressive behavior? As with all identified behaviors we target for intervention. We first conduct a functional assessment of the aggressive behaviors, trying to determine antecedents, reinforcers and environments that contribute to its occurrence. For some children, aggression may be function of sensory issues and language deficits. From the information obtained, we identify more appropriate behaviors for the child to perform when those issues present themselves. Also, we establish a reinforcement hierarchy which will be used to shape behavior to more appropriate occurrences. The techniques of shaping, chaining, and differential reinforcement are used to teach the child to respond in a more functional and less aggressive manner.
5. What services are offered in addition to the in-home therapy (i.e., social skills groups, speech therapy, etc.)? Are these services also covered by Medicaid? For families in which there is a request made for additional services, or a need for additional services is noted by our clinical staff, appropriate recommendations are made to professionals that can meet these needs. We encourage families to consent to our communicating with these professionals if it will help us to further understand the needs of the child with ASD. Payment for the services of the consulting professionals is arranged between the families and the consultant.
B. Entering and Exiting the program:
1. Do you accept all children under the current Medicaid age limit who apply? If not, what are your entrance requirements, such as age or IQ? We accept all children who meet the guidelines as established by Medicaid. To date, we have not denied any family seeking services.
2. What testing do you require initially? We have found that it is oftentimes impossible to establish rapport that would allow for optimal formalized testing of children during the initial visit. We would prefer to conduct more functional skills assessments in the child's home as an ongoing part of the intensive behavioral treatment. Functional skills assessments often include completion of the Vineland Adaptive Behavior Scales, as well as hands on assessment of the child's skill levels. We will conduct a formal evaluation when it is clinically necessary, or this information is requested. In these situations, different indices of receptive and expressive communication abilities as well as IQ and achievement testing is completed. This preferably takes place once a rapport with the child has been established between the clinician and the child.
3. Under what circumstances will you accept testing by other agencies, such as schools or private therapists? We will accept such test results and will consider the interpretations made in all circumstances. We will use this information for baseline data and comparison of current skills and ability levels.
4. What are the current out-of pocket expenses that a parent must pay for the entrance testing? Zero. No formal testing is required.
5. Can parents arrange to have these expenses spread out over a longer time period? Not applicable as our program does not require formal testing for admission.
6. How is the number of therapy hours determined? The Research literature supports that programs with 25 hours of one-to-one therapeutic intervention per week using an ABA approach are most effective in managing behaviors, systematically instructing, as well as generalizing the skills the children learn. The State of Wisconsin will allow 35 hours of treatment per week to work with the children who meet Medicaid guidelines. Preschool age children in our program typically receive the 35 limit for services. Children in school a full day oftentimes receive the lesser amount of 25 hours per week..
7. Do you require that the child may not be in any other educational program when he begins therapy? If so, for how long? No! We have found that school based programs (i.e. Birth to Three, Early Childhood, and Special Education Programs) provide the children with exceptionally important opportunities for making gains both academically and socially. We attempt to support these agencies through meeting and consultation where we typically discuss treatment issues, socialization, self-regulation, positive behavior management strategies, and alternative teaching approaches. We are limited to the number of hours we spend in school based programs, as our program is primarily an in-home intensive behavioral treatment program. Our services within the school must meet strict guidelines and follow a formal treatment plan. The State of Wiscosin allows our program to provide transitional services, generalization of skills and consultation with the school.
8. How is a child's progress evaluated, and how often is this done? The Senior Therapist engages in ongoing assessment of the child's progress towards the operationally defined goals of the tratment plan. This progress is reviewed weekly with the family and line staff in a team meeting and every four to eight weeks with the supervising psychologist. Our company has regionally based Area Coordinators that are available to Senior Therapist to further ascertain a child's progress.
9. What are your criteria for a child exiting the program? This decision takes into account the progress the child has made towards their goals, family input, and team data across environments. All are critical in determining when a child is ready to end services or graduate from this intensive treatment to less structured programming.
10. Under what circumstances can a child be dismissed from your program? A child can be dismissed if the State of Wisconsin either terminates funding or services, or if parents or caretakers decide to remove the child. Parents may have the opportunity to resume services if the child still meets Medicaid guidelines with our company or another provider.
Therapists:
1. What are the minimum educational requirements for line therapists? The State of Wisconsin requires at minimum that the line therapist candidate be in their second year of college or that they have substantial work experience with children with autistic spectrum disorders. Most line staff are students studying to be Early Childhood Teachers, Social Workers, Psychologists, Special Education Teachers, or Human Development Specialists.
2. What kind of training are the line therapists given? Who provides the training and what are their qualifications? Line therapists are recruited by the main office via advertisements, and then interviewed by the Senior Therapists and families. Training begins upon their successful placement with a child, is child specific, and is conducted primarily by the Senior Therapist. Our professional Senior staff must have a Bachelors degree in a related field of study and experience with children with special needs. Approximately half of our Senior Therapists have Masters degrees and 3000 hours of supervised experience. Training of the line staff is ongoing and incorporates the weekly team meetings and outside readings. The Area Coordinator assists with specialized techniques, and the Supervising Psychologist provides additional training as appropriate during home visits and at the initial workshop.
3. What should parents do if they have a complaint about a line or senior therapist? We encourage people to work out their disputes together before involving other persons. Complaints should follow up through the company, first by alerting the Senior Therapist, then the Area Coordinator, then the Supervising Psychologist, and finally the Clinical Director. Our company intends to be family friendly, and we try to resolve issues before they become complaints.
Parents:
1. What kind of training is given to parents and other family members? How much training is provided? Initially, a workshop is conducted by the Supervising Psychologist. All persons involved in the child's care and program are invited, with a special invitation extended to family members. Following the workshop, family training is designed to meet the clinical issues being addressed and usually occurs during the weekly team meeting. For example, when self-regulation and problem behavior management strategies are developed, these are shared with parents and family and discussed prior to implementation. When clinical issues such as obsessions and compulsions, anxiety and stressors are identified, these are discussed with families as well, with an indication of what intervention will be most appropriate for their child. Alternative interventions are presented as well, so the parent has the opportunity to provide input into the direction therapy follows.
2. Must one parent be in the home during therapy sessions? What alternate arrangements are acceptable? We require that parents be accessible at all times. This can be via telephone, paging system, or cellular telephone. Parents are therefore not required to be physically present during all hours of therapy, but are encouraged to be present.
3. What, if any, support services, such as respite or counseling, are offered to families by your organization? How are these services paid for? We do not provide services other than the intensive in-home treatment. We are able in many instances to provide professional references to providers that can meet the needs our families report to us. The family then makes financial arrangements with these other providers.
4. Do you provide prospective families a list of families who have used your services and have agreed to be contacted? No. We will not breach the confidentiality of our families in this manner. Instead, we refer prospective families to their regional ASA chapters to provide answers about all the providers available in their prospective areas.
Other Agencies 1. How do you coordinate with area school districts that the children you are supporting attend? In most instances, the Senior Therapist, parents and IEP staff are able to forge a solid working relationship. We support the parents and child and consult with school staff. We may meet monthly with school staff and more often with school Speech, O.T., and P.T. staff. Our services model with the school is consultative in nature. However, several school districts have established guidelines with our agency's input to which our staff adhere. We see this establishment of guidelines as the future trend for our program's involvement in schools at any level.
2. How do you coordinate with private therapists that the family employs who are not a part of your organization? We value the consultants the family has decided to bring into the case, and communicate regularly with those consultants provided the proper permission to do so is in place. However, we will not implement any treatments that are aversive to the child, are not research based or pose ethical issues for staff. Children with ASD respond to many different treatment approaches and we are extremely careful to document progress or regression.