Behavioral Pediatrics

ABA has essentially become synonymous with treatment of ASD, and medically speaking, nothing else despite a wide-array of possibilities. Insurance mandates have now existed in many states across the United States for 10 or more years, but are specific to ABA as a recommended treatment for ASD. In this episode, Mike and Dan guide us through the idea of 're-specialization' for the ABA field, toward greater utility. Specifically, as inspired by Patrick Friman's 2010 publication on bringing ABA to the mainstream, expanding the utility of applied behavior analysis into a primary care role, while preserving and expanding  our current expertise, serve as the main ingredients for this delightfully informative and prospectively delicious brew.

Sit back, relax, and imbibe this stimulating libation of ABA on Tap. And of course-- always, always, analyze responsibly.

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Transcript

SPEAKER_00: 0:00

Hey Mike, how do you feel about today? Feeling pretty good about it?

SPEAKER_02: 0:04

I think today's a great day, Dan.

SPEAKER_00: 0:06

I couldn't agree more. Like you say, any day that you wake up and your name's not in the obituary, you're off to a good start. Speaking of which, today's also a great day to start your own podcast. Whether you're looking for a new marketing channel, you have a message you want to share with the world, or just think it'd be fun to have your own talk show, like we did. Podcasting is an easy, inexpensive, and fun way to expand your reach online. Maybe learn something. Now, Buzzsprout is hands down the easiest and best way to launch, promote, and track your podcast. It's what we use. Your show can be online and listed at all of the major places podcasts can be found, like Apple Podcasts, Spotify, Google Podcasts, etc., within minutes of you finishing your recording. You know, podcasting isn't hard when you have the right partners. And the team at Buzzsprout is passionate with helping you succeed. Join over 100,000 people just like us sharing their message, already using Buzzsprout as the conduit to get their message across the world.

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SPEAKER_00: 1:46

Cheers. Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on tap. In this podcast, we will talk about the history of the ABA brew, how much to consume to achieve the optimum buzz while not getting too drunk, and the recommended pairings to bring to the table. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_02: 2:42

All right, all right. And welcome yet again to another installment of ABA on Tap. I am your co-host, Mike Rubio, along with Daniel Lowry. Mr. Dan, how

SPEAKER_00: 2:55

are you

SPEAKER_02: 2:55

doing, sir?

SPEAKER_00: 2:55

Wonderful. Good to see you after Thanksgiving. Hope you're sufficiently full and ready to go. I like

SPEAKER_02: 3:01

that time reference. I am abundantly full and ready to go. This is to serve as our last episode for our third season. So a quick and early congratulations.

SPEAKER_00: 3:13

Cheers, cheers, cheers. Looking forward to a big 2023. Yes, yes. Lots on the plate. Very, very exciting

SPEAKER_02: 3:18

things. Lots on the plate. I like that reference.

SPEAKER_00: 3:21

And speaking of which, we're looking to expand the plate for ABA, and Mike's going to talk about that a little bit in a minute.

SPEAKER_02: 3:27

Very, very exciting. Let's jump right in. So almost exactly a year ago, we talked, we had a two-part series on collaborative treatment where we alluded to this idea of behavioral pediatrics. We're going to revisit that now with a lot more confidence and impetus as a field I don't believe when we were alluding to it or talking about it last year in our collaborative treatment series the board yet had information on their website the BACB on behavioral pediatrics or this idea of re-specializing the application of ABA but now they do so we've got a lot more information to present and a lot more impetus and excitement to carry us in terms of what this means prospectively for our field so super excited to be talking about this sir

SPEAKER_00: 4:12

absolutely I know you've been hitting the research books pretty hard over the last three, four months with our company looking to expand this. So you're a relative Wikipedia page now on behavioral pediatrics and look forward to discussing it with your brother. We'll

SPEAKER_02: 4:29

see what comes out today. As you know, we keep it fresh and unscripted here, unfiltered, always cold, ready to serve up in the living room from the lab. So yeah, let's actually jump right in. There's a million ways to approach this. I'm not exactly sure what the best way will be to do so here, but I'm just going to go with the flow. The idea really is to understand. So say for us here in California, we just recently and over the summertime celebrated 10 years of Senate Bill 946, right? Autism Insurance Mandate Bill. No more

SPEAKER_00: 5:06

four contracts and you're out with a regional center.

SPEAKER_02: 5:09

Regional center, and that could be a whole different episode for people that don't live in California. I think that's a pretty unique system here for California. But yeah, looking at an autism mandate or insurance mandate over 10 years and realizing that as a field of ABA, we have literally only been utilized for one medical diagnosis over this entire time, at least from that insurance reimbursement perspective. So That really gives us a chance to step back and reflect and say, well, we must be useful in other ways. I know I like to talk about evening the playing field with ABA and something like autism, and we'll have the Playing field is level, that means that we must have applications outside of the realm of individuals with autism or autistic individuals, if I can correct myself there. But it's not like it's been explored by and large. And even with colleagues that we have who are now working in states that have licensure and presumably parameters that should allow for a greater utility and expansion of how ABA is applied, I was redundant there. That hasn't necessarily happened. So let me see. About three, four years back, I ran across, as you know, I'm a big fan of Pat Fryman. And I ran across something that he had written in 2010, 2011 about this notion of bringing ABA into the mainstream. And more specifically... ABA in primary care now that we're at the medical table and benefiting from these insurance mandates sort of being seen as a medically-based service. And ever since then, I've kind of followed this idea to see where it goes, and it seems to have a great deal of utility again, enough that now the BACB is recognizing this. So I'm excited to be talking a lot about all the possibilities that span from this. And I'll be focusing as much as I can on the current work I'm doing, which now leads us to the maybe third and final tier for our discussion. So we went from ABA in the mainstream to ABA in primary care to now this idea of behavioral pediatrics. And again, with thinking about just the general premise of a level playing field. We work with children, by and large, or a lot of the work we do can deal with kids from ages, say, 3 to 18. And it just so happens that, at least from some estimates out in the research arena, that anywhere up to 50% of pediatric visits end up being behavioral in nature and not actually... medically based. So I know that I've unpacked a lot there. Let me hand it over to you and see what thoughts you're brewing over there.

SPEAKER_00: 8:07

Yeah, I think we actually came up with the term ABA off-label, another kind of term for behavioral pediatrics. I think you came up with that, yeah. But it seems very relevant, right? Like you said, ABA, while universal in terms of the strategies and applicability, people use ABA with their significant others, with pets, with all sorts of kids not on the spec Thank you. differently with or without a diagnosis and how you've been continuing to kind of pave this unpaved road and really, really exciting to see how we can bring our services to the forefront. I think this goes nicely, coincides nicely with our more humane approach. And as we look and try to, you know, sand off some of the rough edges of ABA, because if we are going to bring ABA to other fields, I think a lot of the other things that we've talked about in terms of some of the critiques of ABA, that are legitimate should probably be addressed and dealt with so that we can make sure that we bring our best foot forward into this behavioral pediatrics field.

SPEAKER_02: 9:37

And I want to highlight or reiterate something that you alluded to here, which, so to clarify for our non-California listeners, When Dan talks about early start, this is early intervention that's as funded by a state program, early start. We're under the first five initiative here in California. And the important piece that we took from there was that there was a really stark contrast, say, between best practices in early childhood, so what you would see in your idyllic best research-based preschool or nursery school environment, and then some of the procedures and techniques that traditionally we have implemented in ABA, being very specific to things like discrete trial training, which comes with a lot of lab punch, right? And we want to preserve that, but it looks like this allows us to begin to repackage it, to make it look and feel a little bit different. And I like the way you put it. That's the way I like to kind of hear it is you come to this crossroads and you're like, well, wait a minute. This kid over here, again, from an early childhood perspective, these would be the best practices. And then this child of the same age, because of their exceptional circumstance, now gets something completely different that, for me as a developmentalist in my early training, was a real stark contrast. It was bothersome. It was like... Wow, this is weird now. It feels awful. And I jumped right in, head first. Now I need to learn ABA. This is now more back at the turn of the millennium, the early 2000s when I started working here in San Diego. But ever since then, it's been that uphill battle for me. You met me pretty early on, and it was always trying to combine these ideas and these fundamental premises to make them feel like I was working with a two- or three-year-old, not being so rigid and flexible in myself procedurally, even abrasive sometimes. We've talked about it here on the podcast, general assumptions, misconstruals that we've done as a field by and large, blanket ignoring as extinct Things that really, yes, you're absolutely right. This gives us an opportunity to re-specialize, re-utilize, re-package, and more importantly, develop professionally as a field. Realize that we don't have to throw the baby out with the bathwater to use that poignantly, but we got to change that bathwater, I think. It's got a little too soapy. It's getting a little too murky,

SPEAKER_00: 12:18

right? Yeah. I think one quick antidote, and then I think you should jump in because you have a lot of meat on this Thanksgiving dinner plate for behavioral pediatrics. I've been running parent groups for basically my entirety of being in my current company because I'm a big proponent that without parental involvement, ABA services, while they might be able to make a company a lot of money, the effectiveness, the sixth dimension of ABA, good old get a cab, is not going to be there. So during one of my first parent groups, I remember you partaking in this as well. We had a family, a pediatrician, and his wife joined. And this family had a few kids. The oldest child had autism, and then the other two didn't. And by the end of this parent group, the dad, the pediatrician was like, hey, you know what? I want you to write a book and I want you guys to write a book on ABA without autism because I've used all of the strategies on my three-year-old son who doesn't have autism as I have on my 10-year-old daughter that does have autism and they've been equally as effective. And all I can ever find is books on ABA and autism. I want you guys to figure out a way to get ABA without autism into the mainstream because it'll help a whole lot of parents. Flash forward to my most recent parent group. I have a parent that comes that has a 16 year old, a child with autism, and then his brother is 17 or 18 years old. And she recently asked me, hey, my child doesn't have autism diagnosis, but could really benefit from your services as we've helped her, the sibling, get a job and really start to acclimate into society and life. And she said his sibling may have a diagnosis of anxiety or ADHD or something, does not have an autism diagnosis. Can you help? I would love for you to help. I'll even private pay for you to help. And it's a very difficult discussion right now because our help is essentially limited to that F84.0 diagnosis, the ASD diagnosis. That's the only way insurances will pay for it. Yet these clients that are seeing the effectiveness and seeing that it's not specific to to individuals with ASD are really asking for our services. And I think that's kind of the conduit that's kind of opened up this playing field that you're gonna talk about of how we can expand it past this F84.0 diagnosis and really help a lot of people and a lot of families that have behavioral challenges but don't have the autism diagnosis. And why should we discriminate against them when they could benefit from our services as well? So I think those anecdotes are pretty relevant and set a nice stage for you to kind of present your information. So let me pass it back to you.

SPEAKER_02: 14:58

All right. And I have to repeat again, thank you for that setup there. That's perfect. And I have to repeat again that all the information I'll be covering today or the bulk of it can be found on the BACB website in terms of new areas for re-specialization, I think they call it. And you can punch in behavioral pediatrics. And one of the things that Patrick Freiman talks about in some of his publications on this topic is this general notion of what we perceive normalcy to be. That is to be, when you share your anecdotes there, Dan, even for parents, there seems to be this dividing line. This is my child with autism who I have concerns about, who receives services for these behaviors, and then these are my other kids. And once in a while, we hear about the other kids. I'm not saying that they're actively saying that, but I think in our minds, we think, oh, the child with autism, well, they have these behavior concerns, that's why we're here, and of course, the rest of the family's perfectly fine. There are no issues at all.

SPEAKER_00: 15:56

What's interesting with that is I actually had a family, twins Paternal twins, one had autism, one didn't. At a younger age, the one that had autism was much more difficult, didn't have any functional communication or vocal communication. But over probably five years of ABA services, all of a sudden he was a less difficult sibling.

UNKNOWN: 16:15

Yeah.

SPEAKER_02: 16:15

So there you go. And that's, that's the, so again, the general notion here being that unless you've got something diagnostically identified, then childhood is perfect, right? There are no issues. And if you're the parent of a child that doesn't have a diagnosis, then parenting is easy, which is perfect. Couldn't be further from the truth. Parenting is quite a challenge for anybody. And of course, now, if you're adding on top of that some diagnostic traits that are circumstantially causing challenges, then yes, your life is probably just a little bit more complicated because of that, not to mention time-consuming necessary things like ABA services, parent training, things that are going to give you a little bit more work. So I think that we need to start with that general foundation, the idea that parenting is difficult. And thankfully, due to the resiliency of the human animal, by and large, a lot of kids sort of surpassed the trials and tribulations of early childhood, middle childhood, middle school, and come away relatively unscathed. So we're going to apply heuristic here. And I think it's important to, again, credit Pat Freiman's publications here. There's sort of this idea of a rule of thirds. So everybody starts out with some level of concern. Everybody has something that they deal with, whether it's bullying or something during elementary school. But most of us prevail. So we're going to say about the third of us come out completely unscathed. Third of us maybe have a little bit of trouble. And then maybe there's a third that really gets stuck and has quite a bit of difficulty. And maybe these are the kids that now we're seeing come up with a little bit more of a mental health wave that maybe COVID or the pandemic exacerbated a little bit. So we want to look at those areas where you don't have anything diagnosed, but you are having trouble. that 50% and the you know, limited research I've done. And speaking to pediatricians, they don't agree that it's as high as 50%, but they would agree with 30% that at least 30% of the issues they deal with on a day-to-day basis when they're expected to take 15 to 20 minutes with every patient, all the paperwork and things that they have to do for insurance, who's, you know, obviously making sure that everything's aligned so that the reimbursement can be made effectively and nobody's having trouble with that end of things. They got to push these patients along, right? So now 30% of those patients are coming in with something that's behavioral in nature. Picky eating, toileting resistance, nighttime issues, overactivity, which is apparently the term they use before you're diagnosed with ADHD. But the way the current system is set up is an issue has to arise. Something must be diagnosable. A code must be applicable before your health insurance is going to assist with that. So what ends up happening, and not to anybody's fault other than the circumstance, is that a lot of these then go untreated. So your pediatrician is going to tell you something very wise and something very general like, no worry, they'll grow out of it. I can see that medically they're OK. I can see that you're having some trouble, say, with some outbursts or some tantrum behavior because of your child's temperament. But I think everything's going to be OK. Everything seems to be within range. Now we send you off. that parents are like, okay, well, good. Maybe I feel good about that. Maybe I have to go deal a little bit more. That's fine. But maybe this problem worsens. And it gets a little worse. And it gets a little worse. And now we've got a stigma, right? Because the idea that your child needs some sort of therapy. or their child isn't okay, well that doesn't feel good as a parent. So maybe I'm also gonna wait and let them outgrow it, wait a little bit more and just deal and just deal. And then now we have a problem that's diagnosable and can get sent out and referred to a specialist and now your insurance covers it. But now we have a problem where we had several years where this could have been preempted. So herein comes the idea of behavioral pediatrics. Primary care, right? Puts us at primary care, a preventative application. And again, this is where you... very comprehensively and wisely made the TIDA early start and how we use that in terms of early intervention and saying there's no diagnosis here. In fact, we're trying to differentiate or preempt any sort of idea of diagnosis here. We're trying to get ahead of it.

SPEAKER_00: 20:51

Well, that's, in fact, what Lovaas did with his study. And he showed that, I think it was 89-ish when it was published, that at that time, if the individual got ABA treatment by the end of preschool, it saved like a million or two million dollars over that individual Joel's lifespan. Premise of preventative. These individuals didn't have diagnoses or anything at that time. They were just really struggling in school. So if they could get this service early, they would actually need less services throughout the duration of the life. So this is kind of an extension of what he did.

SPEAKER_02: 21:23

Absolutely. And again, if we want to talk about... Or go a little bit earlier there and talk about Skinner. Again, we've been pigeonholed, to use your phrase. And the idea that Skinner had was really to bring these principles to the improvement of humanity in general. And that's what we're talking about. We've been relegated to one particular diagnosis, but clearly there's a bigger application. So in going back to these pediatric visits and in talking to some of these pediatricians, they quickly agree. The idea that I don't have time to deal with a behavioral issue. Very candidly or frankly, most of the pediatricians I've talked to will also say, I don't have the training. That's not what I do. I'm medically trained, as they should be. I believe there is, at least through medical school, there might be a... a six-week, four- to six-week round where they get to do a little bit of a cursory overview on behavior, but that's it, right? So really there's room for our content expertise to come in and help with these things. And again, in most of the contact I've had with pediatricians, they agree quickly that if they could then hear the behavioral concern from the parent, and they're ready for a lot of these, they've gotten used to them, do their medical work up quickly, and then say, okay, as far as the other problem... Here you go. Here's a referral. Go see these folks over there. And they're going to go ahead and help you with that behavioral issue to see if we can take care of the problem or maybe. it might differentiate the diagnosis. So the idea that your child is age seven or eight, they should be completely potty trained, but somehow are having daytime accidents at school, and the pediatrician doesn't see immediately, can't notice a medical reason for that, so that it might be a behavioral concern, and now we can go and help and take care of that. Now, incidentally, in doing some of this research, it turns out that A good percentage of kids suffer from enuresis, diurnal enuresis, meaning daytime. And a lot of this, going back to that rule of thirds, a lot of this gets resolved by middle school. But now imagine the idea that you've been peeing your pants in front of your friends until you're 11 or 12. That could be pretty stigmatizing. I would say that could be very stigmatizing. Certainly not the first kid to get invited to the sleepover, right? But again, this is one of those issues that... a lot of stress and tension between the parent and the child,

SPEAKER_00: 24:07

right? Or even the child themselves, anxiety and depression about being in social situations and am I going to be myself? Low

SPEAKER_02: 24:13

self-esteem and low self-efficacy and, yep, maybe some withdrawal. So these are all things that, again, and not to say that enuresis would go largely untreated, but the way it's approached might leave these parents in a circumstance where there's not enough contact. Sure. Enter ABA professionals who, We're very used to the living room. We're very accustomed to providing behavior plans, if you will. We'll shift gears into talking about behavioral prescriptions, hopefully near the end of this episode, and just kind of looking at how we're going to expand the utility of some of the procedures we do draw up. And we'll be utilizing much more generally here, or prospectively, with the idea of behavior pediatrics. So not that it's going to be envisioned as in-home service, as we do now two or three times a week. but looking more at being able to condense our expertise and provide a six to eight consultation session type of service. Take some strong data, provide front load, provide some strong support, and then see where that leaves the family with regard to this behavioral issue.

SPEAKER_00: 25:19

Sure. I think a couple of the things that you mentioned that are really important is the truncated nature of the pediatrician visit and the fact that first in ABA, as we mentioned, we always have to rule out medical concerns first as part of our ethics code. And if that is the concern, then that's going to be dealt with by the pediatrician. We're not really going to need to step in to that realm. But assuming, as you mentioned, that it's not a medical concern, then it's going to be an environmental issue. And that environmental issue is likely not going to be able to be dealt with in that 15, 20, even 30 minute doctor's visit. There's going to be a lot of environmental variables that are going to have to be dealt with in that time. So that's where we come in and we'll be able to spend a longer time with that individual to really come up with an accurate plan. In addition, the plan that's created may not be the plan that's effective. And there has to be a lot of modification Because if we're going to say the treatment with individuals with ASD is similar to the treatment without ASD, the clients that we work with that have ASD need a lot of modifications. Rarely is the behavior plan that we set up on day one the same as the behavior plan that we're going to have in month six and two years down the road. So we're going to need some revisitation. to modify. Hey, is it working? Is it not working? Do we need to modify some things? Are there some changes in the environment that you didn't think of the first time you met with us because you were so stressed or whatever? So there's going to need to be some follow-up here that likely the pediatrician doesn't have time for on their schedule. So we can really come in and help with that environmental thing. We can add that active kind of monitoring piece, which is probably not there. And in fact, a lot of times with both pediatricians and mental health providers, the Booking, if you need an appointment, is going to be weeks or months out. So hopefully we can come in and really modify and kind of stay on top of in those six to eight visits the environment so that when the parent leaves, it's not just a one-time thing, but it's a six to eight visit thing where they really have an empowered, solidified behavior plan or behavioral prescription, as you'll talk about, that's really effective and not something that's just, kind of generically thrown out in a 15 or 20 minute initial visit.

SPEAKER_02: 27:25

Yeah, no, you cover a lot of good ground there for sure. And that is the idea. It's this idea that there's limited amount of time and there's also a content expertise piece, which again, most pediatricians I've spoken to are quick to say, this is not our area. We don't have the time. We don't have the experience. We would love to be able to pass this off to folks like yourselves. Another shift in mindset that I think is important, Dan, that you make me think of here is, at least for us as ABA professionals in looking at this expansion prospectively, is changing our mindset from the idea that, and I think we've talked about this before and as a field we're looking at this, the idea that we're fixing something that's wrong as opposed to dealing with a commonplace everyday problem. And this is, I think, is important from a parenting perspective because, again, as a parent, you're going to run into problems. A two-year-old is genetically engineered and designed specifically to cause problems. You would know. I know firsthand right now. Now, it's not to say that something's wrong with my child. In fact, every Everything is right with her, right? Now, and again, I'm not trying to be cavalier there. I know that that's different for some of the families we work with who have been given a certain level of assessment or reporting to say this area has fallen behind, something is wrong. But if it's anything that this idea with Early Start or being preventative has taught us, is that these problems are commonplace. Again, back to the level playing field. Yes, this child might have a language delay, and that might be causing unique complications, but the idea that they cry a lot at 24 months Well, that's probably pretty comparable across two kids if we're making that comparison. Again, looking at my young daughter, my 22-month-old, who certainly has outbursts, certainly has tantrums. As far as I can tell, is moving along very well in her communication, but is clearly designed to explore things. when I feel I don't have time, or to take a different route as we're walking her home from preschool, or to, and what is she doing while she's being exploratory? She's looking around. But if I don't have the time, I might, you know, and you're not listening, you're not coming with me right now, so now you're misbehaving. Again, these are, nothing's wrong in that scenario. It might feel like something's wrong in that moment, but these are common everyday problems. We can look at a list, at least from the literature, again, you know, toileting and accidents, whether it's night or day, poor appetite, night fears or illogical fears of thunder or lightning, things like that, night waking, being hyperkinetic or overactive, bedtime resistance, noncompliance or attention seeking, which can be common across kids of all ages, picky eating, co-sleeping, which has nothing to do with the child's habits. As parents, you by and large create that problem yourself, right? And it happens across the board And, again, it's a problem in this society here for American culture, not necessarily a problem across the board, right, or for everybody. And then, of course, really, really commonplace things that are necessary evils, so to speak, like sibling rivalry. Where do you learn to control your aggression, to defend yourself, to do things without getting really, really dangerously hurt? Sure. usually your brothers and sisters right that's how you learn to fight or you know things that again are necessary evils that are going to have us change our mindset as behavior analysts to say these are problems not that something's diagnostically wrong or diagnostically relevant these are actually routine problems that most three to seven year olds face per parent reporting also per pediatrician reporting this is the stuff that they're getting in their offices sure that they don't necessarily have the time nor the constant expertise. From that list that I just read, I mean, that's an everyday menu for any of our RBTs,

SPEAKER_00: 31:43

right? Yeah, absolutely. And I think you bring up a good point, too, about fixing my child's behaviors versus fixing my child. And that's what we're trying to get into is this child is having some behaviors, but every child has, you know, everybody's on a spectrum of some... With communication, with socialization, with toileting, things like that, everyone's on a spectrum. And if we can keep it as fix my child's behaviors... From our experience of the other side, I think we'll see a different level of parent and child interaction, a different level of prescription of where that parent thinks that child's going to go. A whole lot of things are avoided if we can keep it at fix my child's behaviors. versus fix my child.

SPEAKER_02: 32:27

You make a very important point there in terms of the dividing line between normalcy and pathology. Exactly. And what we're talking about here is a concept that was introduced to me back in graduate school many moons ago by a gentleman named Dr. Joseph Price. I think he's still at San Diego State. And he taught me about the notion of developmental psychopathology. So when we talk about an autism spectrum, you alluded to the idea of a spectrum or a continuum. Sure. And again, this points back to this fundamental understanding that everybody faces certain challenges, such as life. Sometimes, given the totality of the impact on the outcome of life, we might diagnose those troubles. But by and large, everybody's going to struggle through something. Sure, absolutely. And that's what this is really pointing to and saying, Unless you draw that line, there's a lot of... It's an arbitrary line.

SPEAKER_00: 33:27

It's like a border of a country. Right, right,

SPEAKER_02: 33:28

exactly. It's an arbitrary line. Based on certain traits, and yes, there's been a lot of work put into it, but you're right. At the end of the day, it's arbitrary. But for the... Our purpose is here in the application that we're looking at to say to a parent, you don't get any help with these routine behavior problems, at least from a reimbursement perspective, until... there's a problem. So we're not going to help you avoid the problem. We have to wait till there is a problem, and then we'll help you. And what we're saying with this idea, what our What the field is looking at prospectively with this idea of, say, ABA in primary care or in pediatrics, for example, is let's preempt. Let's get ahead of it.

SPEAKER_00: 34:12

Which is interesting because I recently got two emails from my medical insurance, have you scheduled your annual exam? And then I had. I had already done it, so I didn't respond, and then I got another one. Have you scheduled your annual exam? The whole premise there being that the annual exam is actually preventative and will save the insurance company money if we can catch things ahead of time. So the same. Same premise here. It's kind of like the annual exam. Can we get out in front of these things? Can we diagnose them before it's stage five, when it's stage one, or something like that? Or something very like, can we get out in front and prevent these things?

SPEAKER_02: 34:45

And that's the idea. And then not to mention that based on some of the stigmas that exist in accessing, say, traditional talk therapy or psychoanalytic-based therapy, the idea that you're admitting there's a problem, that's even a whole different area for people. That's a whole different premise for people. So getting ahead would be one piece, and there's not a lot of help being offered there, at least not currently. And then we can also look at different estimates that are out there in terms of undiagnosed conditions, right? So we're looking at estimates from the U.S. Department of Health and Human Services. They're saying that it's about 20% of kiddos who I think it's ages seven and nine or so, or maybe seven and 13, that are living with at least one diagnosable mental health condition that hasn't been identified. Interesting. So we're trying to get ahead of even that particular piece. Right. So let's let's avoid the diagnosable condition, knowing that these are routine, common, everyday parenting challenges. Right. A two year old is going to tantrum depending on your goodness of fit as a parent, your level of education. Right. And then some level of treatment, if things are going awry, so you're going to your pediatrician and saying, hey, I'm really having trouble with my two-year-old, my three-year-old. They cry for a long time. They seem to be moving okay along the developmental milestones. Everything's fine. They come back six months later, I'm really having trouble with... And it keeps going on and on and on. Again, we can really get ahead of these things knowing that a good percentage of parents... are going to be having these difficulties. And because something hasn't been diagnosed as a problem, as a condition, then there's no help being offered there. So we can really do a lot of work in preventing issues, not just addressing the rehabilitative side, which is where ABA lives, by and large, right now.

SPEAKER_00: 36:51

Yeah, I was watching a show last week that was on doctors, and there were some doctors on the show, and they were talking about how the medical model currently hasn't really been based too much around the preventative side. It's the after the fact. It's once you have the symptoms, how do we deal with these symptoms? Maybe prescribe whatever needs to be prescribed to deal with the systems. But this doctor was actually saying she's really starting to focus a little more on the preventative side of things. But she was saying in medical school, some doctors don't even get anything on the preventative side. And that's that, you know, goes across all the different domains and even down trickles down to us with the behavioral side of things and how that's never really been a focus or that historically hasn't been too much of a focus. Um, and obviously insurance companies with the same way. Um, although I will say, um, my girlfriend's insurance company also actually offers free gym memberships on the preventative side. If you work out daily, then maybe you'll be healthier and cost less on the, on the backend. So it seems like there is a slight shift, uh, and aware, at least an awareness of the importance of preventative medical, various different eating healthy, working out, stuff like that. And insurances are starting to fund that now because they do see it as an investment as this behavioral pediatrics could certainly be an investment and save families and insurance companies a lot on the long run.

SPEAKER_02: 38:14

So until then, it... We stand to face a lot of obstacles with actually deploying this type of service to consumers, knowing that it wouldn't be covered under your general well-child visits, at least not currently. But I like what you're thinking about.

SPEAKER_00: 38:31

It's kind of like, let's say 20% of people end up getting type 2 diabetes or something like that. If we can give 100% of our people$80 a month gym memberships or whatever... that's still probably going to be far cheaper than the 20% that get the diabetes and need lifelong care in hospitals and things like that.

SPEAKER_02: 38:53

So you remind me that, at least in the literature thus far, Four different dimensions or foci have emerged from this discussion of bringing ABA into different aspects of primary care as well as integrating it into different aspects of medical treatment. So we've talked about routine behavior problems. Sure. Another area would be what's looked at as behavior problems with significant differences Medical dimensions, meaning so like encapresis, we deal with kiddos that get backed up or that don't have good motility, good digestive motility, meaning they don't move their bowels every day, and that can cause... a tremendous amount of trouble, and that is largely a behavioral issue that differentiates into a medical condition. I know you and I have had some clients in common. I make the kind of poor and sort of crass joke, all you have to do is talk to anybody who's had surgery who needed painkillers after that surgery, and you don't move your bowels for two, three days. The notion of doing so is... Yes. Yes. Yes.

SPEAKER_00: 40:26

In a different, he was in the parent group a few weeks prior, I go over some slides that talk about some common comorbidities of individuals with autism. And, you know, seizures and epilepsy is one of them. Another one is GI issues. And it talked about how up to 80% of individuals, I think it's up to 85% of individuals with ASD have GI issues. And then the parent group, the following week, he came back and he said, hey, I want to reflect back on that. Is it because they have autism that they have GI issues, or is it because a lot of them eat very limited repertoires of food? And you eat very limited repertoires of food, not enough fiber, you're going to get backed up. So it kind of goes into the behavioral side of things, as you're just talking about. A lot of these behavioral things, you could take autism out of it. It's the food issue leading to the medical problem. So this dad also kind of brought up, foreshadowed early in our career at this company, those two issues. We're going to see if

SPEAKER_02: 41:22

we Yes. Absolutely. also going to affect your ability to digest. So you put all those things together and I think you're really driving the point home here as to how we might be able to differentiate some of these things. Now looking at somebody that's undiagnosed, to use that term loosely, but is suffering some sort of encapresis. Another dimension would be medical problems with significant behavioral dimensions. So if you've been Diagnosed with late-onset diabetes, for example. You can go to a dietician or a nutritionist, and they'll tell you what to eat, but actually preparing those things and getting them in your mouth is all behavior. Making them a new routine. Back to your example about getting a discount on your insurance for a gym membership. Actually getting to the gym. largely behavioral. Absolutely. Something I certainly struggle with. Same here. And then... So that was, I mentioned the routine behavior problems, behavior problems with significant medical dimensions, medical problems with significant behavioral dimensions. And then there's one more area, which is, I wanted to touch on this just because we've been able to explore it a tiny bit already. And this would be compliance or noncompliance with medical regimens. So one thing that we've come across that I think we've talked about anecdotally here on the podcast is a lot of the clients that we have who also take medication and some of the complications that that can bring about. So one way that we've explored Our re-specialization at the medical table is with our psychiatric partners. We happen to be very fortunate and have psychiatric partnership that works a few floors above us. So we have patients in common or clients in common, if you will. And we've come across some very interesting circumstances over the years with regard to parent concerns on side effects or parent errors in administering the medication or misunderstanding, which really easily brings us into this idea of health education and behavioral prescriptions. So you've got a medical prescription in these cases, right? These kids are taking medication, something like Risperdal or Abilify is sort of a common medication that our clients might take. And they have a prescription, meaning they have dosing instructions, but how they actually carry that out There's a lot of margin for error there. The idea that sometimes parents don't like side effects so they stop the medication this day or they forget, those are all behavioral dimensions that we could help with with regard to adhering to now that medical regimen.

SPEAKER_00: 44:31

Yeah, just until that medicine gets inside and swallowed in your digestive system, it's all behavior.

UNKNOWN: 44:37

Yeah.

SPEAKER_00: 44:37

That medicine's not going to work if you're not following the behavioral things around the medicine, typically the prescription on the outside. But unless that's followed, the medicine's not going to be effective. So one thing that

SPEAKER_02: 44:47

we've discovered, and this is not knocking anybody at all, but in those interactions, again, just I'm thinking about myself as a patient. My dog go to my doctor, hey, we're going to put you on this medication. They're talking, la, la, la, la, la, la, la, la. They give me this big... packet of documents that explains all sorts of information that I never read and then I end up taking this medication and maybe I have side effects maybe I don't but all of the information that I needed was either told to me or is in that health education packet that I'm not bothering to look at because I can receive that packet but actually reading it and understanding it is a behavioral dimension. So that's where we come in, whether it's with routine behavior problems or adherence to medical regiments or the other prospective foci that I mentioned. And we're sort of nearing the end of our time here, so I want to make sure we have some time to discuss this. The idea that we're going to start with health education. And a lot of that means we have to educate ourselves, right? Our constant expertise right now is in the application of certain behavioral procedures. By and large, pretty specific to autistic individuals with regard to treatment. So we have to shift gears, like we mentioned earlier, in terms of our mindset, because we're no longer addressing a set of diagnostic traits. We're really boiling this down to human behavior, which is super cool, right? So now, just to use the example that we're working on currently, well, I mean, so I'll talk about the routine behavior problems, and then we'll talk about the adherence to medical regimens. You know, any pediatrician will tell you, or most pediatricians, at least the ones I've talked to will say, between the ages of two and five, anger outbursts, let's call them tantrums, are something that we hear a lot about. If you go into the literature and you ask any parent of a two to five year old, they're probably gonna talk to you about tantrums and how they happen. So this is now something routine that somebody in that circumstance going to their pediatrician with concerns might feel a little bit isolated. So this health education is necessary to tell them, hey, look, this is what the literature says. You're not alone. In fact, such and such percentage of parents are dealing with your particular issue. This is not abnormal. Again, this is under... We're very used to working with the tail on the left end of the normal distribution. We're talking about folks statistically here right under that big dome. So the first part is in them helping them understand the prevalence, the comorbidities that might come, the different physiological parameters. That means that we have to understand those things medically as well, right? Not part of our content expertise currently. And then from that... what is now called behavioral prescriptive treatment. Sure. Now, how is that different from our behavior intervention plans or behavior support plans? Still working on that answer. It's all semantics, probably. Well, very, very similar. I think that where there is one very important difference, and this now going back to the developmental trajectories, is that now we're not looking at addressing a specific behavior problem solely like a lot of our intervention plans very very targeted and focused very good thing but we're also looking at a ton of other collateral pieces so if you're looking if you're talking about a child who is having trouble with wetting themselves okay well you can put them on a timer you can make sure they're getting access to the bathroom you can buy special devices to detect wetness so that it gives them an alarm or something vibrates on their wrist and they can get themselves to the restroom. But at the end of the day, you still have to strengthen those pelvic floor muscles. So you have to exercise those. And we wouldn't necessarily think about that in a behavior intervention or support plan. So I think that a prescriptive treatment is now, or behavioral prescriptive treatment is now looking at every part of the developmental framework and trying to say, what behaviors can you engage in? Not just in response to the actual behavior, but throughout your day. How are you bolstering your physical development or otherwise to be able to then address, in this case, the wedding accidents or the aneurysis, right? So I think that's where The prescriptive treatment gets a little bit different. It's going to really motivate us, hopefully, as a field, as a set of very dedicated professionals, to expand our knowledge, to develop professionally. And then, really interestingly for me, is to open up our understanding of human development in general, which I think is going to spill over inevitably into... our current treatment of, say, for autistic individuals. Hopefully, that makes a lot of our more traditional or antiquated procedural faults go by the wayside.

SPEAKER_00: 49:47

Yeah, yeah, no, that's super exciting. Have you actually written any behavioral prescriptions for any of your clients yet?

SPEAKER_02: 49:56

We've played with a few drafts. Everybody that has been introduced to this topic has given it a shot. And we've sort of worked at allowing everybody their own liberty and freedom to format however they want. So yeah, we've been able to do some of these things. And some of this a little bit specific to, which is a good segue, into the adherence to the medical regiments and looking at the medication use. So looking at the health education, being able to repeat the mechanisms of action for those medications, which has already been given to the patient by the psychiatrist, but now we get to reiterate and talk about it a little bit more, with really, really specific regard to identifying the possible side effects and the desired effects of the medication because all of those should have consequences. So if your child is hyperkinetic, hyperactive, moving around all the time, prone to elopement, to use that very common ABA term, so you're suddenly not taking them out into the community for walks, all of a sudden they get a medication and that tendency to run off goes away, we should be ready to support the family and say, hey, let's change our programming. Let's get out to the community. Sure. That's a desired effect. They're not acting in a hyperactive manner. Let's give them new access, not just sort of rest on our laurels. We're happy this kid's not running away anymore. Well, they're not running away. That means let's give them access to a lot more interaction, a lot more open spaces. Where else can we take them? Just like on the other end. So your child's not going to be on a medication. We're looking at the possible side effects. which are increased appetite, and you tend to keep a lot of snacks at your home. We have to prepare for that environmentally. You're going to feel a lot better about your child munching on a whole bunch of celery sticks or apple slices than you are about them finishing the bag of chips. But what you give them access to, again, how you can actually control or influence those parameters, it's very accessible. We just need to be able to talk about it more. So we have done a couple... drafts with regard to some of those medications, and then some behaviors like sibling rivalry. Ways to now not just address the child who's doing the hitting, but ways to also address the other child, which from a behavioral or an observational standpoint, a social learning standpoint, that child who's hitting can also learn from. So again, that's where the prescriptive treatment or the behavioral prescription, I think, tends to be a little bit more open-ended, maybe on what we call antecedent-based strategies, and hopefully gets a little bit more creative on that end so that you're not just looking for the undesired behavior and targeting that. You're doing that as well as working on a whole bunch of other collateral possibilities

SPEAKER_00: 53:01

throughout. Gotcha. Yeah, that makes a lot of sense. I think you're making the environment ready for the medication, which is really exciting, right? I'm sure a lot of the medical studies are done with a high degree of internal validity, as they have to be, as was the initial ABA research done in a lab, as it has to be. You have to eliminate the confounds. But the problem is most of these people aren't taking this medication in the lab. Most of the ABA, while initially it was very lab-like, we're trying to make it more external validity and make it have more external validity, make it be more generalizable. Like we say, take it from the lab to the living room. And we're trying to make the environment ready for the ABA. And that's kind of what you're talking about with the medication is how do we make the environment ready for the medication because it's only going to be minimally effective if the environment's not ready. Sure, they can take the medication, but if there's these side effects that they're not... They might be aware of... It's one thing to go to your pharmacist and they're like, okay, do you understand this and that, and that's going to be the side effect? Yeah, whatever. All you're thinking about is the medication and the fact that, yeah, maybe I have... I'm constipated, as you talked about, or whatever it is. And yeah, I don't care about any of the other side effects because right now all I'm focused on is I've got to relieve this constipation, but... if a side effect is depression or something like that, sure, the constipation gets alleviated, but now I have a whole nother side effect that was mentioned to me. Sure. It was on that paperwork that you mentioned, but I wasn't worried about that because I was only focused on this one, uh, one effect that I really needed to be dealt with right now. So it's kind of like, you know, football, it's football season right now. And, um, there's a lot of side effects with playing football, right? Concussions, you could tear your ACL. There's a lot of things that could happen. And it's one thing, you know, when you're starting, they're like, Hey, you could tear your ACL or you could have these things. But making sure the environment's ready if they do happen is going to help you get back on the football field faster and increase your your likelihood to follow through with that and same thing with the medications if we can make the environment ready then the medications will actually be a lot more effective as well

SPEAKER_02: 55:03

that that's the exact idea dan it's uh a lot of times i think we're we're very linear and the way we apply whether it's aba or even medication use um You know, if you're having digestive issues, you take the medication to address the symptom. But the idea that you might completely restructure your diet or start eating certain foods that will alleviate that, that's also going to be important. And I think this is where this notion of ABA and more preventative applications and this idea of behavioral pediatrics as routine behavior problems comes. you know, really hits home or really drives that point home. But then even in the adherence to medical regimens, the notion that you're already getting treatment for something, let's make sure that this is going to work optimally. This is going to give you the best outcome possible. And a lot of these things are behaviorally mitigated, as you were pointing out. Sure.

SPEAKER_00: 55:56

I mean, if you're going to make one huge change in the environment, if the rest of the environment isn't ready to maintain the That's not going to be that effective. We can do as much like we found, and a lot of ABA companies still do, go in and just do a whole bunch of direct services with no parent training. It might make a little bit of effect, but unless you're helping out the other variables in the environment, as soon as you leave... It's going to minimize the effects. So same thing with the medication. We're making a huge change in the environment. We're adding a medication, which is going to obviously affect the neurotransmitters and this individual's behavior. But we have to look at the environment around it to make sure that that's ready for this huge change.

SPEAKER_02: 56:33

But it's really going to change the face of sort of our aesthetic, right? Absolutely. I think the NBA, in its current criticism, has received a lot of criticism. heat because a lot of the general public is thinking about it that it looks a certain way. We can't get away from our discrete trial training idea. You know, people, that's the way they see it. Compliance oriented. Compliance oriented. And we're not saying that there's no place for that, but the way you're describing this new application, it's much more open-ended, much more wide open, really forcing us as professionals to develop a new toolkit, right? To really restructure our tools so we can keep the same tool belt, you're just going to have some different things in there. You're going to have to go back to the shed and come out with some different things. We really have to expand, not just the way we've, our application, but create some new tools. Really, I like the idea of bringing ABA into the mainstream, right? This is everyday technology. commonplace things that can help anybody with anything at any time if you just put it into play.

SPEAKER_00: 57:39

Sure. Yeah. If you can build a single-family home, you can probably build a townhouse. You can probably build a condo. Exactly. You can probably build a business, an industry. There's a lot of things that you can use the tools for. Why would you just do one thing?

SPEAKER_02: 57:51

Well, and again, taking this back to the beginning, that's really the main point here is that we've been overly specialized thus far, at least from a medical treatment perspective. and been, you know, limited, designated only to that F84.0, as you put it. But as we're seeing throughout our discussion here, there's a much, much wider array of applications that ABA could be very, very helpful within. So we've unpacked a lot, Dan. I don't know if you've got any closing comments for us.

SPEAKER_00: 58:24

No, just really grateful for that we were able to have the 2022 that we had, barring motorcycle accidents and COVID and stuff like that. We're really looking at 2023, hopefully getting every other week podcasts out there. If not more, having a lot of guests on. Hopefully, if you listen to these podcasts and you resonate, you really like what we talk about, we'd love to have you on. If you really disagree with what we talk about, we'd love to have you on. 2023, keeping out on AB on tap. Really, really looking forward to big things on the horizon.

SPEAKER_02: 58:56

Yeah, our social media has been pretty active. Thanks to you, Dan. We're getting more people giving commentary and giving us crew critique as well as support and I agree with you. We really look forward to 2023 being much more of an open forum. We love talking at you, but we want to hear more from people out there. We're going to bring on more guests. Yeah, just really prepare to make this a much more open forum to be able to handle some of those criticisms of ABA as well as talk about prospects and things that are going to advance the field. So we will be kicking off our fourth season sometime in January. We'll see. As Dan said, we're going to try to increase the flow and the frequency of these episodes, but we'll be kicking off the fourth season with our 25th episode. So sit back, relax, and always analyze responsibly. Happy holidays. Happy holidays. Cheers.

SPEAKER_01: 59:47

ABA on tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.