Autism: Options for Behavioral Health Treatment
Recently, I had the opportunity to collaborate with the California Floortime Coalition in an effort to collate “Options for Behavioral Health Treatment for Autism.” The effort was in response to the Comprehensive Autism Care Demonstration Annual Report. This report is in response to Senate Report 114-49, pages 157-158, accompanying S.1376, the National Defense Authorization Act (NDAA) for fiscal year (FY) 2016 which requires a report to the Committees on Armed Services of the Senate and the House of Representatives on the results of the Comprehensive Autism Care Demonstration (ACD). There have been eight annual reports since 2016. (ACD, January 8, 2024)
TRICARE Behavioral Health Services for Autism
For military families, TRICARE covers multiple services for beneficiaries with Autism Spectrum Disorders (ASD). Applied Behavioral Analysis (ABA) services are covered under the Comprehensive Autism Care Demonstration but other services are as well. Such as:
- Speech and Language Pathology
- Occupational Therapy
- Physical Therapy
- Medication Management
- Psychological Testing
- Psychotherapy
Options for Behavioral Health are needed
The Autism Care Demonstration (ACD) currently offers ABA services for all TRICARE-eligible beneficiaries diagnosed with Autism Spectrum Disorder. The ACD began on July 25, 2014 and extended until December 31, 2028. This extension is to determine the appropriate characterization of ABA services as a medical treatment OR other modality under TRICARE’s program coverage requirements.
The most recent ACD Report, dated 8 January 2024, discusses the evidence regarding clinical improvement of children diagnosed with Autism Spectrum Disorder receiving Applied Behavioral Analysis services. The findings concluded ABA services do not meet the TRICARE hierarchy of reliable evidence standard for proved medical care. (ACD January 8, 2024.) In fact, in 2024 the Department concluded that “focusing only ONE type of intervention may lead to MISSED opportunities for developmental growth of the individual and the family.“
Developmental Relationship-based Interventions (DRBIs)
Although ABA is the most widely known form of behavioral therapy, there are many other interventions available. These interventions are based on different theoretical framework, namely a developmental, relationship-based understanding of behavior & child development. Evidenced-based and supported by research, Developmental Relationship-based Interventions (DRBIs) are a category of behavioral health treatments with a number of different interventions. DRBIs have been published as empirical studies and deemed to show evidence of effectiveness. Examples include:
- DIRFloortime (The Developmental, Individual differences, Relationship-based model)
- PLAY Project (which is based on DIRFloortime)
- Responsive Teaching
- PACT (The Paediatric Autism Communication Therapy)
- Joint Attention Mediated Learning (JAML)
- Video Interaction to promote Positive Parenting (VIPP)
- and others….
Developmental Relationship-based Interventions (DRBIs) support a child’s innate drive for learning and social connection, rather than learning theory (which is based on prompts, rewards & consequences). DRBIs use strategies that support a child’s initiative and are especially focused on supporting parent-child communication and relationships. Since DBRI models are HIGHLY focused on impacting the way parents (and other caregivers) interact with the child, the hours of direct services are far fewer than ABA. Hours per week may vary from 1-10 hours/week (in contrast to ABA which is often 25-40 hours/week).
Choice – for individuals and families with Autism Spectrum Disorder
DRBIs and behavioral approaches are very different in both theoretical framework and in clinical practice. Some families may prefer one or the other, and some children respond best to one or the other. Increasingly, legislatures and insurance companies are making it possible for prescribing physicians and psychologists as well as families to have a choice.
In summary, DRBIs offer an alternative to ABA for behavioral health treatment for autism. Over the past few years, the growing consensus is the research has reached a level to designate these interventions as evidence-based for practice and should be included in insurance coverage.
