Payors and Assessments-- Is this Behavior Analytic?

The tug of war that behavior analysts and insurance companies engage in can be all-encompassing! The dichotomy of clinical effectiveness vs. necessity of standards is real enough that the Behavior Analyst Certification Board® (BACB) has an ethics code that relates to it (2014):

"2.04 d. Behavior analysts put the client's care above all others and, should the third party make requirements for services that are contraindicated by the behavior analyst's recommendations, behavior analysts are obligated to resolve such conflicts in the best interest of the client. If said conflict cannot be resolved, that behavior analyst's services to the client may be discontinued following appropriate transition."

Behavior Analyst Certification Board®

While Code 2.04 may not specifically be written for insurance companies, there are most definitely times when behavior analysts’ clinical recommendations are at odds with what the insurance company (payor) will accept. One of the biggest areas where this comes into play is with assessments. The BACB has something to say on this, too:

3.01 Behavior-Analytic Assessment

(a) Behavior analysts conduct assessments prior to making recommendations or developing behavior-change programs. The type of assessment used is determined by the client's need and consent, environmental parameters, and other contextual variables. When behavior analysts are developing a behavior-reduction program, they must first conduct a functional assessment.

(b) Behavior analysts have an obligation to collect and graphically display data, using behavior analytic conventions, in a manner that allows for decisions and recommendations for behavior-change program development.

Behavior Analyst Certification Board®

The BACB tells behavior analysts the type of assessment used is determined by the client’s (1) needs and (2) consent, (3) environmental parameters, and other (4) contextual variables.

When to Assess

According to The Council for Autism Service Providers Practice Guidelines, client's behaviors must be assessed before creating a treatment plan and periodically to guide treatment and evaluate progress (for example, on a semiannual basis). Some payors require certain assessments at regular intervals. Each learners are different and some may need assessment more often than every 6 months and some may need it less. Functional assessment of behaviors should be conducted when creating a Behavior Intervention Plan or if the learner is not making expected progress.

Types of Assessment

ABA Skill Repertoire

Designed for Behavior Analysts to identify behavioral and skill excesses and deficits that guide the creation of an appropriate and effective treatment plan. Examples include VB-MAPP, ABLLS-R, PEAK, EFL.

Adaptive Behavior

Assesses the person's independent display of skills necessary for normal daily living. Adaptive Behavior includes grooming, getting dressed, avoiding danger, eating, following school rules, managing money, chores, getting and maintaining a job, and making friends. Examples include the Vineland and the ABAS-3.

Autism Screening and Assessment

Identifies children on the autism spectrum and assesses the severity of core symptoms, deficits, and behavioral outcomes. Many of these instruments are used as outcome measures in research and clinical settings, especially clinical trials (Payakachat, 2013). This assessment is performed or supervised by a professional whose scope of practice includes diagnosing. Examples include the CARS, ADOS and ADI.

*Developmental

Measures various aspects concerning a child's physical and mental growth and development while mapping a child's performance compared with children of similar age. Examples include PEP-3, Vineland and Bailey III.

*Functional Assessment of Problem Behavior

Identifies the aspects of the environment that may contribute to the development and continued occurrence of problem behavior. That is functional assessments are designed to identify where, when, and why problem behavior occurs (CASP, 2014). Examples include the MAS, QABF and FAI.

Intellectual

Tests an individual's current intellectual functioning often measured through various reasoning tasks and assigning an intelligence quotient (IQ). The assessment is done by Psychologists. Examples include the Standford-Binet and WISC-5.

*Parental Stress

Identifies issues that may lead to problems in the child's or parent's behavior and stress. Examples include the PSI-4 and PSS.

*Social and Emotional

Detects and monitors signals that indicate whether a child may be delayed in aspects of social-emotional development, such as communication, autonomy, affect, and interaction with people. Examples include the Social Skills Checklist, SRS-2 and SSRS.

Speech and Language

Measures of a person's communication skills. The evaluation is done by a speech-language clinician. Examples include the CELF-5, TOPL and TOPS.

*Transitional and Vocational

Evaluates a person's strengths, needs, preferences, and interests as they relate to the demands of current and future living, learning, and working environments. Examples include the Brigance Transitional Skills Inventory and Career Ability Placement Survey.

*BCBAs and BCBA-Ds can usually administer these assessments with training and sometimes certification depending on the instrument.

Qualification Levels of Assessment

The Standards for Educational and Psychological Testing published by the American Educational Research Association (AERA), American Psychological Association (APA), and the National Council on Measurement in Education (NCME) maintain that individuals should use only those tests for which they have the appropriate training and expertise. Many assessment vendors require that the provider demonstrate qualifications in order to purchase assessments. For Example Pearson has 3 levels of qualifications (2021).

"Qualification Level A

There are no special qualifications to purchase these products.

Qualification Level B

  • A master's degree in psychology, education, speech language pathology, occupational therapy, social work, counseling, or in a field closely related to the intended use of the assessment, and formal training in the ethical administration, scoring, and interpretation of clinical assessments.

OR

  • Certification by or full active membership in a professional organization (such as ASHA, AOTA, AERA, ACA, AMA, CEC, AEA, AAA, EAA, NAEYC, NBCC) that requires training and experience in the relevant area of assessment.

OR

  • A degree or license to practice in the healthcare or allied healthcare field.

OR

  • Formal, supervised mental health, speech/language, occupational therapy, social work, counseling, and/or educational training specific to assessing children, or in infant and child development, and formal training in the ethical administration, scoring, and interpretation of clinical assessments.

OR

  • Work for an accredited institution

Qualification Level C

Tests with a C qualification require a high level of expertise in test interpretation, and can be purchased by individuals with:

  • A doctorate degree in psychology, education, or a closely related field with formal training in the ethical administration, scoring, and interpretation of clinical assessments related to the intended use of the assessment.

OR

  • Licensure or certification to practice in your state in a field related to the purchase.

OR

  • Certification by or full active membership in a professional organization (such as APA, NASP, NAN, INS) that requires training and experience in the relevant area of assessment.
  • Certification by or full active membership in a professional organization (such as APA, NASP, NAN, INS) that requires training and experience in the relevant area of assessment ."

The above qualification levels are taken directly from Pearson Assessments

What should I do if I don't meet the qualifications for a requested assessment?

Some of the assessments in the below list are not behavior analytic in nature and for some, behavior analysts do not have the qualifications to administer the assessment. So, what do behavior analysts do if they want to use a replacement assessment that isn’t accepted by the insurance company? This is a tricky question and not one that is easily answered. We see several options.

  • Expand your scope – Some behavior analysts may be in a position where they can seek more education on the topic. This is especially important if you see assessments that you want to use, and you feel will be beneficial to your client. Clinical Psychologists, for instance, take coursework in evaluations, assessments, and statistics.
  • Find someone with the right experience who can partner with your or supervise you – Many behavior analysts work in organizations where there are other professionals who have the necessary experience. Or you can see outside help.
  • Shape the behavior of the insurance company – Make the case for the assessments that you need to make the important clinical decisions that you need to make. The more people who do this, the more likely insurance companies will respond. It is also necessary to make sure that there is adequate research and evidence-basis for the assessments that you are suggesting.
  • You'll also want to check your state's psychology or other practice laws to be sure you're operating not just within your scope of practice, but within what is lawful for your state.

While there is no easy answer to this conundrum, it does highlight the need for behavior analysts to become more familiar with the assessment tools that exist and are evidence-based, and work together with other behavior analysts as well as professionals outside of our field to get to the best outcomes for the individuals whom we serve. 

List of Most Common Assessments Requested by Payors

(if there are any assessments that you feel are very commonly used and are missing, contact emaley@motivity.net)

ABAS-3 (Adaptive Behavior Assessment System)

Description & Use: Provides a complete assessment of adaptive skills across the life span.

Assessment Type: Adaptive Behavior

Research: “For the 11 skill areas assessed—norm-referenced scaled scores. For the 3 adaptive domains and the General Adaptive Composite (GAC)—norm-referenced standard scores, confidence intervals for standard scores, and percentile ranks. In addition, all scores can be categorized descriptively”

Qualifications: Level C: MA (psychologist, SLP, OT) A master’s degree (MA, MS, MSW CAGS) in psychology, school counseling, occupational therapy, speech-language pathology, social work, education, special education, or related field; OR BA (occupational therapist) A bachelor’s degree (BA, BS) in fields listed above AND License or certification from an agency/organization that requires training and experience in assessment

Ages: birth to 89 years

Reference & Publisher

Assessment of Basic Language and Learning Skills (Revised) ABLLS-R®

Description & Use: The ABLLS-R® is an assessment, curriculum, and skill tracking program based on the behavior analysis of Language from Skinner's book, Verbal Behavior (1957). It was designed to be used to help guide the instruction of language and critical learner skills for children with autism or other developmental disabilities. 

Skill areas: The ABLLS-R® provides a comprehensive review of 544 skills from 25 skill areas including language, social interaction, self-help, academic and motor skills that most typically developing children acquire prior to entering kindergarten. The task items within each skill area are arranged from simpler to more complex tasks. 

Ages: The ABLLS-R® is for assessing Basic Language and Learning Skills and is recommended for children of all ages, but mainly focuses on language skills developed by typical developing children ages 2-6, when children learn to speak their first language.

Assessment Type: ABA Skill Repertoire Assessments

Research:
1) Validations of the Assessment of Basic Language and Learning Skills Revised for Students with Autism Spectrum Disorder using an Expert Review Panel.

2) A Pilot Study on Patterns of Skill Development of Neurotypical Children as Measured by the ABLLS-R: Implications for Educational Programming for Children With Autism

Qualifications: None. Training is recommended.

Reference & Publisher: You can purchase and learn more at Partington Behavior Analysts website. The ABLLS-R® assessment is sold as a set (includes: 1 ABLLS-R® Guide & 1 ABLLS-R Protocol) for $64.95 or separately for $39.95 each. BAI also offers the ABLLS-R® Data and Task Organizer kit for $495. The kit does not come with the ABLLS-R® assessment but does come with 2 boxes of picture cards and directions. The picture-stimuli correlate with the ABLLS-R® assessment and can be helpful but is not required for administering the ABLLS-R® assessment.

ADOS-2 (Autism Diagnostic Observation Schedule Second Edition)

Description & Use: “Allows you to accurately assess and diagnose autism spectrum disorders across age, developmental level, and language skills"

Ages: 12 months through adulthood

Assessment Type: Autism Screening and Assessment

Qualifications: Level C: MA (psychologist, SLP, OT) A master’s degree (MA, MS, MSW, CAGS) in psychology, school counseling, occupational therapy, speech–language pathology, social work, education, special education, or related field; OR BA (occupational therapist) A bachelor’s degree (BA, BS) in fields listed above AND License or certification from an agency/organization that requires training and experience in assessment

Reference & Publisher

Assessment of Functional Living Skills (AFLS)

Description & Use: The Assessment of Functional Living Skills (AFLS) is a criterion-referenced skills assessment tool, tracking system, and curriculum guide. AFLS is used for teaching children, adolescents, and adults with developmental disabilities the essential skills they need in order to achieve the most independent outcomes.

Skill Areas: The AFLS Full Set assesses and provides curriculum guides for Basic Living Skills, Home Skills, Community Participation Skills, School Skills, Independent Living Skills and Vocational Skills.

Ages: The AFLS is a criterion-referenced assessment that is designed to be used from early elementary through adulthood.

Assessment Type: ABA Skill Repertoire Assessments

Research: Measuring Outcomes of Parents Teaching Functional Skills to Their Son With Autism Using the Assessment of Functional Living Skills the AFLS®

Qualifications: None. Training is recommended.

Reference & Publisher: You can purchase the paper copies at the Functional Living Skills Store. The AFLS is also available in a digital version.

Developmental Profile 3

Description & Use: “Allows you to quickly screen a child for developmental delays in five key areas” 

Assessment Type: Developmental

Ages: Birth to 12 years, 11 months

Research: Standardized on a nationally representative sample of 2,216 individuals

Qualifications: Level B: BA (schoolteacher) A bachelor’s degree (BA, BS) in psychology, school counseling, occupational therapy, speech–language pathology, social work, education, special education, or related field.

Reference & Publisher

Daily Living Activities-20 (DLA-20)

Description & Use: “The Daily Living Activities (DLA) Functional Assessment is a functional assessment, proven to be reliable and valid, designed to assess what daily living areas are impacted by mental illness or disability. The assessment tool quickly identifies where outcomes are needed so clinicians can address those functional deficits on individualized service plans.” 

Assessment Type: Adaptive Behavior

Ages: all ages

Research: “The DLA is a reliable and valid measure for the purposes of level of care consideration, treatment planning around outcomes, and to correlate and predict DSMIV, Axis V. Two studies with 971 consumers over repeated measures will be reviewed with the results reflecting a satisfactory treatment plan time-saver for case coordinators. The tool is published in the Research on Social Work Practice (Abstract and other reference articles are in Appendix B). Please note, however, that since 2005, the DLA has been copyrighted to protect reliability and validity, not for additional monetary remuneration beyond training fees.”

Qualifications: Level A: The consumer’s primary clinician or case manager typically has the most information about daily functioning at home or in the community and are best prepared to complete the form.

Reference & Publisher

Essentials for Living (EFL)

Description & Use: A Communication, Behavior, and Life Skills Curriculum, Assessment, and Professional Practitioner’s Handbook. EFL is designed for verbal and non-verbal children and adults with moderate-to-very severe disabilities, including autism, and limited skill repertoires. It is, “composed of functional skills and behaviors, which are essential for effective daily living and which result in an improved quality of life for children and adults” McGreevy.

Skill Areas: Essential for Living includes over three thousand skills sorted into domains on communication, language, daily living, social, functional academic, and tolerating skills, along with a domain on severe problem behavior, which encompasses the core components of autism and many other developmental disabilities.

Assessment Type: ABA Skill Repertoire Assessments

Ages: 2 through adulthood

Research: no published research as of May 2020

Qualifications: “[EFL] was written in language familiar to most professionals in the fields of special education, developmental disabilities, and rehabilitation.” Training is recommended.

Reference & Publisher: The EFL can be purchased on Patrick McGreevy's site.

Early Start Denver Model Curriculum Checklist

Description & Use: The Early Start Denver Model Curriculum Checklist for Young Children with Autism is used to comprehensively assess the skills of toddlers and preschoolers with autism spectrum disorder across multiple developmental domains and to establish individualized teaching objectives. Administered every 12 weeks, it is an essential component of the intervention program described in the authoritative manual, Early Start Denver Model for Young Children with Autism. Sold in sets of 15 ready-to-use booklets.

Assessment Type: ABA Skill Repertoire Assessments

Ages: Toddlers

Research: Early Start Denver Model for young children with autism: Promoting language, learning, and engagement.

Qualifications: Become certified in ESDM

Reference & Publisher

FAST (Functional Analysis Screening Tool)

Description & Use: “The Functional Analysis Screening Tool (FAST) is a 16‐item questionnaire about antecedent and consequent events that might be correlated with the occurrence of problem behavior. Items are organized into 4 functional categories based on contingencies that maintain problem behavior. “

Assessment Type: Functional Assessment of Problem Behavior

Ages: all ages

Research: Reliability and Validity of FAST

Qualifications: Level B

Reference & Publisher: Download FAST PDF

PDDBI (Pervasive Developmental Disorder Behavior Inventory)

Description & Use: “Assesses responsiveness to intervention in children with ASD. Unlike existing assessments for ASD, the PDDBI was developed to assess both problem behaviors as well as appropriate social, language, and learning/memory skills.”

Assessment Type: Autism Screening and Assessment

Ages: 1 year, 6 months to 18 years, 5 months

Qualifications: Level B: A degree from an accredited 4-year college or university in psychology, counseling, speech-language pathology, or a closely related field plus satisfactory completion of coursework in test interpretation, psychometrics and measurement theory, educational statistics, or a closely related area; or license or certification from an agency that requires appropriate training and experience in the ethical and competent use of psychological tests.

Research: Standardization sample consisted of 369 parents and 277 teachers of children with well-defined autism from a range of racial/ethnic backgrounds and geographic regions.

Test-retest stability for the teacher ratings ranged from .65 to .99 over an average 2-week interval. For the parent sample, test-retest stability ratings ranged from .38 to .91 over a 12-month interval.

Concurrent validity was assessed through comparison with the Childhood Autism Rating Scale, the Nisonger Child Behavior Scales, the Vineland Adaptive Behavior Scales, and the Griffiths Mental Development Scales.

Clinical validity was assessed through comparison with the ADI™-R, the ADOS™-G, and the Vineland Adaptive Behavior Scales.”

Reference & Publisher

VB-MAPP

Description & Use: The Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP) is a criterion-referenced assessment tool, curriculum guide, and skill tracking system that is designed for children with autism, and other individuals who demonstrate language delays. The VB-MAPP is based on B.F. Skinner’s (1957) analysis of verbal behavior, established developmental milestones, and research from the field of behavior analysis.

Skill Areas: The skills assessed include mand, tact, echoic, intraverbal, listener, motor imitation, independent play, social and social play, visual perceptual and matching-to-sample, linguistic structure, group and classroom skills, and early academics. 

Ages: 2-6

Assessment Type: ABA Skill Repertoire Assessments

Qualifications: Level B: A degree from an accredited 4-year college or university in psychology, counseling, speech-language pathology, or a closely related field plus satisfactory completion of coursework in test interpretation, psychometrics and measurement theory, educational statistics, or a closely related area; or license or certification from an agency that requires appropriate training and experience in the ethical and competent use of psychological tests.

Research: See a list of research related to VB-MAPP on Mark's Website

Reference & Publisher: Order the books from VBPress and digital VB-MAPP app

Vineland-3 (Vineland Adaptive Behavior Scales)

Description & Use: “Vineland Adaptive Behavior Scales Third Edition is the leading instrument for supporting the diagnosis of intellectual and developmental disabilities. Vineland-3 not only aids in diagnosis, but provides valuable information for developing educational and treatment plans” 

Ages: birth to 90+

Assessment Type: Adaptive Behavior

Qualifications: LEVEL B: Tests may be purchased by individuals with: A master's degree in psychology, education, occupational therapy, social work, or in a field closely related to the intended use of the assessment, and formal training in the ethical administration, scoring, and interpretation of clinical assessments. OR · Certification by or full active membership in a professional organization (such as ASHA, AOTA, AERA, ACA, AMA, CEC, AEA, AAA, EAA, NAEYC, NBCC that requires training and experience in the relevant area of assessment. OR · A degree or license to practice in the healthcare or allied healthcare field. OR Formal, supervised mental health, speech/language, and/or educational training specific to assessing children, or in infant and child development, and formal training in the ethical administration, scoring, and interpretation of clinical assessments.

Research: “Total sample size 6,535. Norm sample for Interview and Parent/Caregiver Forms each comprised 2,560 people. The Teacher Form sample was 1,415 students.”

Reference & Publisher: Order from Pearson

Additional References:

Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for
behavior analysts. Littleton, CO: Author.

Council of Autism Service Providers (“CASP”). Ver. 2.0 (2020). Applied Behavior Analysis
Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. https://casproviders.org/wp-content/uploads/2020/03/ABA-ASD-Practice-Guidelines.pdf

Pearson. (2021, Feb 2). Qualifications Policy. https://www.pearsonassessments.com/professional-assessments/ordering/how-to-order/qualifications/qualifications-policy.html

Texas Education Agency. (2019) Autism Evaluations. https://www.txautism.net/evaluations

Emaley McCulloch
VP of Clinical Products
at
Motivity