An evidence-based medicine review panel in Oregon is considering adding applied behavioral analysis (ABA) to the Oregon State Health Plan. A previous panel rejected the therapy in 2008, citing lack of controlled trials. ABA is up for review once again after the state Legislature unanimously passed SB 365, requiring all private health insurance companies to cover ABA for children up to age 9 by 2016, as well as health plans for public employees and teachers by 2015. Senator Alan Bates D-Medford, who is also an osteopathic physician, led the appeal from the Legislature for the Health Evidence Review Commission to reconsider their prior decision.
Dr. Alison Little is an advisor for the subcommittee for Oregon’s Health Evidence Review Commission. She has testified nationally against ABA coverage, citing lack of double-blind, randomized controlled studies supporting the therapy’s effectiveness. Many studies were based on just one patient, and there were almost no studies for older children. Little said:
“Not all children benefit and a great many remain impaired.
Little previously testified against covering ABA in Florida, but U.S. District Court Judge Joan Leonard in Miami ordered the state to provide coverage for people up to age 21, calling the state’s opposition to the therapy
“unreasonable and arbitrary and capricious.”
Gina Green, a San Diego psychologist and the executive director of the Association of Professional Behavioral Analysis, claims that random controlled studies are difficult because autistic behavior manifests differently between individuals. It would also be impractical and unethical to subject parents to the chance that their child could be in a placebo group for the duration of the study.
Louis Hagopian, psychologist at Johns Hopkins University in Baltimore, claims that meta-analysis found applied behavior analysis was most effective when a functional behavioral assessment was conducted prior to starting therapy. He explains that children with autism have difficulty communicating, and may act out to receive attention. The inappropriate behaviors are reinforced when parents and caregivers give in to the child. Applied behavior analysis improves the child’s communication skills, and helps them to understand other people’s social cues. The therapy requires intensive hours to be successful, which makes it quite costly.
Children who do not receive therapy may exhibit difficult behaviors, including self-injury and aggression towards others. Some may also scream, spit, bite, or eat non-food items such as dirt or feces. They may also engage in dangerous behaviors, such as wandering into traffic or sticking objects in to electrical outlets. Without therapy, many will spend their lives in special education and institutions.
Supporters of applied behavioral analysis believe that many children can lead normal, independent lives, particularly if they receive treatment during the preschool years. While ABA is expensive, many thousands of dollars will be saved down the road when these children are able to function as independent members of society.
There are currently over 400,000 children on the Oregon Health Plan, many of whom suffer from autism. ABA has been a standard of care in many states for years, and it will soon be decided whether Oregon will join their ranks.