Standards of Practice for

Applied Behavior Analysis

in Minnesota

Prepared by the Minnesota Northland

Association for Behavior Analysis (MNABA)

September 2012
Contents
Part I. Executive Summary / p. 1
What is Applied Behavior Analysis? / p. 1
Outcomes of ABA-based Treatments / p. 1
ABA in Minnesota / p. 1
ABA Across the United States / p. 1
Purpose of this Document / p. 2
The Importance of Establishing Applied Behavior Analysis in Benefit Sets / p. 2
How ABA Can Contribute to Cost Savings in Minnesota / p. 3
Recommendations / p. 3

Part II. Standards for Service Delivery / p. 4

Treatment Consultation to Parents and Professionals: Mediator Models
for Intervention Across the Lifespan / p. 4
Focused Behavior Intervention / p. 8
Comprehensive Applied Behavior Analysis Treatment / p. 10

Part III. Recommended Guidelines for Billing and Reimbursement / p. 13

Qualified Applied Behavior Analysis Professional / p. 13
Registered Behavioral Technician / p. 14
Outreach Services Modifier / p. 14

Conclusion / p. 15

Members and Advisors of the Standards Task Force / p. 16

1 Standards of Practice for Applied Behavior Analysis in Minnesota

Part I. Executive Summary

What is Applied Behavior Analysis? ABA in Minnesota
Applied Behavior Analysis (ABA) is a set of rigorous, Minnesota has a strong legacy of support for and
data-driven practices grounded in over 40 years of leadership in behavior analysis. At the University level,
peer-refereed evidence in the treatment of disordered B.F Skinner did some of his seminal studies while at
behavior and skill deficits. Using the relationship the University of Minnesota; St. Cloud State University
between human behavior and its environmental became one of the first programs to offer course
antecedents and consequences as the basis for sequences for professional training in ABA approved
assessment and intervention, the impact of ABA by the Behavior Analyst Certification Board (BACB)
has been demonstrated in clinical settings, homes, . The state Department of Human Services was an
schools, community, and the workplace, and across early adopter of ABA in the treatment of people
age and ability spectrums. Currently ABA is prevalent with complex disabilities, formally incorporating
in the treatment of autism spectrum disorders but is ABA into state services in the 1980s. In recent years,
also a critical component of successful intervention Minnesota’s school districts have created professional
in traumatic brain injury, disruptive and oppositional positions for Behavior Analysts. Positive Behavior
behavior disorders, and intellectual and developmental Support, a framework for the application of behavior
disabilities. analysis, is being implemented in Minnesota schools
by the Department of Education and in home
Outcomes of ABA-based Treatments & community-based settings by the Minnesota
Treatments based in ABA are cost-saving investments Department of Human Services.
that are proven to improve the lives of individuals
with complex disabilities and promote the ABA Across the United States
independence of families. When ABA is practiced by Nationally and internationally, the practice of
appropriately trained professionals (Board Certified ABA is increasing. The professional base of Board
Behavior Analysts and other licensed mental health Certified Behavior Analysts now includes over 10,000
professionals with stated competency in ABA), it certificants in 40 countries worldwide. Over 30
results in decreased medical needs and decreased states in the U.S. now recognize BCBAs as licensed
reliance on paid supports, creating enormous cost professionals who are third-party billable. Board
savings over the lifespan.
2 Standards of Practice for Applied Behavior Analysis in Minnesota

Certification requires a masters’ degree including 245 The Importance of Establishing

hours of coursework (in assessment, treatment, single- Applied Behavior Analysis in
subject experimental design, and ethics) and 1500
Benefit Sets
hours of supervised practice. The Behavior Analyst
We contend it is more consistent with a mission
Certification Board issued comprehensive conduct
to improve the lives of people with mental health
guidelines for the practice of behavior analysis in
disorders to manage treatment outcomes than
2004, which were updated in 2010. The Association
treatment processes. Treatments based in ABA
for Applied Behavior Analysis International (ABAI),
are individually-tailored and produce outcome data
the Association for Professional Behavior Analysts
that ensure accountability to consumers and funders.
(APBA), and state chapters of ABAI and APBA around
ABA-based treatments have empirical bases for
the United States have called for specific practice
efficacy across a wide range of disorders and when
standards including credentialing of Behavior Analysts
the treatment is effective, the data support it. When
by the BACB to ensure a high quality of service for
treatment is not effective, the data are clear about
consumers.
that too. Behavior Analysts request additional funding
for effective treatment, and refer to other providers
Purpose of this Document when their treatment is ineffective.
As the technology of behavior analysis has been The burgeoning demand for services for people
adopted across professions and the consumer base with mental health disorders, coupled with limited
has widened, it has become necessary to articulate health care dollars, renders critical the expectation
what behavior analysis is and who is qualified to for rigorous outcome measurement by all service
practice behavior analysis in the public domain. Many providers. Justifying health care expenditures is best
common parenting, educational, and therapeutic done through objective outcome data, rather than
strategies developed by behavior analysts enjoy simply ensuring that people have access to services
widespread use (e.g. positive reinforcement, task designed ostensibly for their diagnostic category, even
analysis, exposure therapies). those with empirical support for the treatment of
This document has been developed to provide specific disorders. Providers of ABA-based treatments
consumers, policy makers, and funding agencies are leaders not only in developing and using evidence
critical information about essential components of based practices but also in demonstrating those
ABA-based interventions (i.e., what ABA is) and the practices are effective with each individual for whom
professionals allowed to call themselves Behavior they are brought to bear, and seeking alternatives
Analysts and claim to practice ‘ABA’ or ‘Behavior for the consumer when the data do not support
Analysis’ (i.e., who can offer ABA services to the continuation.
public). The science of behavior and applications Associated with the burgeoning demand for
for consumers has advanced dramatically since the services is the lack of available mental health
field of ABA emerged in 1968. To protect consumers resources, including Behavior Analysts, throughout
and ensure correct application of ABA techniques, Minnesota. The Minnesota Department of Health
the terminology must be standardized and carefully designates 9 of the 11 regions in Minnesota (and 70
defined in accordance with scientific and clinically of Minnesota’s 87 counties) as meeting federal criteria
standard terms in the field. For example, a Behavior for mental health professional critical shortage areas.
Analyst practices the science of Behavior Analysis. Specific reimbursement models are needed in order
The term ‘behavior modification’ is outdated and to enable professional outreach to rural areas, and
should no longer be used; ‘behavior therapy’ is non- to challenging urban environments.
specific and does not necessarily refer to the science
of Behavior Analysis.
3 Standards of Practice for Applied Behavior Analysis in Minnesota

How ABA Can Contribute to Cost Recommendations

Savings in Minnesota 1. Establish Applied Behavior Analysis as covered
In addition to its clinical effectiveness, Comprehensive treatment in the benefit sets for children,
ABA reduces total cost of care for children with adolescents, and adults with developmental
ASD across the lifespan. In a 2007 study by and mental health disorders.
Chasson, Harris, and Neely, costs associated with 2. Require any professional using the title ‘Behavior
Comprehensive ABA were compared with special Analyst’ or claiming to practice ‘Applied Behavior
education costs in the state of Texas. Results indicated Analysis’, ‘Behavior Analysis’, or ‘ABA’ to be
that Texas would save $208,500 per person across either (a) credentialed by the Behavior Analyst
eighteen years of Comprehensive ABA. Based on Certification Board as a Board Certified Behavior
approximately 10,000 children with autism in Texas, Analyst (the educational and experiential
a total savings of $2.09 billion was estimated. requirements are available at http://www.bacb.
In 1998, Jacobson, Mulick, and Green estimated com/index.php?page=158 or (b) have Applied
that individuals diagnosed with autism or other Behavior Analysis listed on competencies filed
pervasive developmental disorders require specialized with that professional’s relevant licensing board.
services costing approximately $4 million per person
3. Establish the Board Certified Behavior Analyst as a
over their lifetimes. With the implementation of
sufficient credential for third-party reimbursement.
Comprehensive ABA, savings of between $1 million
to over $2 million per individual were estimated across 4. Work with the MNABA to employ methods
their life span. derived from current best practices in ABA to
In 2006, researchers in Ontario, Canada completed evaluate outcomes for individual recipients of
a study to determine the cost-effectiveness of mental health treatment that will ensure that
expanding Comprehensive ABA treatment to all appropriate, cost-effective services are provided
children diagnosed with autism (Motiwala, Gupta, to consumers.
Lilly, Ungar, and Coyte, 2006). Results indicated that 5. Use MNABA and other nationally-recognized
“total savings from expansion of the current program expert resources such as the Association of
were $45,133,011 in 2003 Canadian dollars” (p. Professional Behavior Analysts, the Behavior
136). In addition, the authors stated that “expansion Analysis Certification Board, and the Association
of IBI [intensive behavioral intervention, synonymous for Behavior Analysis International, to identify
with Comprehensive ABA] to all eligible person qualified experts for prior review activities that can
represents a cost-savings policy whereby total costs for help determine appropriate, cost-effective services
care of autistic individuals are lower and gains for consumers.
in dependency-free life years are higher” (p. 136).
Regardless of the many factors underlying the
current increases in autism diagnosis, the extent to
which early intervention including Comprehensive
ABA prevents a person from needing these expensive
services can result in tremendous cost savings as well
as reducing the number of people who will require
life-long intensive care and treatment.
4 Standards of Practice for Applied Behavior Analysis in Minnesota

Part II. Standards for Service Delivery

Treatment Consultation to Parents What Clinical Activities are Involved?
and Professionals: Mediator Models The clinical focus of a mediator model is empowering
for Intervention Across the Lifespan the mediator to develop and implement treatment
plans that they can sustain in the absence of clinical
These services are time-limited and achieve clinical
support. Mediator input is therefore critical at all
outcomes for the person with a disability through
phases of service—the goal is not simply knowledge
enhancing the skills of the most relevant ‘mediators’
transfer from Behavior Analyst to mediator, but
in the person’s life, such as parents (see Appendix 1)
a mediator-professional partnership in which the
or professionals in the home, school, or community
Behavior Analyst’s expertise in ABA is combined with
(see Appendix 2). In doing so, the contextual fit and
the mediator’s expertise of the family and the context
sustainability of the treatment, and therefore quality
to produce a desirable and sustainable outcome.
of life for the family and stakeholders, improve.
A key assumption is that behavior change of the
Working effectively with mediators to develop
person with a disability is accomplished through the
and implement high-quality treatment plans, and
mediator changing his/her behavior. To accomplish
achieve clinically significant behavior change, requires
this, a functional assessment of mediator behavior
expertise in behavior analysis applied at the level
should occur in addition to functional assessment
of the person and at the level of the mediator. This
of the focus person’s behavior. A functional
model does not include direct service to the person
assessment includes interviews and observations
with disabilities.
(described below) that are aimed at understanding
the relationship between environmental circumstances
and the behaviors of interest. Conducting functional
assessments is one of the core skills of a Behavior
Analyst.
5 Standards of Practice for Applied Behavior Analysis in Minnesota

Mediator models of service should include the in a mediator model of service. A desirable
elements listed below. It is expected that individual outcome should be mediator independence in
service providers will have varied emphases but data summary and interpretation, as well as
generally design their services and address the intervention development.
needs of unique populations (e.g., mediators with 6. Adherence in the absence of clinical support.
disabilities) within this framework, contributing their Mediators are encouraged to leave each meeting
results to the growing evidence base. with the clinical team having made a verbal
1. Functional assessment of the person’s and commitment to a plan of action (e.g. “say what
the mediator’s behavior (interview and direct you will do”)until the clinical team returns. At the
observation). Functional assessment results are next visit this is the first focus of the mediator/
then linked directly to intervention components, clinician data review (e.g. “How well do the data
and are developed in conjunction with mediator. you collected show that you did what you said
2. Hands-on coaching and feedback to develop you would do.”) If they did not do what they said
the mediators as skilled interventionists. they’d do, the clinician’s job is to determine with
Mediators are coached, in the natural the mediator what barriers were in the way, and
environment, using a combination of verbal uncover solutions to those barriers so the mediator
prompting, gestural prompting, and descriptive can be more successful/adherent to what they say
feedback. Mediators should be challenged to they’ll do in the coming days and weeks. If they
identify what they did well and what aspects of implemented the plan as designed, the data will
the intervention plan they could improve upon in provide strong evidence of intervention efficacy
the coming observation interval. or need for further tailoring.
3. Tailoring technically-sound behavior analysis
interventions into the intervention context. Who Should Receive These Services?
This is the heart of the mediator-professional Mediators of individuals with severe emotional
relationship. The proposed plan must be disturbances who commit to a mediator-focused
technically correct (an intervention that fits intervention in which they will be the focus of clinical
the findings of the assessment) and must also attention on behalf of the person in their care should
involve the mediators to ensure a fit between participate in this model of service. Determining
the intervention and the context. Over time the if a mediator-focused intervention will be a good
mediator will take a more active and independent fit should be accomplished via rigorous screening.
role in implementation. Without this contextual Screening should address —
fit, a technically correct intervention will not be • Mediator capacity to participate in mediator-
adhered to over time and will not sustainably focused intervention. Determine if life context
improve the quality of life for the person, family, (e.g., marital relationship, job/financial status,
classroom, roommates, or other stakeholders. family/friends stressors, sibling concerns,
4. Data-based decision-making. Mediators will etc) or work context (supportive school or
collect data on a regular schedule so a record of agency administration/co-workers, sufficient
the person’s challenging and desirable behavior paraprofessional staffing, limited upcoming
is available to judge the effectiveness of the turnover, etc) supports enrolling in the service.
intervention plan in the absence of daily staff • Mediator preference for an intensive mediator-
supports. This record of mediator adherence to focused intervention. Is it appealing for the
the plan in the absence of clinical staff should be mediators, or do they prefer a therapy focused
available to compare to the observations of the on the person with a disability?
clinical staff.
• Barriers that may exist, currently or in the near
5. Regular data review and intervention future, to persistent participation in the service
development. Data-based decision-making is (upcoming long vacations, other conflicting
standard for any behavior analysis service, but therapies).
should also be a training focus for mediators
6 Standards of Practice for Applied Behavior Analysis in Minnesota

• Whether mediator-focused intervention can plan should identify general goals, specific objectives,
successfully address the needs of the person measurable outcomes, and level of service for
with a disability. consumers and for mediators of the intervention.
Before making a determination to continue,
It is important to note that if mediators are
modify, or terminate services, objective measures of
desperate for services they may be inclined to give
the behaviors (e.g., frequency, duration, or intensity)
the ‘right’ answers to screening questions and enroll
identified in the agreed-upon treatment plan must
in a service that is too intensive, inconsistent with their
be available for review. Measures of the mediator’s
parenting/teaching/professional philosophies, or ill-
treatment plan implementation across relevant
timed given other responsibilities and stressors in their
environments to help ensure generalization and/or
lives or workplace. Well-meaning but inexperienced or
maintenance of learned skills should also be reviewed.
poorly trained clinicians may enroll clients who will not
Commercial and non-commercial quality-of-life
or cannot benefit from mediator-focused training.
measures can also assist in determining the overall
impact of the service on the person and the family/
How Often Should a Specific classroom/residence in which they function. Periodic
Service be Provided? summative data evaluation should be conducted
Two 3- hour sessions, 1-3 times per week. More/ every 6 months to determine the ongoing fit of,
longer sessions may be required in high-needs and medical necessity for, the intervention.
cases (e.g., multiple person being served in the Service coordination is a responsibility of Behavior
same environment). Mediators should commit to Analysts. In this capacity Behavior Analysts will be
a minimum length of participation in the service in contact with other mental health professionals,
to master all components of the particular curriculum. medical professionals, and related therapists who
Prior to fading the intensity of services, the person’s are currently involved with the person’s care and
behavior should be improved in key routines in the treatment. A primary strength of a behavior analysis
training environment and generalization environments service is the use of behavioral baselines that can
that are important to them and their stakeholders. serve as a record of treatment effectiveness for the
Ideally, mediators should have contributed individual and combined effects of the treatments the
substantially to the development of the intervention person is receiving. These other treatments can inform
plans for at least 1 routine without assistance from treatment goals for the behavior analysis service (e.g.,
the clinical team. if a person is receiving counseling and is working on
expressing feelings with a counselor, the Behavior
How to Ensure that Services Analyst can work with the mediators to create the
are Useful and Effective conditions for practicing the expression of feelings
Prior to enrolling in any mediator-focused service, and record data on the behavior during naturally-
a rigorous screening-in process should occur to ensure occurring opportunities throughout the day).
the service is a good fit for all involved, and that The Behavior Analyst should be informed about
the mediator is willing and able to commit the time other clinical service options in the community and
required to complete the program or full scope of available supports that might help to make the
the service. Screenings can include phone and/or mediator-focused ABA service realistic for a family
in-person conversations. with substantial barriers to participation in such a
The intervention plan should be based on a service. For example PCA or respite services may be
comprehensive functional assessment, including at important to include in order for mediators to make
minimum a functional assessment interview and direct time for mediator-focused training. In turn, they may
observation of behavior. The intervention plan should need to train PCA and respite staff to implement any
be developed collaboratively with mediators (and the successful intervention to ensure maximum benefit of
person, if able) and guided directly by the information the intervention for the person.
gained in the functional assessment process. The
7 Standards of Practice for Applied Behavior Analysis in Minnesota

When there are questions about the designing new support plans for routines/situations
appropriateness or efficacy of services, these should they and their person would like to improve. Often the
be reviewed by an expert panel of Behavior Analysts data will reflect the person’s response to more than
and other professionals. one treatment - person may be involved with medical
treatment, occupational therapy, speech therapy,
What Qualifications and Performance counseling, etc. Parents should be encouraged to
Standards are Required of the Service work with all of their person’s clinicians to start/stop/
Providers? adjust treatments with reference to the behavioral
baselines so a proper evaluation of the impact of the
The qualifications of those conducting assessments,
treatment can be made. In the best case, the behavior
developing treatment plans, and providing
analyst properly prepares the parent to have effective
consultation, parent education/training, ongoing
data review and treatment planning conversations
monitoring and supervision of behavioral services
with each of their person’s clinicians. By virtue of
should be —
participating in an applied behavior analysis service
• [Preferred] Board Certified Behavior Analysts and developing an understanding of data-based
(BCBA) or be enrolled in formal academic and evaluation of treatment effects, parents should be
supervision program leading to BCBA empowered members of any treatment team making
• If not a BCBA, then 1) Master’s degree in a related decisions on behalf of their person and family.
field, 15 units of graduate level coursework in At the conclusion of the service, person should
behavior analysis or 2) licensed or certified in experience improved behavioral repertories and
related field with behavior analysis in its scope parents should experience greater independence
of practice. in developing interventions, interpreting data, and
• In addition, 3–5 years of experience delivering making data-based decisions about next steps. In
and supervising treatment programs for person, the best case, parents should be afforded the chance
adolescents, and adults with developmental to systematically train support staff implement the
disabilities, or licensed or certified in related field effective interventions.
with behavior analysis as its scope of practice (e.g. In this spirit, as much as parents care to expand
licensed speech therapist with specialized training and generalize effective interventions, they can and
in ABA). should cover more and more of the person’s day, and
additional specific interventions should be developed
Responsibilities and Training of Parents to address the key routines of the day that require
and other Mediators of Treatment attention. It is recommended that, for person with
severe challenging behavior, intervention begin in the
Mediator models of ABA services involve full
home setting and generalize to community locations
commitment to participation and leadership in
when an effective plan has been established. Parents
the treatment by the mediator. The treatment will
should feel comfortable and confident implementing
of limited benefit otherwise.
behavior analysis interventions prior to using them in
the community. Responding effectively to challenging
Self-Directed or Self-Determination behavior should be established in their repertoires.
Option for These Services The person’s challenging behavior should be under
A great strength of an applied behavior analysis effective stimulus control of the intervention plan’s
service is the use of objective behavioral baselines that key components prior to attempting to use the plan
can be used to evaluate the individual and combined in the community. Exposure to the community should
effects of the variety of interventions often utilized by initially be brief to ensure success, gradually fading in
person with complex behavioral and mental health time spent in community based on success. Following
needs. A Behavior Analyst should involve parents in these guidelines emphasizes the safety of the person,
summarizing the data they collect, interpreting it, the effectiveness of the plan, and builds a history of
making decisions about next steps based on it, and success for the parent.
8 Standards of Practice for Applied Behavior Analysis in Minnesota

How Often Should a Specific Service

be Provided?
Behavioral services should be individualized to the
consumer’s needs and be based on the presenting
problem behavior’s function as well as its frequency,
duration and severity, as well as breadth and impact
of skill deficits.
Accordingly, Focused Behavioral Intervention
services may range from a weekly minimum of 2 hours
of parent education/training along with 2–4 hours of
direct therapy with the person to 20 hours a week of
a combination of parent and person-focused therapy.
Services are typically provided for 6 months to 2 years.
Focused Behavior Intervention
These models of intervention focus on the remediation How to Ensure that Services
of specific behavioral challenges that limit the safety, are Useful and Effective
quality of life, or independence of person (and often Focused Behavioral Interventions are designed
the people they live and interact with). These services to decrease aberrant behavior related to the
differ from consultation and mediator training in developmental and mental health disorders of
that they not only provide support to the parent or children, adolescents, and adults, and equip them
professional, but also direct therapy to the person. with critical social and adaptive skills in order to
Depending on the nature of the clinical challenges fully participate in family and community life. These
and the existing capacity of the mediators, the services also rely on properly preparing mediators
duration of these services may be longer or shorter to use positive behavior management strategies
than the mediator model and more or less intensive effectively. Focused Behavioral Interventions services
(see Appendix 3). are tailored to the individual needs of the consumer.
Before making a determination to continue,
Who Should Receive these Services? modify, or terminate services, objective measures of
People whose mental health symptoms include the behaviors (e.g., frequency, duration, or intensity)
behavioral challenges (e.g., aggression, self-injury, identified in the agreed-upon treatment plan must
noncompliance) in specific routines (e.g., toileting, be available for review. Measures of the mediator’s
dressing, feeding) that threaten the health or safety treatment plan implementation across relevant
of the person or others and act as a barrier to the environments to help ensure generalization and/or
person’s ability to remain in the least restrictive setting, maintenance of learned skills should also be reviewed.
limit participation in family, social, and community life, Standardized and non-standardized, quantitative
and restrict overall independence. quality-of-life measures can also assist in determining
As is the case with any ABA-based service, the overall impact of the service on the person and
Focused Behavioral Intervention is not specific to the family/classroom/residence in which they function.
a particular disorder or age range. Although the Periodic summative data evaluation should be
presence of aberrant behavior is commonly used to conducted every 6 months to determine the ongoing
identify appropriate consumers of Focused Behavior fit of, and medical necessity for, the intervention.
Intervention, the absence of appropriate behaviors A functional behavioral assessment (evaluation of
must also be considered when determining who environmental/behavior relations using observations,
should receive such services. Therefore, individuals interviews and record reviews) or functional analysis
who require skill building are also appropriate for (evaluation of environmental/behavior relationship
this service. by structured manipulation of the environment)
of the problem behavior(s), and adaptive behavior
assessment (evaluation of preexisting levels and types
9 Standards of Practice for Applied Behavior Analysis in Minnesota

of behaviors that could replace problem behavior), • In addition, 3–5 years of experience delivering
should be conducted and used to develop an and supervising treatment programs for person,
appropriate treatment plan. The treatment plan should adolescents, and adults with developmental
identify general goals, specific objectives, measurable disabilities, or licensed or certified in related field
outcomes, and level of service for consumers and for with behavior analysis as its scope of practice.
their parents and/or primary caregivers. Formative data
The qualifications of those providing intensive
should be collected on a daily basis and evaluated at
services directly to the person should include —
least every 2 weeks to and used to determine short-
term next steps in treatment. Periodic summative data • [Preferred] Bachelor’s degree in psychology, Board
evaluation should be conducted every 6 months to Certified Assistant Behavior Analyst (BCaBA), or a
determine the ongoing fit of, and medical necessity related field with relevant experience.
for, the intervention. The plan should also indicate • If no Bachelor’s degree, then a high school diploma
that the consumer would be a good candidate for with competency-based training, and in all cases
Focused Behavior Intervention, and that the family/ with regular on-site supervision and a background
caregiver agrees to participate in and implement, check.
as appropriate, the recommended treatment plans.
Mediator involvement throughout the delivery Responsibilities and Training of Parents
of intervention will enhance treatment effectiveness. and Other Mediators of Treatment
Mediators (family members, professionals, Mediator training (e.g., implementation of the
paraprofessionals, etc) must receive training in order treatment plan, generalization and maintenance
to assist in maintaining benefits of treatment outside of acquired skills) is an integral part of Focused
regular therapy sessions. Clinicians should help Behavioral Intervention and must occur in order for
design training materials, instruction sheets and data the full benefits of the intervention to be realized.
collection forms that are user-friendly for mediators Training should be provided at least bi-weekly.
and provide them with structured opportunities to
practice the new skills they are developing as part
Self-Directed or Self-Determination
of their person’s intervention program.
Option for These Services
When there are questions about the
appropriateness or efficacy of services, these should It would be difficult for most families to readily
be reviewed by an expert panel of Behavior Analysts determine the necessary training and experience
and other professionals. for professionals qualified to provide ABA treatment.

What Qualifications and Performance

Standards are Required of the Service
Providers?
The qualifications of those conducting assessments,
developing treatment plans, and providing
consultation, parent education/training, ongoing
monitoring and supervision of behavioral services
should be —
• [Preferred] Board Certified Behavior Analysts
(BCBA) or be enrolled in formal academic and
supervision program leading to BCBA
• If not a BCBA, then 1) Master’s degree in a related
field, 15 units of graduate level coursework in
behavior analysis or 2) licensed or certified in
related field with behavior analysis in the scope
of practice within that field.
10 Standards of Practice for Applied Behavior Analysis in Minnesota

• U. S. Department of Health and Human Services

(1999) Mental health: A report of the surgeon general
http://www.surgeongeneral.gov/library/mentalhealth/
chapter3/sec1.htmlwww.surgeongeneral.gov/library/
mentalhealth/chapter3/sec1.html
• American Academy of Pediatrics (2012) http://www.
healthychildren.org/English/health-issues/conditions/
developmental-disabilities/Pages/Autism-Spectrum-
Disorders.aspx
• National Autism Center (2009), National Standards
Report http://www.nationalautismcenter.org/pdf/
NAC%20Findings%20&%20Conclusions.pdf
• Centers for Medicare and Medicaid for the U.S. Dept.
of Health and Human Services (2010)http://www.
impaqint.com/files/4-Content/1-6-publications/1-6-2-
project-reports/FinalASDReport.pdf

Who Should Receive These Services?

Children with a diagnosis of ASD who display
Comprehensive Applied Behavior significant delays in development as well as severe
Analysis Treatment behavior disorders are appropriately treated with
Comprehensive ABA is well documented in more Comprehensive ABA treatment. The disorder is
than 500 studies and multiple task force reports as so severe that the children are unlikely to a) be
the most effective and well-established treatment safe in the home or community; b) attain normal
for individuals with autism spectrum disorders (ASD). developmental milestones; or c) succeed in a regular
It is important to emphasize that Comprehensive classroom without substantial one-to-one support.
ABA is not long-term caretaking—it is an intensive Comprehensive ABA treatment is only appropriate
approach that has been empirically demonstrated for children for whom the goal of treatment is to
to remediate the core symptoms of autism to a restore normal functioning as much as possible, and
greater extent than any other intervention through who demonstrate strong response to treatment on
its high-dose treatment methodology, intentional objective quantitative measures. While the age range
generalization from the treatment setting to the of person benefitting from Comprehensive ABA
natural environment, and frequent use of data-based treatment has been thoroughly studied with persons
decision-making. aged between one to 12 years, existing data suggest
Comprehensive ABA is a medically-necessary response to treatment can be evaluated after six
treatment for autism that has the unique potential months of treatment and that age at intake is not
to restore normal functioning. Numerous national necessarily a predictor of treatment response. For
and state task forces endorse ABA as having the children whose six month learning pattern suggests a
strongest evidence of efficacy to consistently produce positive response to this treatment package, the range
meaningful benefits to children diagnosed with in duration of treatment can be six months to five
ASD, reflecting the established and growing body years, with an average of three years.
of peer-reviewed literature. The list below is only a
sample of national support for the effectiveness of a
Comprehensive ABA approach for the treatment of
autism —
11 Standards of Practice for Applied Behavior Analysis in Minnesota

How Often Should a Specific Service Before making a determination to continue, modify,
be Provided? or terminate services, quantitative measures of the
Comprehensive ABA (appendix 4) is typically delivered behaviors (e.g., frequency, duration, or intensity)
intensively in the home or center, directly to the child, identified in the agreed-upon treatment plan must
at as young an age as is possible (ideally commencing be reviewed. Standardized and non-standardized
prior to age 4). Treatment requires many of hours of quantitative quality-of-life measures can assist in
service weekly and may last in duration for 1–5 years. determining the overall impact of the service on the
The research supports 10–60 hours per week (3–12 child and the family in which they function. Periodic
hours daily, 5–7 days/week), depending on the needs summative data evaluation should be conducted
of the child. The intensity of treatment is gradually every 6 months to determine the ongoing fit of, and
increased over the first six months and is often faded medical necessity for, the intervention.
during the last course of treatment. This service is A developmentally-appropriate behavioral
delivered to consumers in rural areas in an outreach assessment should determine the targets of the
model (appendix 5) with hours per week often treatment plan. The treatment plan should identify
determined by proximity to a provider. goals, objectives, measurable outcomes, and level of
Because these services are aimed at remediating service for the child. Frequent review of the data will
all symptoms of the mental health disorder of autism guide frequent adjustments to the treatment plan. The
(challenging behavior, skill deficits) that impact almost supervisor should review direct observation data on a
all areas of development, the treatment objectives are weekly basis at minimum, while treatment plans are
comprehensive rather than focused. The majority of typically reviewed every 3 months.
the hours of treatment are delivered directly to the Clinical Supervision should be provided at
person by highly trained staff, and parents receive a minimum of 2 hours per week. The Clinical
substantial support in participating in the treatment. Supervision ratio should be a minimum of 1 hours
Current research indicates that effective treatment of supervision for every 10 hours of treatment, with
is initially intensive in very structured sessions, and a typical ratio of 1 hour of Behavioral Assessment,
incorporates naturalistic teaching techniques as soon Clinical Supervision, Case Management, and Parent
as the child demonstrates that she/he benefits from and Community Training for every two hours of direct
this type of treatment. As the child progresses and therapy. Supervision time may need to be increased
meets established criteria for placement in small group to meet the needs of individual person (e.g., start up,
settings, she/he should receive treatment in those assessment, and new staff training).
settings (e.g., community outings, playgroups, etc.). Parent training throughout the delivery of
If 6-month summative data do not indicate intervention will enhance treatment effectiveness.
progress, then transition to special education supports Family members must receive training in order to
is recommended. assist in generalizing and maintaining benefits of
treatment outside regular therapy sessions. Clinicians
should help design training materials, instruction
How to Ensure that Services
sheets and data collection forms that are user-
are Useful and Effective
friendly for family members and provide them with
Comprehensive ABA is designed to remediate the
structured opportunities to practice the new skills they
symptoms of autism and equip children with critical
are developing as part of their child’s intervention
social and adaptive skills in order to fully participate in
program.
family, school, and community life. These services also
Comprehensive ABA services could be determined
rely on properly preparing family members participate
to be ineffective for various reasons: lack of family
in the treatment to promote generalization and
participation in the program, frequent absences, or
maintenance of treatment gains. Comprehensive ABA
cancellation of treatment sessions. Alternately, the
services are tailored to the individual symptoms and
child may master skills to the point that she/he no
needs of the child.
longer demonstrates sufficient deficits to warrant
intensive services.
12 Standards of Practice for Applied Behavior Analysis in Minnesota

When there are questions about the Responsibilites and Training

appropriateness or efficacy of services, these should of Parents and Caregivers
be reviewed by an expert panel of Behavior Analysts Family training (e.g., implementation of the treatment
and other professionals. plan, generalization and maintenance of acquired
skills) is an integral part of Comprehensive ABA.
What Qualifications and Performance Training for parents/caregivers should be provided at
Standards are Required of the Service least monthly. Additional training should be included
Providers? for parents/caregivers who are able to observe
The qualifications of those conducting the behavioral sessions, and for skills that are rapidly changing
assessments, developing the treatment plans, and and need to be carried over outside of the sessions.
providing consultation, parent education/training, Families must be involved in the treatment in order
and/or ongoing monitoring and supervision of for the full benefits to be realized.
behavioral services should be:
Applied Behavior Analysis Professional: Board Self-Directed or Self-Determination
Certified Behavior Analyst-Doctoral (BCBA-D), Board Option for These Services
Certified Behavior Analyst (BCBA) or be enrolled in It would be difficult for most families to readily
formal academic and supervision program leading determine the necessary training and experience
to BCBA. (If not a BCBA, then 1) Master’s degree in for professionals qualified to provide ABA treatment.
a related field, 15 units of graduate level coursework
in behavior analysis or 2) licensed or certified in related
field with behavior analysis in its scope of practice).
In addition, 5 years of experience delivering and
supervising treatment programs for person with
autism is preferred.
For the purpose of accessibility, the BCBA-D or
BCBA should take responsibility to delegate Behavior
Assessment, Behavior Analysis, Case Management
and Clinical Direction responsibilities to a Board
Certified Associate Behavior Analyst (BCaBA),
whenever possible. However in no cases would the
case be appropriately supervised without a minimum
level of direct onsite supervision by the BCBA-D or
BCBA.
The qualifications of those providing intensive
services directly to the child should include —
• Applied Behavior Analysis Technician: Behavior
Therapist, Bachelor’s degree in psychology, Board
Certified Assistant Behavior Analyst (BCaBA),
or a related field with relevant experience .
• Behavior Technician or Behavior Aide: If no
Bachelor’s degree, then a two-year degree or high
school diploma with competency-based training,
and in all cases, regular on-site supervision and
a background check.
13 Standards of Practice for Applied Behavior Analysis in Minnesota

Part III. Recommended Guidelines

for Billing and Reimbursement
Since 1998 the Behavior Analyst Certification Qualified professionals with expertise in Applied
Board has defined the national and international Behavior Analysis include licensed behavioral
standards for the applied practice of behavior health professionals (e.g., psychologists, social
analysis. Throughout the United States and countries workers) with expertise in Applied Behavior
around the world, the credential of Board Certified Analysis (e.g., in competencies claimed to their
Behavior Analyst (BCBA) is the standard for third licensing board), licensed Behavior Analysts, and
party reimbursement and other practice privileges. professionals certified by the Behavior Analyst
The BACB increasingly represents the minimum Certification Board.
requirement for a professional to claim to offer
behavior analysis or ABA in their clinical practice, Reimbursement for services rendered by an Applied
and we suggest Minnesota adopt this rigorous Behavior Analysis Professional would be made for the
standard to protect the public interest and ensure following CPT codes —
best outcomes for consumers.
90866: Applied Behavior Analysis Assessment
includes behavioral interviewing of
Qualified Applied Behavior the patient and caregivers; designing,
Analysis Professional conducting and interpreting functional
A professional with expertise in Applied Behavior behavioral assessments, functional analyses,
Analysis who uses Applied Behavior Analysis criterion-referenced assessments, preference
principles and procedures to functionally analyze assessments, and direct observation and
behavior disorders, assess circumstances associated recording of behavior; per hour of the
with skill deficits and problems as well as strengths, qualified professional’s time, including face-
designs and oversee treatment implementation, and to-face time administering the assessments
monitors treatment outcome. Qualified professionals to the patient and time interpreting the
are ethically obligated to employ state-of–the-art results and preparing the report
evidence-based treatment procedures.
14 Standards of Practice for Applied Behavior Analysis in Minnesota

90871: Applied Behavior Analysis Intervention Reimbursement for services rendered by an Applied
includes developing, implementing, Behavior Analysis Technician would be made for the
supervising, monitoring, or refining following CPT codes —
applied behavior analysis intervention
90867: Applied Behavior Analysis Assessment
plans for individual patients that emphasize
includes behavioral interviewing of the pa-
identifying and altering environmental
tient and caregivers; conducting functional
events (e.g., motivating operations, setting behavioral assessments, functional analyses,
events, antecedents, consequences) that criterion-referenced assessments, prefer-
are functionally relevant to establishing ence assessments, and direct observation
and shaping new responses, increasing and recording of behavior administered by
appropriate responses, and reducing a technician under the direction of and with
problem behaviors; each hour of the interpretation by a qualified professional;
qualified professional’s time each 15 minutes of the technician’s time

90873: Applied Behavior Analysis Consultation 90872: Applied Behavior Analysis Intervention
includes training parents, teachers, includes implementation of applied behav-
technicians, other caregivers, and ior analysis intervention plans for individual
organizations on the use of behavior- patients that emphasize identifying and
analytic strategies for increasing appropriate altering environmental events (e.g., motivat-
behavior and decreasing problem behavior; ing operations, setting events, antecedents,
each hour of the qualified professional’s consequences) that are functionally relevant
time to establishing and shaping new responses,
increasing appropriate responses, and
90874: Team Conferences for Applied Behavior reducing problem behaviors by a technician
Analysis includes applied behavior analysis under the direction of a professional; each
program goal development and/or review of 15 minutes of the technician’s time
patient progress toward goals with family;
each hour of the qualified professional’s
time. Outreach Services Modifier
Minnesota currently experiences a shortage of mental
Registered Behavioral Technician health professionals and Behavior Analysts in rural
An individual who has had some college coursework areas. Consumers in these areas are chronically
and supervised practical experience in applied underserved. In order to deliver medically-necessary
behavior analysis. ABA technicians use ABA principles services to consumers in rural areas, additional
and procedures to assist in functionally analyzing funding is required to compensate for the greater
problem behaviors, assessing circumstances associated costs of travel. In addition, telemedicine and electronic
with skill deficits and strengths, implementing consulting avenues (such as detailed email or
some ABA interventions, and monitoring treatment telephone communication) need to be reimbursed
outcomes under the supervision of a qualified at the same rates as the “face-to-face” services
professional. Some ABA service provider agencies described in the above section.
designate technicians with the most training and
experience as “lead therapists” who are responsible
for some aspects of day-in, day-out intervention
for some patients, such as (a) monitoring treatment
integrity, (b) updating and maintaining data graphs,
(c) making certain changes in treatment goals
and procedures, and (d) assisting with parent and
therapist training, all under supervision and in close
consultation with the qualified professional.
15 Standards of Practice for Applied Behavior Analysis in Minnesota

Conclusion
Applied Behavior Analysis is a treatment methodology
with a rigorous empirical basis, having shown efficacy
in the treatment of a variety of developmental and
mental health disorders across the lifespan. At the
heart of the science of Applied Behavior Analysis
is a commitment to tailoring intervention based
on quantitative outcome measures that make a
clinically-significant difference in the lives of people.
The burgeoning demand for services and declining
funding outlooks require funders and policymakers
to rigorously measure outcomes and take steps to
ensure that limited funds are being spent on medically
necessary services that produce real-world results.
Applied Behavior Analysis offers evidence-based
practices with data-driven tailoring for the individual
needs of consumers and their stakeholders in pursuit
of meaningful, sustainable change and improved
quality of life. MNABA looks forward to working
with the Department of Human Services and related
agencies to put Minnesota on the forefront of cost-
effective and results-oriented services.
16 Standards of Practice for Applied Behavior Analysis in Minnesota

Members and Advisors of the Standards

Task Force
Members of the Task Force were selected based Individual Task Force Members
on several criteria among the following —
• Tara Bertone, MA, CCC-SLP
1. Graduate (Masters or Doctorate) degree in
• Sheryl Cotton, BCaBA
Applied Behavior Analysis or closely related field
• Amy Dawson, JD
2. Board Certified Behavior Analyst (BCBA)
• Troy Fry, MA, BCBA
3. Considerable experience in providing ABA
services to individuals and families • John D. Hoch, PhD

4. Considerable familiarity with contemporary • Peggy Howell, BA, MHP

research in ABA services • Jami Hughes, PsyD, LP, BCaBA
5. Leadership positions in developing and • Jennifer V. Larson
monitoring service delivery standards • Eric V. Larsson, PhD, LP, BCBA-D
• Timothy R. Moore, PhD, LP, BCBA-D
Agency Endorsers and Advisors • Kara Riedesel, BCaBA
• Alliant Behavioral Pediatrics • Nancy Schussler, PhD, LP, BCBA-D
• Autism Matters
• Behavioral Dimensions, Inc.
• Behavior Therapy Solutions of Minnesota
• Holland Center
• Lazarus Project
• Lovaas Institute for Early Intervention
• Minnesota Early Autism Project
• Rochester Center for Autism
• University of Minnesota Autism Spectrum
Disorders Clinic