The Council of Autism Service Providers has updated the applied behavior analysis practice guidelines for the treatment of autism spectrum disorder.
The Council of Autism Service Providers (CASP) has published updated applied behavior analysis (ABA) practice guidelines for the treatment of autism spectrum disorder (ASD). These guidelines provide health care providers and government health agencies with the latest evidence and best practices regarding the use of ABA for individuals with ASD.
At intake, the standard of ABA care involves the use of multi-method, multi-informant data sources to provide providers with a well-rounded view of patient functioning. As part of the assessment process, behavior should be directly observed and recorded by behavior analysts.
At initial assessment, behavior analysts should conduct a record review to understand patient needs and develop a treatment plan. In the record review, providers should gather information about the patient’s medical history, treatment response to prior interventions, current treatment plan, and cultural and familial considerations that may affect treatment.
Following the record review, providers should interview both patients and caregivers to further understand patient needs and the desired outcomes of treatment. As a hallmark of ABA, providers should measure behavior through direct observation and define target behaviors in measurable terms through continuous and/or discontinuous procedures. These observational measurements should be frequently repeated to assess treatment progress.
These practice guidelines provide information about standards of care in ABA that should be used in planning, implementing, and evaluating assessment and treatment services.
Behavioral observation types include functional behavior assessments, skills-based assessments, and standardized assessments. However, the guideline authors caution that providers should not rely on only 1 method of assessment to determine the ABA treatment course. Instead, the use of multiple measures that include both direct observation and caregiver reports is encouraged.
Additionally, providers should utilize risk assessments and assessments from other medical professionals when developing a treatment plan.
Treatment planning for people with ASD should be individualized to each patient and involve collaboration with caregivers and medical professionals to achieve optimal outcomes.
To provide patients with quality ABA services, the individualized treatment plan needs to take into consideration evidence-based best practices, the patient’s age and baseline functioning, target behaviors, caregiver circumstances and skills, and the resources needed to successfully implement the treatment plan. The scope of each treatment plan generally falls into one of 2 major categories: focused and comprehensive.
Focused ABA is narrower in scope and generally targets only 1 or 2 treatment domains. Focused ABA treatment is appropriate for patients who may need to acquire a more limited number of skills or who demonstrate high-risk behaviors that need immediate attention due to health/safety concerns.
In contrast, comprehensive ABA is much wider in scope and is intended to improve or maintain behaviors across multiple skill domains. Comprehensive ABA treatment is frequently used as an early intervention among young children with ASD, as it is intended to address developmental delays and establish foundational skills.
Providers should determine the appropriate treatment intensity based on each patient’s baseline skills and necessary treatment scope. However, the guideline authors indicate that typically “the practitioner should err on the side of caution by providing a higher level of service intensity.” To increase accessibility, ABA services can be administered in person, via telehealth, or through hybrid models.
According to the CASP guideline, tiered service-delivery models are well-documented in peer-reviewed literature as the primary methodology for yielding substantial improvements in cognitive, language, social, behavioral, and adaptive skills. These models employ the use of treatment teams that work under the direction of behavior analysts and can be two-tiered or three-tiered. The use of tiered models is beneficial for providers, caregivers, and funders as it is cost-effective and increases access to ABA services.
In order for the tiered service-delivery model to be effective, the following should be implemented:
Measuring treatment outcomes can be complex, as treatment plans often establish both short- and long-term goals whose outcomes may fluctuate over the course of treatment. Outcome measures should reflect each patient’s specific treatment goals and can include both objective, standardized assessments and qualitative feedback from patients and/or caregivers.
The guideline authors caution that there is currently no consensus that defines treatment progress or the prescribed batteries of tests for patients undergoing ABA treatment of autism. Further, demographic and cultural factors should be considered when interpreting outcomes.
Providers should begin to consider discharge planning at the start of treatment, clearly defining the desired outcomes of treatment and sufficient progress that warrants discharge. The patient can be discharged under the following conditions:
The transition plan should also account for multiple stages of transition, as patients gradually reduce support and ultimately achieve a more independent level of care.
In some cases, families may need to end or temporarily suspend services due to funding issues, family circumstances, unreconcilable differences in treatment ideation, or during the transition to a new provider. In these situations, providers should outline why the decision was made and the clinical recommendation for ongoing services. Further, the provider should facilitate the continuation of care (upon consent from the family and/or patient).
“These practice guidelines provide information about standards of care in ABA that should be used in planning, implementing, and evaluating assessment and treatment services,” the guideline authors stated. While the guidelines were written based on scientific evidence and expert clinical opinion, the authors emphasize that the application of the recommendations must be individualized to each patient with ASD.
