Saturday, November 7, 2015

How Much Therapy?


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"Intensity"  is a term often used when describing very rigorous or challenging fitness programs, but did you know "intensity" is also how ABA treatment dosage is described? So when you wonder to yourself, or question the ABA team about "How much therapy does my child need? How much ABA is enough? Is this too much therapy? What if I can only afford a few hours a month?", what you are really asking about is intensity of treatment.

First, a little background information:
The 1987 Lovaas research article (which is THE study in the field of ABA) reported on the results of intensive, highly structured behavioral treatment with a group of children who-- at the time-- were largely considered to be hopeless and unteachable.  From this article and many others since, we now know that intentionally intensive treatment (40 hours/week) can bring about huge gains across functioning domains (language, social skills, behavior reduction, etc), that skill/behavior gains often fade after treatment without proper generalization, early intervention produces the most gains, it is important to provide services in the child's natural environment (e.g. home), and the involvement and training of the parent/caregiver is critical for treatment success.

In 2014, the BACB published a helpful guide for insurance companies who must make decisions about how and when to fund ABA therapy. In this guide the ideal "magic number" of treatment intensity is described as an analysis of multiple variables, such as intensity of treatment goals, client needs & severity of deficits, and client response to treatment. A range of 10-25 hours/week for focused treatment and 30-40 hours/week for comprehensive treatment is recommended.

So now that you have some background information, what does all of this mean?

Basically, determining the ideal treatment dosage of ABA therapy for your child is a complex decision. Many factors have to be considered. Added to this, is that funding source recommendations may not line up with what the clinical team is recommending. In other words, your insurance provider may approve 10 hours of therapy/month, but the BCBA may tell you at least 15 hours/week will be necessary. What I see happen very often, is that the families I work with receive the therapy amount they can afford and not the the therapy amount that is needed.  

I know this question of "How much therapy does my child need?" is confusing and frustrating for the average parent. So here are some takeaway tips to aid your understanding. When I am making a decision about how much therapy to recommend for a particular client, these are some of the points I consider :
  •  What are the treatment goals? - The more intense the treatment goals, the more likely 20+ hours per week will be recommended. During a client intake, if the parents are telling me they want to work on feeding, toileting, language, severe behavior reduction, etc., what I am hearing them describe is an intensive and comprehensive ABA program. Think about it like this: for just one of those goals, literally hundreds of learning trials could be necessary for your child to master the skill. Its very unrealistic to ask for comprehensive treatment, but only want to pay for a few hours of therapy per week.
  • What is the treatment setting?- Will therapy sessions occur at home, at school, in the community, or at a clinic/center program? This can impact how much therapy the child can receive. For example if you only want behavioral help at your child's karate class, that limits the frequency of therapy to when the karate class is held. Conversely, if the child is not in school and therapy will occur at home then treatment intensity should increase to maximize the availability.
  • Can relevant stakeholders be considered on the "team"? - Buy In. Read it, learn it, live it. The less involved the parents, teacher, or related professionals (e.g. the private OT) with the ABA treatment plan, the more the weight of treatment integrity will fall on the ABA team. I see this all the time: a family is receiving ABA services, the ABA team expresses that the child is making huge gains, and the family disagrees. Why? Well, if the parents are not involved with treatment/not generalizing treatment then they likely won't see the gains that the therapists see. While your child will use words with me, when I leave your house they will go back to pulling you by the arm to indicate what they want. The more the ABA team can count on the family to reinforce the treatment plan, the more confidence they will have in decreasing therapy hours.
  • How therapeutic are the child's non-ABA hours? - This is closely related to the previous point. How much of the child's non-ABA hours are contributing to or generalizing the skills and behaviors being addressed? Ideally, there would be generalization across individuals and settings. I recently had to discuss this with a client, whose son has in -home ABA and is in an inclusive classroom. Unfortunately, the classroom environment is such that it encourages and reinforces the very problem behavior the ABA team is working to reduce. So in that scenario, I could not count school hours as therapeutic or likely to promote skill acquisition... quite the opposite. So this would be a situation where I recommend increasing the intensity of ABA services.
  • Are there any company policies/limitations to consider? -  Some companies won't staff a case for less than 5-10 hours a week of services. Scheduling wise, it can be more difficult to find professionals if you only want minimal therapy hours. Another example is if your insurance provider will pay for 40 hrs of ABA a week, does the company have enough staff to cover that? Sound like a silly question? Believe me, issues like this happen both with very low treatment intensity and very high treatment intensity.
  • Where are we in the course of treatment? -  Is the client new to ABA and an early learner, or have they received therapy for years and are now close to terminating services? This also must be considered when deciding how much therapy the individual should receive. It is typical that the intensity of ABA begins very high, and then is carefully reduced over time until services are no longer necessary. If therapy services will be fading soon, or the client needs focused/short term help, then a lower intensity of therapy may be fine.


References:



Eldevik, S., Hastings, R. P., Hughes, J. C., Jahr, E., Eikeseth, S., & Cross, S. (2010). Using participant data to extend the evidence for intensive behavioral intervention for children with autism. American Journal on Intellectual and Developmental Disabilities, 115, 381-405.


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