BILL ANALYSIS                                                                                                                                                                                                    



                                                                     AB 796


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          Date of Hearing:  May 5, 2015


                   ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS


                                Susan Bonilla, Chair


          AB 796  
          (Nazarian) - As Introduced February 26, 2015


          NOTE: This bill is double referred, and if passed by this  
          Committee, it will be referred to the Assembly Health Committee.


          SUBJECT:  Health care coverage:  autism and pervasive  
          developmental disorders.


          SUMMARY:  Expands the eligibility for a person to be a qualified  
          autism service professional to include a person who possesses a  
          bachelor of arts or science degree and meets other requirements  
          as specified, or is a registered psychological assistant, a  
          registered psychologist or an associate clinical social worker.   
          Expands the eligibility for a person to be a qualified autism  
          service paraprofessional to include a person with a high school  
          diploma or equivalent, and six months experience working with  
          persons with developmental disabilities. 


          EXISTING LAW:


          1)Establishes the Board of Psychology, within the Department of  
            Consumer Affairs (DCA), to license and regulate the practice  
            of psychology.  (BPC  2900 et seq.)









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          2)Establishes the Board of Behavioral Sciences, within the DCA,  
            to license and regulate clinical social workers, professional  
            clinical counselors, marriage and family therapists and  
            educational psychologists.  (BPC  4990 et seq.)

          3)Establishes the Medical Board, within the DCA, to license  
            physicians and surgeons and regulate the practice of medicine.  
             (BPC  2000 et seq.)

          4)Establishes the Physical Therapy Board, within the DCA, to  
            license physical therapists, and regulate the practice of  
            physical therapy. (BPC  2600 et seq.)

          5)Establishes the Occupational Therapy Board, within DCA, to  
            license occupational therapists, and regulate the practice of  
            occupational therapy. (BPC  2570 et seq.)

          6)Establishes the Speech-Language Pathologists and Audiologists  
            and Hearing Aid Dispensers Board, within DCA, to license and  
            regulate the practice or speech-language pathology, audiology  
            and hearing aid dispensing. (BPC  2530 et seq.)

          7)Establishes an entitlement to services for individuals with  
            developmental disabilities under the Lanterman Developmental  
            Disabilities Services Act (Lanterman Act).  (Welfare and  
            Institutions Code (WIC)  4500 et seq.)

          8)Grants all individuals with developmental disabilities, among  
            all other rights and responsibilities established for any  
            individual by the United States Constitution and laws and the  
            California Constitution and laws, the right to treatment and  
            habilitation services and supports in the least restrictive  
            environment.  (WIC  4502)

          9)Defines "behavioral health treatment," for purposes of payment  
            under a health care service plan contract or a health  
            insurance policy, as professional services and treatment  
            programs, including applied behavior analysis and  
            evidence-based behavior intervention programs, which develop  








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            or restore, to the maximum extent practicable, the functioning  
            of an individual with pervasive developmental disorder or  
            autism, and sets forth criteria that must be met related to  
            the treatment plan, prescription of the treatment, and the  
            providers authorized to provide such treatment, which includes  
            qualified autism service professionals, as specified. (Health  
            and Safety Code (HSC)  1374.73(c)(1), Insurance Code (INS)  
            10144.51(c)(1))



          10)Defines as "qualified autism service provider" as:



            a.  A person, entity or group that is certified by a national  
              entity, such as the Behavior Analyst Certification Board,  
              that is accredited by the National Commission for Certifying  
              Agencies, and who designs, supervises, or provides treatment  
              for pervasive developmental disorders or autism, as  
              specified; or,



            b.  A person licensed as a physician and surgeon, physical  
              therapist, occupational therapist, educational psychologist,  
              clinical social worker, professional clinical counselor,  
              speech-language pathologists, or audiologist, who designs,  
              supervises or provides treatment for pervasive developmental  
              disorders or autism, as specified.  (HSC  1374.73(c)(3) et  
              seq.)



          11)Defines a "qualified autism service professional" a  
            behavioral service provider approved as a vendor by a  
            California regional center to provide services as an associate  
            behavior analyst, behavior analyst, behavior management  
            assistant, behavior management consultant, or behavior  








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            management program as defined in Title 17 CCR  54342. (HSC   
            1374.73 (c)(4)(D), INS  10144.51(c)(4)(D))



          12)Defines "qualified autism service paraprofessional" as an  
            unlicensed and uncertified individuals who is employed and  
            supervised by a qualified autism service provider; and,  
            provides treatment and implements services pursuant to a  
            treatment plan developed and approved by the qualified autism  
            service provider, as specified.  (HSC  1374.73 (c)(4))

          13)Defines a "qualified autism service professional" as an  
            individual who provides behavioral health treatment and is  
            employed and supervised by a qualified autism service  
            provider, as specified.  (WIC  1374.73 (c)(4))

          14)Defines a "qualified autism service paraprofessional" as an  
            unlicensed and uncertified individual who is employed and  
            supervised by a qualified autism service provider; and,  
            provides treatment and implements services pursuant to a  
            treatment plan developed and approved by the qualified autism  
            service provider.  (WIC  1374.73 (c)(5))

          15)Defines a "qualified autism service professional" as an  
            individual who provides behavioral health treatment; is  
            employed and supervised by a qualified autism service  
            provider; provides treatment pursuant to a treatment plan  
            developed and approved by the provider; and, is a behavioral  
            service provider, as specified.  (INS  10144.51 (c)(4))

          16)Defines a "qualified autism service paraprofessional" as an  
            unlicensed and uncertified individual who is employed and  
            supervised by a qualified autism service provider; provides  
            treatment and implements services pursuant to a treatment plan  
            developed and approved by the qualified autism service  
            provider; has adequate education, training and experience as  
            certified by a qualified autism service provider, as  
            specified.  (INS  10144.51 (c)(5))








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          THIS BILL:


          1)Adds additional criteria to the definition of "qualified  
            autism service professional" within the HSC as follows:
             a)   Is approved as a vendor by a California regional center  
               to provide services as an associate behavior analyst,  
               behavior analyst, behavior management assistant, behavior  
               management consultant, or behavior management program as  
               defined in Section 54342 of Title 17 of the California Code  
               of Regulations.
             b)   Possesses a bachelor of arts or science degree and has  
               either of the following:


               i)     Twelve semester units from an accredited institute  
                 of higher learning in either applied behavioral analysis  
                 or clinical coursework in behavioral health and one year  
                 of experience in designing or implementing behavioral  
                 health treatment; or,
               ii)Two years of experience in designing or implementing  
                 behavioral health treatment.


             c)   The person is a registered psychological assistant or  
               registered psychologist.
             d)   The person is an associate clinical social worker  
               registered with the Board of Behavioral Sciences.


          2)Adds additional criteria to the definition of a "qualified  
            autism service paraprofessional" within the HSC as follows:
             a)   Meets the criteria set forth in the regulations adopted  
               pursuant to Section 4686.3 of the WIC or meets all of the  
               following:
               i)     Possesses a high school diploma or equivalent;
               ii)Has six months experience working with persons with a  
                 developmental disability; 








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               iii)Has 30 hours of training in the specific form of  
                 evidence-based behavioral health treatment administered  
                 by a qualified autism provider or qualified autism  
                 service professional; and,


               iv)Has successfully passed a background check conducted by  
                 a state-approved agency.


          3)Adds additional criteria to the definition of a "qualified  
            autism service professional" within the INS as follows:
             a)   Is a behavioral service provider who meets one of the  
               following criteria:
               i)     Is approved as a vendor by a California regional  
                 center to provide services as an associate behavior  
                 analyst, behavior analyst, behavior management assistant,  
                 behavior management consultant, or behavior management  
                 program as defined in Section 54342 of Title 17 of the  
                 California Code of Regulations; or,
               ii)Possesses a bachelor of arts or science degree and has  
                 either of the following:


                  (1)Twelve semester units from an accredited institute of  
                    higher learning in either applied behavioral analysis  
                    or clinical coursework in behavioral health and one  
                    year of experience in designing or implementing  
                    behavioral health treatment; or,
                  (2)Two years of experience in designing or implementing  
                    behavioral health treatment.


             b)   The person is a registered psychological assistant or  
               registered psychologist.
             c)   The person is an associate clinical social worker  
               registered with the Board of Behavioral Sciences.








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          4)Adds additional criteria to the definition of a "qualified  
            autism service paraprofessional" within the INS as follows:
             a)   Meets the criteria set forth in the regulations adopted  
               pursuant to Section 4686.3 of the WIC or meets all of the  
               following:
               i)     Possesses a high school diploma or equivalent;
               ii)Has six months experience working with persons with a  
                 developmental disability; 


               iii)Has 30 hours of training in the specific form of  
                 evidence-based behavioral health treatment administered  
                 by a qualified autism provider or qualified autism  
                 service professional; and,


               iv)Has successfully passed a background check conducted by  
                 a state-approved agency.


          FISCAL EFFECT:  None.  This bill has been keyed non-fiscal by  
            the Legislative Counsel.


          COMMENTS:


          Purpose.  This bill is sponsored by the  DIR Floor Time  
            Coalition  .  According to the author, "AB 796 recognizes that  
            there is no one size fits all behavior health treatment for an  
            individual diagnosed with autism.  Every child on the autism  
            spectrum presents differently, as such treatment options must  
            reflect that spectrum.  This bill ensures children diagnosed  
            with autism will receive insurance coverage for the type of  
            evidence-based behavior health treatment that is right and  
            selected for them by the medical professional that knows the  
            child best." 








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          Background.  The Lanterman Act guides the provision of services  
          and supports for Californians with developmental disabilities.   
          Each individual under the Lanterman Act, is legally entitled to  
          treatment and habilitation services and supports in the least  
          restrictive environment.  Lanterman Act services are designed to  
          enable all consumers to live more independent and productive  
          lives in the community. 


          The term "developmental disability" means a disability that  
          originates before an individual attains 18 years of age, is  
          expected to continue indefinitely, and constitutes a substantial  
          disability for that individual.  It includes intellectual  
          disabilities, cerebral palsy, epilepsy, and pervasive  
          developmental disorder/autism spectrum disorder (PDD/ASD).   
          Other developmental disabilities are those disabling conditions  
          similar to an intellectual disability that require treatment  
          (e.g., care and management) similar to that required by  
          individuals with an intellectual disability.  

          Autism Spectrum Disorders.  Defined as a group of  
          neurodevelopmental disorders linked to atypical biology and  
          chemistry in the brain that generally appears within the first  
          three years of life, autism is a growing epidemic among  
          children.  While there are many "autisms," the diagnosis is  
          often characterized by delayed, impaired or otherwise atypical  
          verbal and social communication skills, sensitivity to sensory  
          stimulation, atypical behaviors and body movements, and  
          sensitivity to changes in routines.  Although symptoms and  
          severity differ among individuals with an autism diagnosis, all  
          individuals affected by the disorder have impaired communication  
          skills, difficulties initiating and sustaining social  
          interactions and restricted, repetitive patterns of behavior  
          and/or interests.  ASD, is one of the commonly-used terms to  
          describe the various "autisms" and other PDD, and it more  
          appropriately captures the array of symptoms and varying levels  
          in the severity of symptoms experienced by individuals with a  








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          diagnosis within ASD.
           
           Information released in March 2014 by the Centers for Disease  
          Control (CDC) Autism and Developmental Disabilities Monitoring  
          (ADDM) Network, estimates prevalence of ASD for children born in  
          2002 and surveyed in 2010 to be 14.7 per 1,000 children, which  
          translates to one in 68 children.  This is a drastic increase  
          from CDC data for children born in 2000 and surveyed in 2008,  
          which estimated the prevalence of children with ASD to be one in  
          88.  Average prevalence for children surveyed in 2006 was one in  
          110 children.  ASD continues to be five times more prevalent for  
          boys than for girls. 

          Early Intervention Services.  Research shows that a child's  
          development can be greatly impacted by early intervention  
          treatment services, especially when provided during a child's  
          first three years.  During that time, a child is developing  
          motor skills and language, and begins to socialize with others.   
          Early intervention services for babies and toddlers that have  
          been diagnosed with, or seem to be at risk for, a developmental  
          delay or disability often include physical, cognitive,  
          communication, social/emotional and self-help skill building.   
          While there is no proven cure for ASD, early intervention can  
          dramatically change the trajectory of a child's life over time,  
          including his or her ability to learn new skills throughout  
          childhood and an increased ability to integrate into, and have a  
          positive relationship with, his or her community.

          Treatments for ASD.  According to information retrieved from the  
          National Institute of Mental Health, there are various  
          modalities for treating ASD.  Specifically, there are a several  
          different types of behavioral health treatment that have been  
          scientifically studied and found to be effective.  There are  
          also a number of behavioral treatments in practice that have not  
          yet met the criteria to be considered "evidence-based."

          Applied Behavior Analysis (ABA). A widely accepted  
          evidence-based treatment for ASD is ABA.  There are many  
          research articles demonstrating the efficacy of ABA as an  








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          intervention for individuals with autism. These studies range  
          from group design outcome studies to single subject studies  
          supporting the use of one specific intervention or technique. 
          The goals of ABA are to shape and reinforce new behaviors, such  
          as learning to speak and play, and reduce undesirable ones.   
          This is done by systematically applying interventions, based  
          upon the principles of learning theory, to improve socially  
          significant behaviors to a meaningful degree. Further, the  
          contingent use of reinforcement and other important principles  
          to increase behaviors, generalize learned behaviors or reduce  
          undesirable behaviors is fundamental to ABA.
          For example, ABA techniques use rewards-goldfish crackers,  
          playing with toys, praise-to teach children all kinds of  
          behaviors, lessons and life skills, step by tiny step, in  
          intensive, one-on-one drills.

          Developmental, Individual Difference, Relationship-based  
          (DIR)/Floortime Model-aims to build healthy and meaningful  
          relationships and abilities by following the natural emotions  
          and interests of the child. One particular example is the Early  
          Start Denver Model, which fosters improvements in communication,  
          thinking, language, and other social skills and seeks to reduce  
          atypical behaviors. Using developmental and relationship-based  
          approaches, this therapy can be delivered in natural settings  
          such as the home or pre-school.

          TEACCH (Treatment and Education of Autistic and related  
          Communication Handicapped Children)-emphasizes adapting the  
          child's physical environment and using visual cues (for example,  
          having classroom materials clearly marked and located so that  
          students can access them independently). Using individualized  
          plans for each student, TEACCH builds on the child's strengths  
          and emerging skills.

          Interpersonal Synchrony-targets social development and imitation  
          skills, and focuses on teaching children how to establish and  
          maintain engagement with others.










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          SB 946.  SB 946 (Steinberg), Chapter 650, Statutes of 2011,  
          defined "behavioral health treatment" (BHT) as professional  
          services and treatment programs, including  ABA and  
          evidence-based behavior intervention programs  , that develop or  
          restore, to the maximum extent practicable, the functioning of  
          an individual with PDD or ASD.  The bill mandated coverage of  
          all evidence-based BHTs prescribed by a physician and surgeon,  
          or developed by a psychologist, provided under a treatment plan  
          prescribed by a qualified autism service provider, and  
          administered by a qualified autism service provider, a qualified  
          autism service professional, or qualified autism service  
          paraprofessional. When defining the minimum requirements for  
          providers, the bill referred to a section of Title 17 which  
          references only one type of evidence based BHTs, ABA.  The  
          sponsor believes that this was a mistake.  The sponsor also  
          believes that the spirit of the legislation was to allow for  
          various modalities of treatment. The sponsor indicates that this  
          discrepancy in existing law makes it difficult for parents to  
          obtain coverage for prescribed treatments that their children  
          need.  





          Department of Managed Healthcare (DMHC) Task Force.  SB 946  
          called for the DMHC to convene a task force to report to the  
          Governor and Legislature with recommendations for implementing  
          SB 946.  The 18 member task force met for one year.  An excerpt  
          from the report summarizes the Task Force's recommendations  
          regarding BHT:













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          A guiding principle of the Task Force was that every individual  
          with autism or PDD is unique.  Therefore, behavioral health  
          interventions need to be highly individualized.  Since treatment  
          selection should be made by a team of individuals, who can  
          consider the unique needs and history of the individual with  
          autism or PDD,  the Task Force determined that it would not be  
          informative to state policy makers to merely develop a list of  
          BHTs that are determined to be effective, based solely on  
          current scientific literature  .  Since scientific research and  
          findings naturally advance, the Task Force determined that  the  
          choice of BHTs should be grounded in scientific evidence,  
          clinical practice guidelines, and/or evidence based practice  .





          In regards to the individuals who are most appropriate to  
          administer BHT, the Task Force concluded:





          The Task Force concluded that all  top level providers  [physician  
          and surgeon, physical therapist, occupational therapist,  
          psychologist, marriage and family therapist, educational  
          psychologist, clinical social worker, professional clinical  
          counselor, or speech language pathologist or audiologists]  
           should be licensed by the state.





           The Task Force also included  requirements for individuals who  
            are unlicensed and who are not certified  as follows:










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             a)   Have adequate training and specific competence in  
               implementing BHT for autism, including competence in the  
               scope of treatments outlined in the treatment plan and a  
               minimum of 30 hours of interactive, competency-based  
               autism-specific training, as verified by the treatment plan  
               developer or treatment provider;
             b)   Be enrolled in a bachelor's program or possess a  
               bachelor's degree; be enrolled in an associate's degree  
               program or possess an associate's degree; or, at minimum,  
               possess a high school diploma;


             c)   Receive adequate supervision. At lease 60-75 percent of  
               the supervision should be direct fact-to-face supervision  
                                                                         and include significant co-therapy with the top or  
               mid-level supervisor; and,


             d)   The supervision shall cover the functions of ongoing  
               treatment planning and case supervision.


          Current Related Legislation. SB 479 (Bates), of the current  
          legislative session, establishes the Behavior Analyst Act which  
          would require a person to apply for and obtain a license from  
          the Board of Psychology prior to engaging in the practice of  
          behavior analysis, as defined, either as a behavior analyst or  
          an assistant behavior analyst, and meet certain educational and  
          training requirements.  STATUS: This bill passed the Senate  
          Committee on Business, Professions and Economic Development with  
          an 8-0 vote and is now in the Senate Appropriations Committee.





          Prior Related Legislation. SB 946 (Steinberg), Chapter 650,  
            Statutes of 2011, required health plan and health insurance  
            policies to cover behavioral health therapy for pervasive  








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            developmental disorders or autism.  The bill also requires  
            plans and insurers to maintain adequate networks of autism  
            service providers. 


          AB 2041 (Jones) of 2014, would have required that a regional  
            center classify a vendor as a behavior management consultant  
            or behavior management assistant if the vendor designs or  
            implements evidence-based behavioral health treatment, has a  
            specified amount of experience in designing or implementing  
            that treatment, and meets other licensure and education  
            requirements. The bill would have required the Department of  
            Developmental Services to amend its regulations as necessary  
            to implement the provisions of the bill. NOTE: The bill died  
            in the Senate Appropriations Committee. 


          ARGUMENTS IN SUPPORT: 


          Hundreds of individuals wrote letters of support.  They write,  
          "When the members of the Legislature passed SB 946, the  
          definition for "behavioral health treatments" was broadly  
          defined to include all physician or psychologist prescribed  
          evidence-based forms of therapy.  Despite the best intentions of  
          the Legislature, the law limited this in practice.  Many  
          children are being denied specific forms of prescribed therapy  
          they need.  AB 796 is right for children with autism, for  
          parents of those children and for the state.  By passing this  
          bill, children in California will be able to receive the  
          treatment they need and deserve and state costs will be reduced  
          as health insurance will cover all forms of prescribed,  
          evidence-based treatment for autism." 


          ARGUMENTS IN OPPOSITION:


          The  Autism Research Group  opposes the bill and writes, "?we are  








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          especially concerned about the potential effects of a bill that  
          would allow paraprofessionals untrained in applied behavior  
          analysis to replace ABA professionals.  The developmental window  
          during which children with ASD can optimally benefit from  
          treatment is narrow, and AB 796 could potentially allow precious  
          time to be squandered "treating" children with ASD with  
          experimental treatment, rather than treating children using  
          ABA."


          The  California Association of Behavior Analysts  also write in  
          opposition, "Our concern is less about the particular discipline  
          being employed by the service providers, and more about diluting  
          the training and education requirements of anyone providing  
          services for this population.  SB 946 established standards  
          applicable to the principle treatment for autism, which is  
          behavior analysis.  Since its enactment, the health insurance  
          industry has accepted this as the appropriate treatment for  
          autism, based both on the science and on the qualifications of  
          those providing the services.  AB 796 proposes to elevate into  
          the realm of accepted providers for the delivery of behavior  
          analysis individuals that lack the requisite training and  
          education to provide those services at the level of 'qualified  
          autism professional.'"


          The  Center for Autism & Related Disorders  shares their  
          opposition to the bill, "AB 796 would jeopardize Californians  
          who seek medically necessary treatment for autism spectrum  
          disorder by diluting California's professional standards and  
          allowing children with ASD to be treated by unqualified  
          personnel." 


          POLICY ISSUES FOR CONSIDERATION:


          This bill would amend the definitions of a qualified autism  
          service professional and qualified autism service  








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          paraprofessional.  The author contends that there is a need to  
          expand these definitions to allow more individuals the ability  
          to offer, and be reimbursed for, a variety of behavioral health  
          treatment modalities, other than evidence-based treatment and  
          ABA, for individuals who have ASD and PDD.  The Committee may  
          wish to consider if this bill takes the right approach to  
          achieving this goal.  Currently, providers can only be  
          reimbursed for ABA and evidence-based interventions.  


          In the DMHC's Task Force report, it outlines the qualifications  
          for unlicensed and uncertified front line treatment providers  
          and many of the recommended qualifications have been codified.   
          The author has included some of these qualifications in this  
          bill and aims to allow these unlicensed providers to be  
          recognized as qualified autism services paraprofessionals.  For  
          example, the author wishes to expand the definition of a  
          qualified paraprofessional to include an individual who has a  
          high school diploma and six months of working with individuals  
          who have a developmental disability.    


          The author also wishes to expand the definition of a qualified  
          professional to include an individual who has a bachelors  
          degree, coursework in behavioral health and experience in  
          designing or implementing BHT, while current law requires that  
          the individual be recognized as a vendor approved by a Regional  
          Center.  The vendors that are approved have to be able to show  
          evidence of being able to provide ABA or evidence-based  
          treatment.  By adding these additional qualifications to the  
          definition of a qualified professional, additional modalities of  
          treatment would be permitted to be utilized, such as DIR  
          Floortime.  


          It is clear that the author's intent is to allow for other  
          methodologies to be recognized as reimbursable treatment for  
          developmental disabilities such as ASD and PDD.  The way the  
          author seeks to do this is by curtailing the existing  








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          definitions of autism professionals and paraprofessionals which  
          will allow them to utilize other forms of treatment that are not  
          evidence-based or currently recognized in the code of  
          regulations.  Rather than curtail the criteria for the providers  
          of evidence-based treatments for ASD and PDD, that the DMHC has  
          already thoroughly reviewed and established in law and in the  
          regulations, perhaps a better approach would be to propose  
          legislation that would amend the Insurance Code and the Health  
          and Safety Code to recognize non-evidence-based treatments as  
          acceptable and reimbursable forms of treatment for developmental  
          disabilities such as ASD and PDD.


          REGISTERED SUPPORT:  


          Hundreds of individuals




          REGISTERED OPPOSITION:  
          Autism Research Group


          California Association of Behavior Analysts


          Center for Autism & Related Disorders


          Southern California Consortium for Behavior Analysis




          Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /  
          (916) 319-3301









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