Applied Behavior Analysis

Number: 0554

Policy

For Applied Behavior Analysis for Autism, see CPB 0648 - Autism Spectrum Disorders.

Aetna considers Applied Behavior Analysis (ABA) experimental and investigational for Down Syndrome in the absence of an autism spectrum disorder (ASD) co-morbidity because of insufficient evidence in the peer-reviewed literature.

Aetna considers ABA experimental and investigational for all other non-ASD indications because of insufficient evidence in the peer-reviewed literature.

Background

Applied behavior analysis (ABA) is the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior.  The goal is to demonstrate that the interventions used are responsible for the observable improvement in behavior.  These methods increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations.  The focus of ABA is on the reliable measurement and objective evaluation of observable behavior within relevant settings including the home, school, and community and the effectiveness of this intervention has been well documented through research in controlled studies of comprehensive early intensive behavioral intervention programs.  Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups.  When correctly designed, implemented and monitored, it is safe and effective for some individuals with autism spectrum disorder (ASD).  Applied behavior analysis involves the use of behavioral principles (such as positive reinforcement, or the use of rewards) to encourage the development of the desired behaviors in place of the less adaptive, self-defeating or even harmful behaviors the child may be using.  Given that children with ASD may also have a level of intellectual disability (mental retardation) or deficits in communication, progress may be slow and require much practice, repetition and time to be learned by the child, potentially making this hugely expensive (more than $100,000 per child per year).  There are a number of different methodologies and protocols (particularly related to how many hours of treatment are appropriate per week) consistent with ABA, resulting in ambiguity and suspicion about the term.  There tends to be a high level of parental satisfaction with such programs that typically involve the parents in reinforcing the behaviors being targeted (Myers, 2007).

Feeley and Jones (2006) noted that children with Down syndrome are at an increased risk for engaging in challenging behavior that may be part of a behavioral phenotype characteristic of Down syndrome.  These investigators stated that the methodology of ABA has been demonstrated effective with a wide range of challenging behaviors, across various disabilities; applications to children with Down syndrome and the examination of behaviorally based strategies to specifically address the unique characteristics of children with Down syndrome were limited.  These researchers stated that there were several studies in which a subset of the participants did have Down syndrome, and they reviewed a handful of these studies within the context of functional behavior assessment and positive behavioral supports.  Drawing from these studies and the behavioral literature, as well as the authors’ clinical experience and research, they provided suggestions regarding early intervention for challenging behavior with children with Down syndrome.

Kroeger and Nelson (2006) stated that the incidence of children dually diagnosed with Down syndrome and autism is estimated to be as high as 11 %.  There is a paucity of research investigating linguistic treatment interventions for such children.  This single-subject experiment examined a program designed to increase the language production and verbal behavior of a 9-year old dually diagnosed boy who had been receiving a 15 hours/week home-based ABA program.  Training principles were derived from previously empirically validated research in discrete trail learning and natural environment teaching, as well as modified incidental teaching procedures.  The crux of the language program involved withholding reinforcement until a spoken request was made.  Language production noticeably increased for each target area after the introduction of the language program and was maintained at a 9-month follow-up session.  The authors concluded that a combined treatment approach incorporating direct instruction, natural environment teaching and incidental teaching could be effective in increasing and maintaining responsive and spontaneous speech in a child with Down syndrome diagnosed with autism.  Moreover, they stated that replication studies are needed with such multiple dually diagnosed children to further evaluate the effectiveness and generalizability of this combined language program.

Warren et al (2011) noted that early intensive behavioral and developmental interventions for young children with ASDs may enhance developmental outcomes.  Thus, they conducted a systematically review of evidence regarding such interventions for children aged 12 years and younger with ASDs.  These researchers retrieved 34unique studies that met inclusion criteria, of which 17 studies were case series and 2 were randomized controlled trials (RCTs).  The investigators reported that the strength of the evidence overall ranged from insufficient to low.  Studies of University of California Los Angeles/Lovaas-based interventions and variants reported clinically significant gains in language and cognitive skills in some children, as did 1 RCTof an early intensive developmental intervention approach (the Early Start Denver Model), while specific parent-training approaches yielded gains in short-term language function and some challenging behaviors.  The authors concluded that data suggested that subgroups of children displayed more prominent gains across studies, but participant characteristics associated with greater gains are not well understood and that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvements in cognitive performance, language skills, and adaptive behavior skills in some young children with ASDs, although the literature is limited by methodologic concerns.

van Gameren-Oosterom et al (2013) examined problem behavior in adolescents with Down syndrome and evaluated the association with sex and severity of intellectual disability.  Cross-sectional data of a Dutch nationwide cohort of Down syndrome children aged 16 to 19 years were collected using a written parental questionnaire.  Problem behavior was measured using the Child Behavior Checklist and compared with normative data.  The degree of intellectual disability was determined using the Dutch Social competence rating scale.  The response rate was 62.8 % (322/513), and the mean age was 18.3 years (SD ± 0.8).  The total score for problem behavior was higher in adolescents with Down syndrome than in adolescents without Down syndrome (26.8 versus 16.5; p < 0.001).  Overall, 51 % of adolescents with Down syndrome had problem scores in the clinical or borderline range on 1 or more Child Behavior Checklist subscales; this was more than twice as high as adolescents without Down syndrome.  Adolescents with Down syndrome had more internalizing problems than their counterparts without Down syndrome (14 % and 9 %, respectively, in the clinical range); the percentages for externalizing problems were almost equal (7 % and 9 %, respectively, in the clinical range).  The highest problem scores in adolescents with Down syndrome were observed on the social problems and thought problems subscales (large to very large standardized differences).  Male sex and/or more severe mental disabilities were associated with more behavioral problems.  The authors concluded that serious problem behavior was more prevalent in adolescents with Down syndrome; and they stated that these findings demonstrated the need for a focus on general behavior improvement and on the detection and treatment of specific psychopathology in individuals with Down syndrome.

Weitlauf et al (2014) conducted a systemaic review, the results of which included 65 unique studies comprising 48 randomized trials and 17 non-randomized comparative studies (19 good, 39 fair, and 7 poor quality) published since the prior review.  The authors reported that the quality of studies improved compared with that reported in the earlier review; however, their assessment of the strength of evidence (SOE) and confidence in the stability of effects of interventions in the face of future research remained low for many intervention/outcome pairs.  Early intervention based on high-intensity applied behavior analysis over extended timeframes was associated with improvement in cognitive functioning and language skills (moderate SOE for improvements in both outcomes) relative to community controls in some groups of young children.  However. the magnitude of these effects varied across studies, potentially reflecting poorly understood modifying characteristics related to subgroups of children.  Investigaors noted that early intensive parent training programs modified parenting behaviors during interactions but that data were limited regarding the ability to improve developmental skills beyond language gains for some children (low SOE for positive effects on language).  Social skills interventions varied in scope and intensity and showed some positive effects on social behaviors for older children in small studies (low SOE for positive effects on social skills).  Studies of play/interaction-based approaches reported that joint attention interventions may demonstrate positive outcomes in preschool-age children with ASD when targeting joint attention skills (moderate SOE).  It was also reported that data on the effects of such interventions in other areas were limited (low SOE for positive effects on play skills, language, social skills).  Studies examining the effects of cognitive behavioral therapy on anxiety reported positive results in older children with IQs greater than or equal to 70 (high SOE for improvements in anxiety in this population).  The authors concluded that growing evidence base suggested that behavioral interventions can be associated with positive outcomes for children with ASD.  Despite improvements in the quality of the included literature, a need remains for studies of interventions across settings and continued improvements in methodologic rigor.  They stated that substantial scientific advances are needed to enhance the understanding of which interventions are most effective for specific children with ASD and to isolate elements or components of interventions most associated with effects.

Furthermore, an UpToDate review on "Down syndrome: Management" (Ostermaie, 2017) does not mention ABA as a management tool.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes not covered for indications listed in the CPB:

97151 - 97158 Adaptive Behavior Assessments and treatment

Other CPT codes related to the CPB::

0362T Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior
0373T Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior

ICD-10 codes covered if selection criteria are met :

F84.0 - F84.9 Pervasive developmental disorders [autistic spectrum disorder (ASD)]

ICD-10 codes not covered for indications listed in the CPB:

Q90.0 - Q90.9 Down syndrome

The above policy is based on the following references:

  1. Feeley KM, Jones EA. Addressing challenging behaviour in children with Down syndrome: The use of applied behaviour analysis for assessment and intervention. Downs Syndr Res Pract. 2006;11(2):64-77.
  2. Kroeger KA, Nelson WM 3rd. A language programme to increase the verbal production of a child dually diagnosed with Down syndrome and autism. J Intellect Disabil Res. 2006;50(Pt 2):101-108.
  3. Myers SM, Johnson CP; American Academy of Pediatrics Council on Children With Disabilities. Management of children with autism spectrum disorders. Pediatrics. 2007;120(5):1162-1182.
  4. Ostermaie KD. Down syndrome: Management. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed January 2017.
  5. van Gameren-Oosterom HB, Fekkes M, van Wouwe JP, et al. Problem behavior of individuals with Down syndrome in a nationwide cohort assessed in late adolescence. J Pediatr. 2013;163(5):1396-1401.
  6. Warren Z, McPheeters ML, Sathe N, et al. A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics. 2011;127(5):e1303-e1311.
  7. Weitlauf AS, McPheeters ML, Peters B, et al. Therapies for children with autism spectrum disorder: Behavioral interventions update [Internet]. Report No.: 14-EHC036-EF. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); August 2014.