JOSHUA D. FEDER, MD DFAPA
CHILD, ADOLESCENT, AND FAMILY PSYCHIATRY DIPLOMATE, AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY 415 NORTH HIGHWAY 101, SUITE E, SOLANA BEACH, CALIFORNIA 92075 (858) 509 0523 fax 858 259 8192 email jdfeder@pol.net
May 11, 2009 The Honorable Dick Durbin 309 Hart Senate Office Building Washington DC 20510 Dear Senator Durbin: I am a child and family psychiatrist, currently working California since 1996, and in Maryland, Hawaii, and Massachusetts in previous years. I have worked with persons with developmental disorders since 1980, beginning with behavioral treatments and later learning and teaching about developmental intervention. I work with all ages, from infants and young children to adults who have issues relating and communicating, including many with Autism. I have also published in the areas of autism and I conduct NIH funded research in this area and in pharmacogenetics. In my practice, I use a developmental intervention called DIR/Floortime to treat children with autism. I also serve on the faculty of the Interdisciplinary Council on Developmental and Learning Disorders (ICDL), which educates parents and professionals about DIR/Floortime. There are two recognized treatments for autism, the behavioral approach (applied behavioral analysis or "ABA") and the developmental approach (DIR/Floortime). Children with autism have different needs and require different autism treatments. Consequently, pediatricians, neurologists, and autism advocates like Easter Seals recommend the two treatments. Yet, the proposed Autism Treatment Acceleration Act of 2009 ("ATAA") that you recently introduced has language that specifically names only one type of autism treatment program, ABA along with its providers, behavioral specialists. The fourth edition of Autism Advocate, 2008, the magazine of the Autism Society of America (ASA), of which I am a life member, is devoted to the current state of Applied Behavioral Analysis. In that issue, proponents of ABA, including Dr. Doreen Granpeesheh, who serves as a First Vice Chair of ASA, has written extensively on ABA and runs a large company devoted to ABA called the Center for Autism and Related Disorders (CARD), co‐wrote an article on the future of ABA, stating: “Increasingly, researchers have been suggesting that the idea that there is a best treatment for autism is counterproductive and misleading….The remarkable heterogeneity displayed by people with autism calls into question the idea that randomized clinical trials (RTCs) should, at the time of the development of the field, be considered the gold standard for evaluation whether a specific treatment has merit.”1
Moreover, the state of evidence based medicine (EBM), in virtually all fields, from psychiatry and neurology to cardiology and surgery, while hopeful, is limited by the lack of definitive studies. By definition, EMB “is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”2 The entire body of research in the fields of child development and infant mental health, along with genetics and
environment as well as recent functional brain imaging studies support developmental approaches, and certainly constitutes current best evidence. Because the language of your proposed legislation includes only behavioral programs and not developmental programs, I am concerned that a recognized treatment will be excluded from the Autism Care Centers Demonstration Project, from future research, from equal insurance coverage, and from families to whom information will not be disseminated. I am in full support of autism legislation and I applaud your initiative in ensuring that families receive the support they need. But we do not need federal legislation that only supports one type of autism treatment. The DIR community, including professionals and families, are very concerned that having ABA as the only treatment mandated by government will prevent families from choosing the treatment that is best for their child. As a matter of fairness, parents working with their medical professionals should be able to choose the treatment intervention that is right for their child. Therefore, I respectfully request that in THE ATAA LEGISLATION Every time that occurrence of ABA or behavioral program is referenced, DIR/Floortime and developmental program be added as well. In addition, we hope you will also reference DIR practitioner for every occurrence of behavioral specialist in ATAA. Please feel free to contact me with any questions or discussion. Thank you for your help. Joshua D. Feder, MD Distinguished Fellow, American Psychiatric Association Clinical Assistant Professor, University of California at San Diego School of Medicine Faculty, Interdisciplinary Council on Developmental and Learning Disorders cc: Mayra Alvarez Legislative Assistant Senator Richard Durbin 309 Hart Senate Office Building Washington DC 20510 1. Carr, E., Granpeesheh, D., Grossman, L. The Future of Applied Behavior Analysis in Autism Spectrum Disorder. Autism Advocate 2008; 4:50‐58. 2. Sackett, D., et. al. Evidence based medicine: what it is and what it isn't ‐ It's about integrating individual clinical expertise and the best external evidence. British Medical Journal 1996; 312:71‐72.