Quick recap: in Part I, we discussed early intervention and how it could be improved.  I think we covered some important points (the need to be clear about our targets, whether the term “ABA” is no longer helpful), but we ended with an important question: How are we going to ensure that our best and hopefully-ever-improving practices actually get implemented at the community level?  Without a good answer to this question, any improvements we make to our best practices will be rather academic.

Usually, researchers seem to encourage community adoption of best practices by trying to get more information into communities.  The standard solution we’ve been seeing is for researchers to engage professionals and parents and ensure that they are getting training in the latest methods coming out of the research literature.

Training is all very well and good, but I think we need to go farther.  I worry that people view early intervention on some kind of charity model: they might implicitly think it’s nice when individuals and families get the best version of it, but that it’s not a violation of anyone’s rights if they get a substandard approach.  In this model, people might have a right to get some kind of program, or even an obligation to enrol in one, but they don’t get a right to a good program.  Thus, because nobody’s rights are violated, there wouldn’t be any obligation for society or government to oversee early intervention practices in the community.  However, I disagree, and believe we do have an obligation to ensure program quality.

Unfortunately, it’s hard to deny that there is very little oversight of early intervention providers in most jurisdictions today.  The industry is largely privatized, and perhaps to improve cost-effectiveness, these privatized providers rely heavily on the labour of relatively unskilled interventionists.  There might be a professional, board-certified behaviour analyst in a supervisory role, but the actual interventionists are often college students or graduates fresh out of college, with little training and little knowledge about autism.

How can we change this situation?

Certainly, involving autistic people in the oversight of whatever process we adopt is crucial, as John Elder Robison argues.  But what form should our oversight process take?

This is a big question that’s a bit beyond the scope of this blog post, but let’s consider some ideas.

One very interesting jurisdiction in terms of early intervention is the Canadian province of Nova Scotia.  Nova Scotia decided not to go the privatized route and instead established a program to deliver high-quality Pivotal Response Treatment (PRT).  The program recruits and trains interventionists who deliver the program naturalistically in children’s homes, and aims to retain them over the long-term so the program won’t have to operate with a continuously changing crowd of under-trained college students.  Early interventionists in Nova Scotia have a clear program to follow, and there is a chain of accountability stretching all the way up to expert clinical psychologists.

It sounds like a wonderful model, but there is one glaring problem: chronically insufficient capacity.  The program has continuously struggled with a big waitlist, and even when people finally get in, they only have access to 15 hours of intervention each week, which is less than what’s available in many other jurisdictions.  Unfortunately, it looks like completely abandoning the privatized model – while perhaps still something to keep in mind as a long-term goal – isn’t looking like a good solution in the immediate future, because of the risk that the public program won’t get funded properly.

If we can’t de-privatize the early intervention industry, then instead we’ll have to work to improve oversight within the existing privatized framework.  What would that look like?  Well, any jurisdictions that don’t yet have a professional college of behaviour analysts could establish one, while those jurisdictions that already have one could dramatically strengthen these colleges.  Autistic people, parents, professionals, and researchers could work together with government and these professional colleges to establish clear sets of guidelines and best practices, as well as robust sets of minimum standards, in each jurisdiction.  These standards could include requirements to be met in the training of the people who deliver behaviour intervention in communities.  A robust complaint process could be set up within each college.

We can also continue to experiment with not-for-profit delivery models.  In community settings, I’ve seen that non-profit organizations are often able to preserve the private sector’s ability to leverage resources efficiently, but they do this without preserving the commercial aspects of private companies.

Furthermore, over the longer term, we could work together to advocate for the resources and funding we would need in order to move away from the existing delivery model with the ever-changing staff of under-qualified young interventionists, and instead adopt a model in which behaviour intervention can become a long-term career for those who deliver it in communities.

There are huge differences of opinion on early intervention, but if I can end on an optimistic note, I also think the different vocabularies and paradigms we employ can sometimes mask important areas of agreement.  I hope we can look past our differences and have a genuine conversation about early intervention: one which will hopefully produce a synthesis that can improve on our current practices.

 

What’s your opinion?  Comment below!  (In a manner that respects everyone, of course, please.)