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An Autism Diagnosis and ABA Therapy
Parent Resource
November 22, 2021

An Autism Diagnosis and ABA Therapy

What To Do if You’re Concerned About an Autism Diagnosis

It may be a friend, a teacher, a day-care provider, or perhaps your pediatrician who first mentioned it to you.  Maybe you’ve suspected something is”off” in your child’s development for a while.  There are lots of roads to getting your child evaluated because of concerns about a possible autism diagnosis.  Experts advise if you see symptoms of autism in your child, you should get him or her evaluated by a professional as soon as possible, if only to rule out an autism diagnosis or other developmental disorder.  However, most providers who evaluate children for autism often have extensive waitlists, sometimes even as long as six to 12 months.  Our clinical team recommends that if you are concerned that your child may have symptoms of autism, schedule an appointment with a provider (or multiple providers if there are waitlists) to get your child evaluated as soon as possible.

An autism diagnosis from a qualified medical professional is required for ABA therapy services and other therapies and resources.  Thrive Behavior Centers does not provide diagnostic services, but we are happy to help families find a provider if they suspect autism. Since we specialize in ABA therapy and early intervention for young children with autism, we know how important it is to get a timely evaluation from a qualified healthcare provider.  Finding the right person to evaluate your child can be challenging, and not all diagnostic reports are accepted by insurance plans that cover therapies like ABA for children diagnosed with autism. Call our team at 682-900-1444 or contact us for referrals to local providers who can evaluate your child.

Symptoms of Autism

Autism, or Autism Spectrum Disorder (ASD), is a broad range of symptoms that can include difficulties with communication, social interactions, and learning. In 2020, the Centers for Disease Control (CDC) determined that 1 in 54 children is diagnosed with autism in the United States.

Autism is a spectrum disorder, so the severity and types of symptoms can vary greatly depending on the child. Symptoms of autism are often most recognizable by the age of two or three years but can often be noticed even earlier. An autism diagnosis is often required for a child to get access to life-changing therapies. Not all children who are diagnosed show all the signs of autism or show them in every setting or situation. Common symptoms of autism spectrum disorder include the following:

  • Limited eye contact or avoidance of eye contact
  • Significant challenging behaviors like intense meltdowns or aggression
  • Child does not respond to his or her name
  • Self-stimulatory behaviors or repetitive movements like hand-flapping, rocking, spinning, jumping, moving fingers or objects in front of face.
  • Lack of gestures like pointing or waving
  • Unusual reactions to certain sounds, smells, tastes, textures, lights, etc.
  • Lack of play skills or not using toys as designed
    • Focusing on parts of toys (like the wheels), spinning, lining or otherwise arranging objects or toys
  • Delay or loss of verbal communication (speech & language skills)
    • Lack of babbling or imitating sounds
    • No single words by 16 months, few or no meaningful two-word phrases by age two.
    • Repeating words or phrases out of context (non-functional communication)

Research shows that early diagnosis and intervention are essential to reduce the need for support later in life. If you suspect your child has autism, you will need a professional, medical evaluation and diagnosis to get access to therapy. There is no known cure for autism, but ABA therapy is the most effective, research-based intervention for young children with autism.

Insurance and ABA Therapy

Not all insurance plans cover ABA therapy.  Coverage is mandated by Texas law, but there are loopholes.  Whether your insurance covers ABA therapy depends on your specific plan, and not the company itself.  Company A may provide great coverage for ABA therapy for some plans, but it may not cover ABA therapy at all for a similar plan at another employer.  While you’re waiting for your child’s evaluation for autism, you can call your insurance company and ask the following questions about ABA therapy coverage and your insurance plans.

You can also check out our easy-to-use Guide to ABA Therapy Insurance in Texas.  Click this link for tons of information and resources to help you navigate the complicated world of insurance coverage for ABA therapy.

An Autism Diagnosis for ABA Therapy

An autism diagnosis is required for ABA therapy to be covered by your insurance plan.  Autism Spectrum Disorder (ASD) is the only diagnosis that most insurance plans will accept when they cover ABA therapy.   All insurance plans require a medical diagnosis of autism spectrum disorder before authorizing ABA services. The medical diagnosis should also include diagnostic testing for autism and cognitive testing. Plans will require the diagnosis to be conducted by either a medical doctor (M.D.) or a Ph.D.

Professionals who can evaluate for and diagnose autism include the following (if the required testing is administered and the required information is present):

  • Developmental pediatricians
  • Neurodevelopmental pediatricians
  • Licensed psychologists
  • Psychiatrists
  • Neurologists
  • Some pediatricians (depending on the assessments used and information provided)

In the past, it has been possible for pediatricians or other medical professionals to diagnose autism based on another provider’s (usually a master’s level clinician) assessment.  However, most insurance plans now require a “comprehensive” autism diagnosis that includes the assessments and information below performed by the diagnosing provider.  Assessments performed by third-party providers with a physician later providing a letter indicating an autism diagnosis are not frequently accepted by insurance for ABA therapy. Sometimes even pediatricians are not aware of these insurance requirements.  Scroll down for more information on what information is generally required for a comprehensive autism diagnosis for ABA therapy.

Before scheduling an evaluation, you should know that not all providers offering assessments will actually be able to diagnose your child with autism. Insurance companies will NOT accept an assessment (including the ADOS) as a diagnosis for ABA therapy services from a master’s level clinician.  Insurance companies will NOT accept a diagnosis from the following practitioners:  a BCBA (Board Certified Behavior Analyst), an LPC (Licensed Professional Counselor), an LCSW (Licensed Clinical Social Worker), an OTR (Occupational Therapist Registered), an SLP (Speech-Language Pathologist), an educational diagnostician, any other “assessment specialist.” or another specialist or clinician with or without a Master’s degree.

Educational Diagnoses from a Public School

A medical autism diagnosis is different from an educational autism diagnosis. If your child has been diagnosed with autism through his or her public school district, your child has an educational diagnosis.  Your ABA therapy insurance plan will not accept an autism diagnosis from an educational diagnostician, and educational psychologist, or another employee of a public school.

Think of public education and the private medical field as two different worlds. An educational diagnosis of autism does not cross over to the world of private therapeutic treatment, since it’s based on educational need. In the same way, education professionals may take a medical diagnosis into account, but it does not guarantee special education services in public school districts.

If you have a diagnosis through your child’s school, or you suspect your child may need an evaluation, Thrive Behavior Centers has a list of referrals to qualified medical providers in the DFW metroplex who evaluate children for autism. Click here to get more information or call us at 682-900-1444.

What is Needed for a Comprehensive Medical Autism Diagnosis

Insurance plans will only cover ABA therapy if it is “medically necessary” for the child.  The first step to getting an ABA therapy evaluation for your child is to have a comprehensive autism diagnosis. The requirements for a comprehensive medical diagnosis varies by insurance plan, but generally includes the following:

  • The diagnosis must be performed by a Qualified Healthcare Provider.
  • A diagnosis of Autism Spectrum Disorder including the diagnostic code F84.0.
  • A medical and developmental history of the child.
  • A narrative summary of the child’s symptoms as they relate to the symptoms of autism in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition).
  • A severity rating based on the DSM-5 criteria in the areas of social communication and social interaction, and restricted, repetitive patterns of behavior, interests, or activities (RRPB).
  • At least one parent or clinician-rated screening tool.  Examples include the following:
    • Autism Behavior Checklist[ABC]
    • Childhood Autism Rating Scale[CARS]
    • Checklist for Autism in Toddlers [CHAT;M-CHAT]
    • Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist [CSBS-DP-IT-Checklist]
    • Autism Screening Questionnaire[ASQ]
    • Autism Quotient[AQ]oChildhood Autism Screening Test[CAST]
  • At least one standard psychiatric evaluation for autism. Examples include the following:
    • Autism Diagnostic Interview-Revised[ADI]
    • Autism Diagnostic Observation Schedule[ADOS]
    • Diagnostic Interview for Social and Communication Disorders[DISCO].
  • Identification and consideration of any co-morbid diagnoses (additional diagnoses).

We’re Here to Help

Need help finding a provider to evaluate your child for autism?  Need help navigating insurance coverage and ABA therapy?  The Thrive Behavior Centers Team is here to help.  Click here  to send us a message or call us at 682-900-1444. We believe in being a resource for our communities and helping children with autism get access to life-changing therapy.

We Help Your Child Learn How To Interact With the People Who Matter Most

We see what’s special about each of our clients and want to be a resource to help you help your child.

Each of our ABA centers has a clinical team dedicated to helping your child learn functional communication, self-care, daily living, and social skills — all while empowering you with the tools you need to support them.

We’re here to help your child find their voice and become more independent.

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