Decline in Medicaid-Funded One-to-One Behavioral Support Use in School as Children Age
Objective: This study compared use of and associated expenditures for Medicaid-reimbursed school-based and out-of-school services for children with autism spectrum disorder (ASD) and those with other psychiatric disorders.
Methods: Philadelphia County Medicaid claims were used to identify children ages five to 17 who received behavioral health services through Medicaid any time between October 2008 and September 2009 (N=24,271). Children were categorized into four diagnostic groups: autism spectrum disorder (ASD), conduct disorder or oppositional defiant disorder (conduct-ODD), attention-deficit hyperactivity disorder (ADHD), and other psychiatric disorders. Logistic regression analysis compared use of in-school and out-of-school behavioral health services between children with ASD and children with other psychiatric disorders. Generalized linear models with gamma distribution were used to estimate differences in Medicaid expenditures for in-school and out-of-school services and total Medicaid expenditures for both service types by disorder, with adjustments for age, sex, and race-ethnicity.
Results: The most common diagnosis was ADHD (40%); 35% had other psychiatric disorders, 21% had conduct-ODD, and 4% had ASD. A significantly greater proportion of children with ASD (52%) received in-school behavioral health services (conduct-ODD, 5%; ADHD, 8%; and other psychiatric disorders, 1.7%) Per-child expenditures for both school-based and out-of-school behavioral health services were significantly higher for children with ASD than for children in the other groups.
Conclusions: Medicaid represents an important source of in-school and out-of-school care for children with ASD and their families. States that expand Medicaid under the Affordable Care Act should give careful consideration to covering school-based mental health services for children with ASD.
Recent research suggests that children with autism spectrum disorder (ASD) may now be reliably identified in later infancy, highlighting the need for empirically-validated interventions for infants and toddlers with early symptoms of ASD. Using a multiple baseline design across 15- to 21-month-old toddlers, this study implemented a brief, parent-mediated, Pivotal Response Treatment program, focusing on improving expressive communication. The results indicated that verbal communication improved as a consequence of the intervention, with concomitant improvements in untreated areas for all participants. Following the intervention, symptoms of autism decreased and parents reported satisfaction with the program’s ease of implementation and observed child gains. The results are discussed in terms of developing very early interventions to improve developmental trajectories for infants and toddlers.
Keywords: Autism; Early intervention; Pivotal response treatment; Social communication; Toddlers.
Pivotal response treatment (PRT) is an evidence-based behavioral intervention based on applied behavior analysis principles aimed to improve social communication skills in individuals with autism spectrum disorder (ASD). PRT adopts a more naturalistic approach and focuses on using a number of strategies to help increase children’s motivation during intervention. Since its conceptualization, PRT has received much empirical support for eliciting therapeutic gains in greater use of functional social communication skills in individuals with ASD. Building upon the empirical evidence supporting PRT, recent advancements have increasingly turned to using interdisciplinary research integrating neuroimaging techniques and behavioral measures to help identify objective biomarkers of treatment, which have two primary purposes. First, neuroimaging results can help characterize how PRT may elicit change, and facilitate partitioning of the heterogeneous profiles of neural mechanisms underlying similar profile of behavioral changes observed over PRT. Second, neuroimaging provides an objective means to both map and track how biomarkers may serve as reliable and sensitive predictors of responder profiles to PRT, assisting clinicians to identify who will most likely benefit from PRT. Together, a better understanding of both mechanisms of change and predictors of responder profile will help PRT to serve as a more precise and targeted intervention for individuals with ASD, thus moving towards the goal of precision medicine and improving quality of care. This review focuses on the recent emerging neuroimaging evidences supporting PRT, offering current perspectives on the importance of interdisciplinary research to help clinicians better understand how PRT works and predict who will respond to PRT.
Keywords: ASD; PRT; biological motion; biomarkers; neuroimaging; precision medicine.