You are an infant mental health specialist working with 2 1/2 year old Sammy and his family.  His parents are worried about Sammy’s limited language and his tantrums, which are frequent and seem easily provoked.  You have observed how discouraged his parents have become at his seeming disinterest in playing with them.  Sammy prefers solitary, repetitive play to cuddling or a story with his mom or chase games with his dad.  He loves to build with Legos, but becomes upset when the pieces do not fit together, and it is hard for anyone to figure out how to help him build before he has a meltdown.  You are wondering how to support Sammy’s relationship with his parents when they are struggling to maintain engagement.  Your IMH strategies to support development and relationship do not meet all of Sammy’s needs.  You and Sammy’s parents suspect autism and have decided together to look into possible services.

With current autism prevalence rates recently cited as 1 in 42 for boys and 1 in 189 for girls (Centers for Disease Control and Prevention), infant/toddler-family practitioners in any setting – either a home visiting program or center-based early care and education, will find very young children that may need to be assessed or already have a diagnosis of autism.  What we do not always know is how to support families in navigating the system for referral, assessment and treatment when autism spectrum disorder (ASD) is a question.

The Michigan Autism Spectrum Disorders State Plan was developed in 2012 to build the state infrastructure for comprehensive, lifespan supports to individuals with ASD and their families through access to information and resources, coordination of services, and implementation of evidence based practices.  Current practices in screening, referral, evaluation, intervention, insurance coverage, service coordination and training for parents and professionals across systems were identified in this plan, as well as recommendations to address gaps.

As a result, families and providers can find resource information and professionals able to assist them every step of the way, including autism navigation for families online and over the phone through the Autism Alliance of Michigan (contact: navigator@aaoim.org or 1-877-469-2266)  However, we are all learning about this new system and how to minimize confusion for families.

Screening & Referral

Sammy’s parents are anxious, but relieved when their IMH specialist suggests that they screen Sammy for ASD.  It has been an unspoken worry they have carried. Together, they use the M-CHAT ASD screener, which is the first step required in determining eligibility. They had previously declined this screening at his last well-child check-up and at his child care center, and they never enrolled in Early On.  Sammy’s scores confirm their concerns.  Since the family has Medicaid, the IMH worker knows that will make it possible for Sammy to go through the diagnostic evaluation process to determine covered ASD services and/or Applied Behavior Analysis (ABA) eligibility through their local CMH.

Many young children do not have Medicaid, but in 2012 and 2013, Michigan passed legislation aimed at increasing access to early evaluation and treatment services for children with ASD. Now all commercial insurance plans regulated by the state of Michigan must provide coverage of ASD diagnostic evaluations and treatment services related to ASD.

Comprehensive Diagnostic Evaluation

This is a neurodevelopmental review of cognitive, behavioral, emotional, adaptive and social functioning using valid evaluation tools performed by qualified licensed practitioners experienced in diagnosing ASD.  Providers that administer diagnostic evaluations for ASD typically include pediatricians, psychiatrists, and psychologists. The number of qualified licensed professionals who are trained to diagnose is expanding.  For current information of these provider resources in any geographic area please contact your insurance provider or local CMH.

Behavioral Health Treatment Services (BHT)

Effective January 1, 2016, Michigan Medicaid provides coverage of Behavioral Health Treatment (BHT) services, including Applied Behavior Analysis (ABA), for children under 21 years of age with ASD. ABA is currently the only treatment modality covered under BHT. Behavioral assessments supervised by behavior analysts will fine-tune the types of service interventions needed and intensity recommended.  Behavioral intervention services include, but are not limited to, the following evidence-based interventions:

• Peer-mediated social skills training • Functional based interventions
• Antecedent based intervention • Pivotal response training • Reinforcement systems
• Self-management • Social narratives • Video modeling • Parent training
• Prompting • Chaining

Board Certified Behavior Analysts (BCBA’s) supervise the development of the ABA treatment plan carried out by Behavioral Technicians (BT’s).  Additionally, each CMH has an Autism Supports Coordinator to assist them in gaining ready access to information and resources and to locate the services to address unmet needs.  A young child may also need speech/language, occupational or other therapies, and the supports coordinator can assist the family and the child’s team to make decisions about where to find these services.  In some CMH systems, a child’s IMH specialist may also serve as their supports coordinator.

Sammy was determined eligible for ABA services and a plan for 15 hours per week was decided upon with his family to allow time for additionally needed speech/language therapy and the continuation of IMH services to support their stressed relationships.

Resources

This is an evolving service delivery system.  There will likely be changes as implementation takes shape in various communities and CMHP’s learn how to best accommodate needs of individual children and families.  MDHHS provides updated & detailed information here:  www.michigan.gov/autism.

For further information: 

For additional assistance, please contact a staff member from the MDHHS Behavioral Health and Developmental Disabilities Administration:

Brie Elsasser
Autism Behavioral and Transition Specialist
Email: ElsasserB@michigan.gov
Phone: (517) 373-7289

Linda Fletcher
Autism Medical Specialist
ASD/DD HRSA Grant Project Coordinator
Email: FletcherL@michigan.gov
Phone: (517) 373-9018

Morgan VanDenBerg
Autism Behavioral and Early Childhood Specialist
E-mail: VanDenBergM@michigan.gov
Phone: (517) 373-1813

Citations

Autism Coverage Reimbursement Act. MCL §550.1835 – 1837. 2012.
http://www.legislature.mi.gov/documents/2011-2012/publicact/pdf/2012-PA-0101.pdf (accessed 9/19/14).

O.I. Lovaas. Teaching Individuals with Developmental Delays: Basic Intervention Techniques (Austin, TX: PRO-ED Inc., 2003).

The National Standards Project (NSP) is a program that compiles and reviews the research on evidence-based behavioral and educational treatments for individuals (below 22 years of age) with ASD. The NSP was developed by the National Autism Center in conjunction with national experts, and is used by some insurers to guide coverage policies. NSP is also used by some parents, educators, and providers to develop informed treatment decisions.