AUTISM INTERVENTION PROGRAM GUIDELINE REVISION
Effective as of January 1, 2007
On January 18, 2007, the Ministry of Children and Youth Services announced a plan to make intensive behavioural intervention (IBI) services immediately available to 225 more children currently on Autism Intervention Program waitlists.
For families selecting service delivery through the Direct Funding Option, the Autism Intervention Program Guidelines (August 2006) are being amended to expedite approval of private providers.
The current guidelines require approval of a private provider on a case-by-case basis. Effective January 1, 2007, the regional autism service provider may pre-approve existing and new private funding arrangements where the private provider:
Date of Revision: February 12, 2007
Ministry of Children and Youth Services
Revised August, 2006
1.1 Purpose of the Guidelines
1.2 Program Goal and Objectives
1.3 Program Components
2.1 Referral to Program
2.2 Eligibility Determination
3.1 Wait List Management
4.2 Individual Program Plans
4.3 IBI Services
5.1 Transition Planning
5.2 Transition Supports
5.3 Sharing Information
6.1 Receiving IBI Services From Regional Programs
6.2 Funding for Families to Purchase Services Privately
6.3 Families Who Move While in Receipt of IBI
6.4.1 Core Clinical Staff
6.4.2 Other Staff
6.5 Training/Education in Broader Service Delivery System
These revised program guidelines govern the delivery of intensive behavioural intervention and associated services to children with autism by the nine Regional Program Providers delivering the Autism Intervention Program.
The goal of the program is to provide high quality, evidence-based intensive behavioural intervention (IBI) and associated services, such as Child and Family Supports and Transition Services, that are coordinated with other services that children and youth with autism and their families are receiving.
The objectives for the child with autism are to:
The objectives for the program are to:
Regional Programs are expected to integrate with and build on the success of other services and supports available to children and their families locally and regionally. They will link and coordinate with other programs and services such as:
Policies and procedures developed for the program will be consistent with local systems of services under Making Services Work for People, Healthy Babies Healthy Children, and Preschool Speech and Language programs. Regional Programs are expected to provide services in French in designated areas of the province, as described in the French Language Services Act.
The Autism Intervention Program will operate within the geographic boundaries of the nine regional offices of the Ministry of Children and Youth Services and may provide, as appropriate for the child and family, the following:
The flow of service components is illustrated by the decision tree below:
Through Making Services Work for People, Healthy Babies Healthy Children, Ontario Early Years Centres or Preschool Speech and Language programs, most communities have identified point(s) of access for services. The Autism Intervention Program should use these points of access for intake, whenever appropriate and possible. Depending on the local service system, the program may develop a suitable alternate intake process.
Criteria for Referral
Referrals will be accepted for children who meet all of the following eligibility criteria:
In addition, signed parental consent for the Regional Program to access and/or release any assessment results and reports is required.
Referral or application to the program does not constitute a commitment for intensive behavioural intervention. Before a child begins receiving IBI services, the Regional Program must conduct an eligibility assessment. This assessment should not unnecessarily duplicate other assessments. If the assessment results suggest the child has a different or very mild form of developmental disorder, or that a different approach to intervention would better meet the needs of the child and family, appropriate referrals will be made.
Autism can be viewed as a continuum or spectrum, known as autism spectrum disorder. The disorders on the spectrum vary in severity, but have certain common core symptoms.
This initiative is intended to provide services, including intensive behavioural intervention, for children with autistic disorder or a disorder considered to be towards the more severe end of the spectrum (see Figure 2).
Figure 2: Severity of Autism Spectrum Disorder
Clinical staff will review assessment information provided through the referral process to determine eligibility for IBI. When the Regional Program accepts a new referral to the program, it should identify if there are existing recent assessments for the child, whether appropriate assessment tools have been used, and if these have been completed by qualified health professionals. The assessment to determine eligibility to receive IBI will occur within four to six weeks after a referral has been received.
If additional information is required, Clinical Directors or Supervising Psychologists of Regional Programs will use the same specific core tools. The Regional Program's eligibility determination assessments will not duplicate other assessments. Clinical Directors, as a group, may determine additional, relevant and appropriate tools to be used provincially. It is important to note that not all children will meet the eligibility criteria. Families of children who do not meet the eligibility criteria will be informed and referred to other appropriate services.
All families of children who meet the eligibility assessment for the program will be offered support services while waiting for intensive behavioural intervention to start. Families will be offered training specifically to help ready their child for IBI, to promote skill development and foster integration into small groups. Building on the best practices that already exist across the province, these services promote positive outcomes and may include the following:
Every effort will be made to effectively manage and minimize waiting lists. A consistent wait list management strategy based on date of referral and geography will be used.
The assessment to determine eligibility to receive IBI services will be conducted within four to six weeks after the referral is received. Families, whose children are found to be ineligible, are to be provided with information about other services available in the community.
Each Regional Program must provide Wait List Coordination through a designated position or assignment of the function to other staff. Wait List Coordination is to:
The wait list for service (after eligibility for the program has been determined) is to be chronological with the date of initial referral to the program used as the reference date. Date of initial referral is defined as the point of contact at which the provider begins to collect information about the child. Geography is a factor to be used to recognize the service communities within a region.
The Ministry of Children and Youth Services contracts with service providers (Regional Programs) in the nine regions of the province to provide intensive behavioural intervention.
Before a child starts receiving IBI services, the Regional Program must conduct a full assessment to determine eligibility and, where there is eligibility, intensity, setting and duration.
Diagnostic and assessment information provided in the referral process will be used to determine eligibility, intensity, setting and duration for intensive behavioural intervention. If the information is not adequate or available, additional assessments may be required or administered. Regional Program assessments for intensive behavioural intervention include the following components:
Periodically, Regional Programs, in consultation with the Ministry of Children and Youth Services, may revise the standardized assessments used based on experience and best practices. All Regional Programs must use certain tools (e.g., Diagnostic and Statistical Manual - IV criteria, Childhood Autism Rating Scale (CARS) and Vineland Adaptive Behaviour Scale) to reduce clinical variation, to allow for continuous quality assurance monitoring and to form the basis for outcome evaluation of the overall program. These are also used to demonstrate and measure progress in children.
Prior to initiation of service, the Regional Program will conduct an assessment of family resources, strengths and needs. This may include measures of stress and family functioning.Responsibility for Assessment
It is the responsibility of the Regional Program to determine eligibility, intensity and setting of a child’s intensive behavioural intervention. This applies to both children whose families choose the direct funding option and private service delivery, or regional program service delivery. Once eligibility has been determined and the service delivery option selected:
If the Regional Program determines that a child is ineligible for intensive behavioural intervention, and that a different approach to intervention would better meet the needs of the child, referrals to other community supports and/or programs will be made.Determining Service Intensity, Setting(s), and Duration
The behavioural intervention should be provided at an appropriate level of intensity in appropriate setting(s) for an appropriate period of time, depending on the child, family and community. Clinical determinations of service intensity, settings and duration are designed to facilitate the child’s goal attainment. There is no clear-cut research-based decision-making process for determining optimal intensity, setting(s), or duration of intervention. These are essentially clinical decisions, which should be based on a number of factors described below.
The recommended service intensity, duration and setting will be included in the child’s Individual Program Plan. At regular intervals (minimally, every six months), the clinical team and the family will review the plan and, if indicated, adjust service intensity and setting(s) to meet the child’s changing needs.Intensity
“Intensity” is more than simply the number of hours a child spends in intervention. More importantly, it depends on the quality of intervention provided during those hours. Children may be eligible to receive a number of hours, to a maximum of 40 hours per week, of intensive behavioural intervention. While it is expected that the number of hours will generally fall within the 20 to 40 hours per week range, the exact number of hours is determined by means of a clinical assessment and based on the individual goals for each child. With approval by the Clinical Director/Supervising Psychologist, services delivered by other professionals or qualified paraprofessionals trained in IBI/ABA may be included in the total number of service hours if the service supports achievement of the child's clinically determined goals.
Hours will be provided within available resources of the Regional Program. Service hours lost as a result of unavailability of staff or child cannot be “banked” and made up at a later time. Every effort will be made to minimize service hours that are lost as a result of unavailability of staff.
In determining the intensity of each child’s program, the Clinical Director or Supervising Psychologist should consider:
Effective early intensive behavioural intervention programs can be delivered in a variety of settings, including:
Regional Programs are expected to use a variety of settings based on clinical decisions, made in consultation with parents, to meet the child’s needs. The Clinical Director or Supervising Psychologist will determine if the home is an appropriate setting for service. If the home setting is selected, a parent or other responsible adult must be in the home during intensive behavioural intervention sessions.
In determining the setting(s) of each child’s program, the Clinical Director or Supervising Psychologist should consider, in consultation with the child's parent(s) and appropriate staff:
A child's service needs will change over time. The Clinical Director/Supervising Psychologist will review the child’s progress at regular intervals, using information from service providers and the parents, and will modify the child’s Individual Program Plan accordingly. This may result in increased or decreased intensity.
As a child is identified as approaching transition from the program to school or other community settings, various additional assessments may be undertaken. A discharge assessment is required.
Regional Programs are responsible for working with families to develop an Individual Program Plan for every child who is eligible to receive IBI and will receive service through its program. The regional program will also review and approve Individual Program Plans developed by private providers for children receiving IBI through the direct funding option.
The Individual Program Plan will describe the targeted goals for the services the child receives, guide his/her program and link the child and family to the range of appropriate community services. Regional Program staff will review the child’s Individual Program Plan at regular intervals, minimally every six months, and modify or adjust it based on the child’s progress.
The type of community services that children and families need will vary. Service providers in the community, with parental consent, may be called upon to advise on and participate in elements of a child’s Individual Program Plan. Some of these may include:
Regional Programs will develop an Individual Program Plan, in concert with parents of children eligible for intensive behavioural intervention through its program. The Plan will be developed prior to or as intensive behavioural intervention services are initiated.
The Individual Program Plan:
When an Individual Program Plan includes additional services beyond those provided directly by the Regional Program, the program will assist families to apply for appropriate services through existing mechanisms in their communities. Regional Programs must make sure that all parties, including families, understand who is responsible for service coordination and direct families to ancillary support material.
For those eligible, the Regional Program and private providers offer intensive behavioural intervention which is based on the principles of Applied Behaviour Analysis (ABA), a scientific approach that describes a method to change behaviour and measure the resulting change.
The standards for intensive behavioural intervention are derived from research findings, expert opinion, and clinical practice guidelines developed in other jurisdictions.
Regional Programs are required, according to their service contracts, to provide high quality intensive behavioural intervention services.
Regional Programs and private providers shall deliver IBI services that:
Programs should deliver IBI services in a variety of settings to maximize generalization, maintenance, independence, and flexibility in children’s behaviour and skills, from the beginning of service. IBI services will teach functional, relevant skills.. Program deliverers will record children’s behavioural responses and monitor the responses. Content will be based on the most current scientific evidence available for efficiency, safety and appropriateness.
Teaching methodology will use an ethical, positive approach to any serious behaviours (e.g., self-injury, aggression), based on a comprehensive biopsychosocial assessment, including but not limited to functional analysis; in accordance with Ministry standards and other applicable ethical and professional guidelines.
Regional and private programs do not provide BEHAVIOURAL services that use unproven or experimental approaches.
Regional Programs and private providers will, when children are eligible, provide INTERVENTION services, which:
There are two components of Transition Support Services: transition planning and transition supports. Both these services are provided by the Regional Program. It is the expectation that families who choose the direct funding option will contact the regional program at least six months prior to the child’s transition to school and/or community agency if they are looking for transition support services.
Good transition planning facilitates the integration of children into new environments. Transition planning should begin early and be part of each child’s Individual Program Plan. Each child will have a transition plan that reflects individual strengths and needs. The plan should be integrated with other service providers involved with the family and existing community transition processes.
The following describes the steps Regional Programs, schools, community agencies, families and program staff should take to support smooth transitions.
Laying the Groundwork
The Regional Program should meet with community partners (e.g. child care) and school boards in its catchment area to discuss:
To help school boards plan special education services for children with autism, Regional Programs should, in accordance with appropriate freedom of information rules and confidentiality considerations, offer to provide school boards and community stakeholders with regular updated statistics on the number of children receiving services from the Regional Program including:
Most of a child’s transition planning takes place long before the child leaves the Regional Program and/or direct funding option and should include the following steps:
Transition planning will complement the entry to school planning provided through the Ministry of Education. To provide limited ongoing support to the child and family through the first year of school, the Regional Program will make transition supports available for up to twelve months following discharge from the intensive behavioural intervention program to school.
During the 12 months following discharge, transition supports provided to the child may include the following:
Families, who choose not to receive Transition Support Services immediately following their child's discharge, may become involved at a later time, within the 12-month window. For families who become involved later, services will only be available until 12 months post-discharge from intensive behavioural intervention.
Transition Support Services may be discontinued prior to 12 months, if based on consultation with the family and school, the Regional Program determines the support is not required or is no longer of benefit to the child or family.
Any exchange of information must be done in accordance with privacy legislation and appropriate regard for confidentiality. The Regional Program will work with the family, school board and community partners within the context of privacy legislation, to establish a protocol for sharing information. The protocol may include things like:
Intensive behavioural intervention services can be provided directly by the Regional Program, or purchased with funding, from private providers.
If a family chooses to receive IBI services directly from the Regional Program, the Regional Program will:
Direct Funding Option Overview
All Regional Programs must offer families the option of funding to purchase intensive behavioural intervention services privately. They will support families who choose this option and assist them in its implementation.
To receive funding, parents must provide information about the child’s diagnosis and other personal contact information, including a copy of the child’s formal assessment and diagnosis. The Regional Program determines eligibility and approves funding based on the clinically recommended level/intensity of service.
The Regional Program will provide the family with information about the funding available for private IBI services. Funding is consistent with the range of costs for Regional Program IBI services. It is based on the average salary costs of instructor-therapists and psychologists in the Regional Program. Rate calculation includes the average costs of services provided by the instructor-therapists who work directly with the child and supervision costs.
The hourly rate will be multiplied by the number of IBI hours of services approved by the Regional Program in the child’s Individual Program Plan to reach a total amount of funding. On signing an IBI Services Funding Agreement families will receive a lump-sum payment for the first quarter of service delivery.
Available funding may not cover all of the costs incurred through a private arrangement. Parents must pay any additional out of their own resources.
Funding is to be used for approved intensive behavioural intervention services only, and may not be used to pay for any other services. For example, if the child is attending a centre that provides services such as physiotherapy and music therapy in addition to IBI, this funding can only be used for his/her IBI services.
Regional Programs will provide funding for services which they determine as being adequately clinically supervised. Funding levels will be reviewed at least every six months to ensure that funding is consistent with services being provided. In addition to providing funding to families to purchase services privately, the Regional Program will also offer these families other services including: parent/family training programs and transition supports.
Transition supports for families who purchase intensive behavioural intervention services through the direct funding option will be provided by the Regional Program. It is the family’s responsibility to advise the Regional Program if they are in need of transition supports at least six months prior to the child’s entry into school and/or community agency.
Roles and Responsibilities of Regional Programs for the Direct Funding Option
If the family chooses to receive funding to purchase IBI services from a private provider, the Regional Program will:
Roles and Responsibilities of Private Providers
The selected private provider will, in accordance with the program guidelines:
When a family that is receiving IBI, moves to an Ontario community outside the boundaries served by their Regional Program, there is no guarantee that the family will continue to receive services or that a vacancy for IBI services will be available in the new home region. This applies regardless of whether service was provided through the Regional Program or a private provider.
The sending agency must:
The receiving Regional Program must make accommodations to meet the family’s needs as best it can, given current program demands, i.e. provide IBI services if available, or refer to other services/supports.
Regional Programs will require a range of staff to address all of the components of the program, including management and administration, assessment, IBI delivery, child and family support services and transition supports.
In addition, Regional Programs are required to develop short- and long-term strategies for recruiting and training the clinical staff needed to deliver high quality intensive behavioural intervention. Training Supervisor positions exist within each Regional Program.
It is expected that each Regional Program will have the following core clinical staff to deliver the intensive behavioural intervention:
A Clinical Director is responsible for overseeing, monitoring and evaluation of the intensive behavioural intervention, as well as overseeing assessments and Individual Program Plans. This will include providing training and supervision of senior therapists, interns and trainees to support the overall quality and consistency of the behavioural intervention approach. It will also involve responsibility for fulfillment of the provincial information and evaluation requirement. Regional Programs may need to employ additional clinical psychologists/psychologist associates to support the program.
Qualifications: The Clinical Director will have training and extensive clinical experience in intensive behavioural intervention for children with autism; have a doctoral degree in Psychology; and be registered or eligible for registration with the College of Psychologists of Ontario.
Senior Therapists are responsible for a set number of children and for supervising the instructor-therapists who are working with these children. Senior Therapists will also participate in intensive one-on-one and small group instruction. They will need to accept ongoing clinical supervision from the Clinical Director/Supervising Psychologist to support their intervention work. They will provide families with training related to behavioural intervention and home programming. Qualifications: Senior Therapists should have or be working towards a master’s level graduate degree in psychology or related field, and six months to a year of direct clinical experience in an intensive behavioural intervention program for children with autism. Alternative combinations of extensive clinical experience in intensive behavioural intervention with children with autism and other educational backgrounds might also be appropriate for Senior Therapists. The number of Senior Therapists necessary will vary across regions depending on the number of children to be served.
Instructor Therapists are responsible for providing intensive one-on-one and small group instruction. To support this work, these therapists will be responsible for maintaining a daily data book for each child that will help in monitoring the child’s progress. Senior Therapists supervise Instructor Therapists. Qualifications: Instructor therapists should be community college or university undergraduates in a related field. Previous experience providing intensive behavioural intervention would be of benefit. Alternative combinations of experience and educational background may also be appropriate for Instructor Therapists.
Regional Programs are expected to access existing community services to the greatest extent possible, for assessment, service coordination and administrative purposes. In addition, Regional Programs have been provided with the following:
Wait List Coordinators assist families waiting for assessment or for Intensive Behavioural Intervention services, coordinate and link families to formal and informal resources. In addition, the Wait List Coordinator delivers child and family support services. Qualifications: Wait List Coordinators should be community college or university undergraduates in a related field and have experience in delivering intensive behavioural intervention. Alternative combinations of experience and educational background may also be appropriate.
Transition Coordinators work with school boards and community agencies to set up protocols for the transition of children from the Autism Intervention Program. Coordinators will work with the child’s family and Senior Therapist, and invite schools and community agencies to help develop a transition plan, based on the skills the child will need in school and the community. Transition Coordinators provide a one-point of contact for families and school personnel to implement and coordinate a smooth transition. They provide consultation on working with children with autism to schools or community agencies, upon request. They also provide the twelve months of ongoing transition supports for children discharged from IBI and making the transition to school. Qualifications: Transition Coordinators should have a community college diploma or university undergraduate degree in a related field. Direct clinical experience in an intensive behavioural intervention program for children with autism is recommended as is in-depth knowledge and experience in community-based services and awareness of special education policies and procedures. Alternative combinations of experience and other educational backgrounds may also be appropriate.
Training Supervisors deliver therapist training. Qualifications: The key requirements for these positions include:
Regional Programs may also, where appropriate, use paraprofessionals to support program delivery. Paraprofessionals incorporate into other settings the principles and approaches proven effective in the Autism Intervention Program.
Regional Programs have the ongoing responsibility to provide staff training for Instructor and Senior Therapists according to provincially approved curriculum. Training and education of the broader service delivery system is essential to achieving the goals of this autism initiative including:
Each Regional Program must have designated Training Supervisors who meet the criteria established by the ministry for the position.
Other responsibilities of Regional Programs with respect to training include:
Through a negotiated agreement, the Regional Program will provide training to staff working with the child in these settings. Paraprofessionals may include, but are not limited to: parents, volunteers, child care workers, child and youth workers and/or educational assistants.
Families are to be provided every opportunity to be involved in program decisions that affect their children. In addition to providing informed consent at various stages of assessment, program planning, discharge and transition, families have opportunities for education and training to support their children.
The family is responsible for monitoring the quality of service delivered by private providers through the direct funding option. The family is also responsible for contacting the Regional Program at least six months prior to the child’s transition to school and community agency if they require transition support services.
Regional Programs are accountable to the families they serve for the quality of their services. They are required to develop procedures for:
In addition, Regional Programs are accountable to the Ministry of Children and Youth Services for the management of the program and service delivery, in accordance with government policies, service contract requirements and guidelines.
Ministry of Children and Youth Services
The local office of the Ministry of Children and Youth Services will negotiate a service contract that:
The regional office will monitor on a regular basis.
The Ministry of Children and Youth Services is committed to monitoring the Autism Intervention Program to determine that the program achieves its goals and objectives and makes efficient use of public resources. Systemic processes and outcome evaluation will be done periodically by the ministry and the results reported.
Revision of Program Guidelines
It is expected that, when required, the program guidelines for the Autism Intervention Program will be revised to incorporate policy clarifications and program adjustments.
1Children should be diagnosed by a physician or psychologist prior to contacting the Regional Program. The Regional Program’s assessment will determine eligibility, and should not provide an initial diagnosis. Depending on the adequacy and thoroughness of the referring diagnostician's report, it may be necessary for the Regional Program to conduct further assessment.