State Insurance Mandates and the Workforce for Children With Autism

Workforce perspective on racial and ethnic equity in early childhood autism evaluation and treatment: "The cornerstone of everything we do"

LAY ABSTRACT

Black and non-White Latinx children tend to receive autism diagnoses later in life and with a higher degree of impairment than White children. The purpose of this study was to learn what is currently helping as well as preventing Black and non-White Latinx children from getting access to autism evaluation and services. We held virtual interviews with 26 experts who work with autistic children and their families, including clinical providers, researchers, advocates, and policymakers/government representatives. From these interviews, we identified four themes that have an impact on equity in autism services: (1) who makes up the workforce, (2) workforce capacity and accessibility, (3) workforce payment structure, and (4) changes due to the COVID-19 pandemic. These findings show the need for improved workforce diversity, autism-specific education, payment structures, and additional support for workforce members to avoid burnout. To make childhood autism services more equitable, diversity in recruitment across training levels, cultural awareness, increased autism education for all pediatric providers, and partnerships with caregivers as experts must be prioritized. These investments in the autism workforce will allow professionals in the field to better meet the needs of children and families from Black and non-White Latinx communities and achieve equity in early childhood autism services.

Assessing Growth of BACB Certificants (1999-2019)

Geographic distribution patterns of board certified behavior analysts may be useful in analyzing the growth of the field. First, we present an international snapshot of Behavior Analyst Certification Board (BACB) certificants, then analyze relative growth rates between countries from 1999 to 2019. This is followed by an in depth review of certificant distribution patterns in the United States and Canada, as well as the ratios of experienced behavior analysts to new certificants. These data highlight regions with a potential deficit of qualified supervisors. There are factors that influence different dispersal patterns, and without drilling deeper into the data we may be unable to effectively identify or influence them in order meet the specific needs of a geographic region.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40614-023-00370-5.

Disparities in Pediatric Mental and Behavioral Health Conditions

Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.

Geographic Access to Registered Behavior Technicians among Children with Autism Spectrum Disorder

Research has documented inequities in geographic access to board certified behavior analysts (BCBAs) among children with autism spectrum disorder (ASD). Unexplored is geographic access to registered behavior technicians (RBTs), the frontline ABA providers BCBAs supervise. In this study we examined county-level geographic access to RBTs in the United States, including change in their geographic distribution over time, the current distribution of RBTs related to the distribution of BCBAs, and the current distribution of RBTs as a function of children with ASD. The sample included all U.S. counties in all 50 states and the District of Columbia (N = 3,138). County-level ASD/RBT ratios indicate that the number of children with ASD far exceed RBTs, and the geographic accessibility of RBTs appears to be superior to that of BCBAs.

Updated Strategies for Making Regular Contact With the Scholarly Literature

The Ethics Code for Behavior Analysts (Behavior Analyst Certification Board, 2020a) states that behavior analysts must provide services based on the published scientific evidence (Code 2.01, "Providing Effective Treatment") and maintain competence by reading relevant scholarly literature (Code 1.06, "Maintaining Competence"). Carr and Briggs (2010) acknowledged several potential barriers that might prevent behavior analysts from pursuing this obligation and offered helpful recommendations for circumventing these barriers. Although the nature of these barriers has primarily stayed the same since the publication of Carr and Briggs, the profession and field have grown more complex over the past decade, and several additional barriers have emerged. Luckily, technological advances and resources recently made available offer additional solutions for behavior analysts to consider adopting. Therefore, the purpose of this article is to provide an update to the strategies described by Carr and Briggs for overcoming barriers related to searching the literature, accessing journal content, and contacting the contemporary literature. In addition, we conclude with how leaders might incorporate the proposed strategies into their organization at a systems-wide level.

Mental health status of adolescents in-home quarantine: a multi-region, cross-sectional study during COVID-19 pandemic in Bangladesh

Background

The population's mental and physical health worldwide are currently at risk due to the coronavirus pandemic. We evaluated the mental health status of the adolescents trapped indoors because of the precautionary restrictions and prolonged closure of the educational institutions.

Method

A cross-sectional study was conducted on adolescents from multiple urban and semi-urban areas of Bangladesh from 22 January to 3 February 2021. A self-reported online questionnaire containing questions regarding sociodemographic factors, home quarantine-related factors and mental health symptoms was distributed to collect data. Descriptive analysis, bivariate and multivariable logistic regressions were performed to measure the association of the variables. Cronbach's alpha was estimated to present the internal consistency of the scales.

Results

A total of 322 adolescents (aged 12–19) with a mean age of 16.00 years (SD = 1.84) responded to the invitation. 54.97% (n = 177) of them were male, and the participants were predominantly urban residents (87.27%, n = 281). We observed varying degrees of depression in 67.08%, anxiety in 49.38% and stress in 40.68% of the participants according to DASS-21. Age, sex, education, mother's occupation, total monthly income, playing sports, doing household chores, going out of home, watching television, using the internet, attending online classes, changing food habits, and communicating with friends had a positive significant association with mental health burdens.

Conclusion

Home quarantine has a noticeable adverse impact on the mental health of teenagers. Psychological evaluations and counselling via online and offline programs are essential to improve adolescents' declining mental health conditions.

Trends in Geographic Access to Board Certified Behavior Analysts Among Children with Autism Spectrum Disorder, 2018-2021

Research has documented inequities in geographic access to Board Certified Behavior Analysts (BCBAs) among children with autism spectrum disorder (ASD). However, research on their accessibility is outdated. Between July 1, 2018 and July 1, 2021 the number of BCBAs in the U.S. increased by 65%, from 27,320 to 45,103. In this study we examined trends in geographic access to BCBAs among children with ASD between 2018 and 2021. The sample included all U.S. counties in 50 states and D.C. (N = 3138). Using GIS software we examined change in county-level access to BCBAs between 2018 and 2021 and mapped ASD/BCBA ratios across all counties in both years. Study results indicate that despite modest improvements (e.g., 266 counties added BCBAs), inequitable access persists.

Recent Advances of Telepractice for Autism Spectrum Disorders in Speech and Language Pathology

Telepractice or teletherapy is defined as the means of service delivery via technology-based platforms that allow long-distance interventions across populations, age spans, and geographical locations. Specifically, telepractice capitalizes on communication technologies such as online modules, videoconferencing, and computerized software programs, in servicing populations with communication challenges. Notably, telepractice has emerged as a potentially effective, low-cost, and promising means of conducting and completing online assessment, diagnosis, and intervention sessions for individuals with autism spectrum disorders (ASD). Moreover, telepractice allows the inclusion of parents, caregivers, and educators as potential facilitators in supporting treatment delivery in populations with ASD. This thematic review article aims to highlight and acquaint practitioners and other stakeholders with relatively recent information regarding the advantages and disadvantages of the telepractice service delivery model in ASD. Furthermore, the emergence of the COVID-19 pandemic has impacted service delivery in the field of Health Sciences including speech and language pathology (SLP). Consequently, the need to avoid face-to-face therapy sessions, recommended to SLPs as to all health practitioners, resulted in the call for adaptation and adjustment of service telepractice. This paper attempts to answer this call by suggesting supplementing traditional diagnostic and therapy resources with training modules consisting of online materials and use of animated and specially designed programs in SLP intervention with individuals with ASD. Lastly, the paper includes a discussion of research findings in the field, a conclusion, and a take-home message.

Mental Health Stigma Reduction in the Midwestern United States: Evidence from a Digital Campaign Using a Collective Impact Model

Addressing mental stigma is a key component of improving mental health outcomes. A digital media campaign was implemented to reduce mental health stigma in the Omaha Metropolitan area. The campaign used evidence-based approaches within a collective impact framework. Two surveys were conducted at baseline and at 10-month follow-up to evaluate the campaign within the Omaha and Council Bluffs intervention region, and a control region in Iowa. Analysis revealed significant improvements in desires for social distance and perceptions toward treatment efficacy within the intervention group. Improvements were seen across measures of personal and community attitudes towards mental health conditions, confidence in supporting others, and likelihood of disclosing a mental health condition. The trends were generally not replicated within the control group. Respondents who were aware of the campaign showed fewer stigmatizing views, including lower desires for social distance, improved attitudes toward treatment, and significant improvements in providing support and caring for their own mental health. The results suggest that the implemented evidenced-based approach could potentially create positive shifts in stigma reduction. This evaluation further supports the potential for scaling and adapting digital media campaigns for stigma reduction in different geographic locations.

Brief Report: Medicaid Expansion and Growth in the Workforce for Autism Spectrum Disorder

Over 700,000 children throughout the U.S. have received insurance coverage through welcome mat effects of Medicaid expansion, including children with autism spectrum disorder (ASD). Utilizing health workforce data from the Health Resources and Services Administration, we examined workforce growth (2008-2017) among three types of health providers for children with ASD as a result of Medicaid expansion: child psychiatrists, board-certified behavioral analysts (BCBAs) and pediatricians. We found that state Medicaid expansion was associated with a 9% increase in BCBAs per 100,000 children one year after enactment, a 5% increase in child psychiatrists, and was not associated with growth in pediatricians. Results indicate the importance of new policies that directly address a shortage of providers for children with ASD.

Generosity of state insurance mandates and growth in the workforce for autism spectrum disorder

LAY ABSTRACT

To improve access to health services for children with autism spectrum disorder, US states have passed laws requiring health insurers to cover autism-related care, commonly known as state insurance mandates. However, the features of mandates differ across states, with some state laws containing very generous provisions and others containing very restrictive provisions such as whether the mandates include children aged above 12 years, whether there is a limit on spending, and whether there are restrictions on the types of services covered. This study examined the relationship between generosity of mandates and growth in the health workforce between 2003 and 2017, a period during which 44 states passed mandates. We found that states that enacted more generous mandates experienced significantly more growth in board-certified behavioral analysts who provide behavioral therapy as well as more growth in child psychiatrists. We did not find differences in the growth of pediatricians, which is a less specialized segment of the workforce. Our findings were consistent across eight different mandate features and suggest that the content of legislation may be as important as whether or not legislation has been passed in terms of encouraging growth in the supply of services for children with autism spectrum disorder.