Acute ASD Treatment Program

Key elements

An integrated model of clinical treatment

I was responsible for developing the clinical and operational model for the Acute ASD Treatment Program: establishing treatment priorities and assessment standards, developing data collection systems; designing a staffing model with training standards, and authoring program descriptions needed by state regulators and insurers. The program relied on a Clinical Care Pathway designed to stabilize and then decrease the frequency and intensity of the target behavior(s) contributing to the need for hospitalization, and re-integrate most patients into the community within 3 weeks: intensive, positive, and proactive behavior support driven by functional behavioral assessment; medication management; re-evaluation of community-based supports; treatment of co-occurring conditions as needed, and; intensive parent training (Doehring, 2013a).  The program relied on intensive levels of front line staffing, and a multidisciplinary team approach.  Treatment involved rapid and intensive assessment, daily evaluation and multidisciplinary team review, and cross-agency team meetings for discharge planning.

Day to day clinical training and oversight

I  provided full clinical and operational oversight for 16 months, helping to lead daily patient rounds, weekly treatment updates, and multi-agency case conferences. I assisted in providing supervision and guidance to all clinical staff as needed, and in collaboration with other leaders at Foundations. I was also responsible for developing and delivering specialized training to the in-patient treatment team. I designed and delivered an initial 12 hour training in the clinical model and specific interventions for all new staff assigned to the ASD program, and an abbreviated format for staff elsewhere in the hospital who may occasionally fill a vacant shift or have intermittent contact with patients or families.

A continuum of community-based support

I used the experience to propose a model for a regional and statewide continuum of support spanning school-based behavioral services, community-based wraparound, and residential and in-patient treatment services (Doehring, 2013b).  This model also includes tiered systems of training and oversight similar to those used successfully in Delaware for behavior support, safety, and extended educational services (Doehring, 2011). I framed this model as a story of preventable behavioral crises (Doehring, 2014a) when I advised the Connecticut Autism Spectrum Disorder Advisory Council to consider pilot funding for a small in-patient treatment program (Doehring, 2014b)

Design staffing models and professional development programs to ensure the desired treatment fidelity and treatment intensity

These are key factors in determining the impact for all EBPs (Doehring, 2013), and designing a program from the ground up would give me a chance to test ideas for both. Fidelity can be addressed with training and coaching;  designing and delivering professional development can promote fidelity and create expertise. Treatment intensity can be addressed with staffing (Doehring, 2013).  I carefully designed a staffing model and schedule that would balance the need for consistent support without relying on the 1:1 staffing characteristic of many in-patient programs for persons with ASD.

Build programs that take advantage of powerful, evidence-based practices using positive behavior approaches informed by functional assessment

The most powerful EBPs are those targeting problem behaviors using positive behavior approaches informed by functional assessment (Reichow, Doehring, Cicchetti, and Volkmar, 2011).  A more systematic review subsequently revealed that there may be enough research to tie certain evidence-based practices (or EBPs) to specific behavioral functions to address severe behaviors (Doehring, Reichow, Palka, Philips, and Hagopian, 2014).

Consider broadening eligibility requirements, because many practices and programs for ASD are equally effective for those with ID but not ASD

As my tenure at DAP wore on and as I came to grip with the needs on my own daughter Margot, I came to appreciate that most practices and programs for children with ASD were just as effective for those with intellectual disabilities (or ID) without ASD.  The In-Patient Treatment program was my first opportunity to put this into practice, as it was the first program I was able to design from the ground up. It was clear that most of these behavioral techniques worked equally well on people with intellectual disabilities regardless of whether they also had autism.  I therefore designed the program to accept both populations, which effectively doubled the eligible population.  Persons in the spectrum but without an intellectual disability were already being referred to the traditional in-patient treatment program, and so I also recommended that we continue to serve this population. While this required that we broaden out intervention approach, the variety of patients was very enriching.