Clinic Notes: The New Heath Care Bill and ABA

As everyone knows by now, the Health-Care Reform Bill has passed both Houses and been signed into law by President Obama. The Autism Society issued a statement saying "that Congress took a step in the right direction, . . but we have much more work to do to ensure that families affected by autism have access to appropriate services . . ." The new bill requires coverage for ABA therapy, which many insurance companies were denying saying that ABA was experimental. Good news so far. Now we will see how it's implemented. Thirteen states have filed lawsuits contesting the passage of the bill. We will have to wait a while to see how the ABA coverage is implemented and the actual coverage required. TennCare will pay for ABA in the state where I live and practice. The problem is the the reimbursement rate is $18 dollars an hour. With my overhead I cannot afford to take TennCare patients. Hopefully, the new law will be better.

Clinic Notes: Medication and ABA Redux

My last blog on medication and ABA prompted several insightful comments that I would like to address. First of all I am not pro med. Medication should only be used as a last resort after more conservative behavior therapies have been implemented. And this is what I tell parents who bring their children to my clinic. Furthermore, medications may facilitate other therapies but they will not "cure" or manage the behavior problems by themselves. Medication trials should only be initiated when the potential benefits of the medication clearly outweigh the potential side effects of the medications. If the medication trials do not show a clear effect in increasing the quality of life for the child then the medication should be discontinued. THIS "BEST PRACTICE" GUIDELINE SHOULD BE FOLLOWED BY EVERY CLINICIAN AND PARENT.
Now potential medications can be evaluated in a multi-child study with as much scientific control and safety guidelines as possible. It is difficult to get approval for these studies because the committees in charge of protecting subjects usually turns them down. Often, when these studies are done they are post hoc where medical records of subjects receiving the medications and a control group are examined. These studies usually show no differences between the control group and the medication group. More commonly medications are "evaluated" off-label in a clinical setting. A child having problems in school is given an ADD drug because the parents and teachers complain that he child will not stay on task. Ideally, a behavior program should be implemented first but that is not always done. And the criteria for success should be clear. Parents and teachers may report that the child on the ADD drug is paying attention better. But an examination of the child's grades often show no improvement. The child is easier to manage but that is not enough.
Clearly, there are many children who are over medicated and/or miss-medicated. But there are also a lot of children who could not function without their medication. Clinicians and the public need to be very careful in distinguishing between the two groups.

Clinic Notes: Medication and ABA

The popular press has carried a number of stories recently about the large number of children in our society being over-medicated with psychoactive drugs like Prozac, Ritalin, or Risperdal. These stories quote the possible multiple side effects of these drugs and the harm that could be done to these innocent children. Uncaring parents that don't have time for their kids and careless doctors prescribing, "dope" is the image that is portrayed. Often the first thing parents tell me when they bring their children to my clinic is, "We don't want medications." So where are the uncaring parents and careless doctors? Well, actually they are hard to find. A child on medication is usually a sign of good parenting. I tell parents we will try to do everything we can behaviorally and then see if medications are necessary. And often, about half the time medications are necessary. About 80-90 percent of the children I see each week are on the Autism Spectrum and about half are on medication. Applied Behavior Analysis (ABA) seems o be facilitated by medication in many cases.

Clinic Notes: Does Early ABA Rewire the Brain?

In the developing infants brain billions of axons (nerve fibers) that conduct electro/chemical messages follow growth cones through a tangled web of other axons to arrive at their final destination and connect different areas of the brain. Genes that encode the molecules that guide the growth codes somehow go awry and miss the pathway they are supposed to be following. This mis-wiring is likely the cause of autism, Parkinson's disease, and perhaps other disorders. During development, as different areas of the brain are wired up, the infant then displays new behaviors. Around age four, the majority of the connections are made and there is a die of neurons. The wiring process continues throughout life, but at a much much lower rate. Hence the importance of early intervention. I think that early intervention, especially with ABA, rewires the brain and improves the behavior of the child with autism. Studies support the improvement of children with autism following ABA but do not specify the mechanism.