What treatment approach and support services are recommended for a 7-year-old child with Autism Spectrum Disorder (ASD), Level 2, requiring substantial support, who exhibits significant social communication deficits, restricted interests, repetitive behaviors, and sensory processing differences?

How Counseling, Occupational Therapy, and ABA Can Help This Child

Applied Behavior Analysis (ABA) - Primary Intervention

For this 7-year-old with ASD Level 2, Applied Behavior Analysis should be the cornerstone of treatment, delivered at 20-30 hours per week, focusing on reducing aggressive behaviors, improving emotional regulation, and developing functional communication skills. 1, 2

Specific Benefits for This Child:

Addressing Aggressive Behaviors:

• ABA with functional behavioral assessment will identify what triggers the aggression toward the mother (throwing objects, punching, threatening self-harm) and what consequences maintain these behaviors 3
• Functional communication training will teach alternative behaviors to replace aggression, particularly important given this child's limited ability to express needs beyond basic requests 3
• The severe skin-picking requiring specialist consultation for protective equipment represents repetitive self-injurious behavior that responds to ABA-based interventions 3

Reducing Screen Dependency:

• ABA techniques can systematically teach independent play skills and alternative coping mechanisms to replace the extreme screen dependency that causes "complete dysregulation" when unavailable 1, 4
• Teaching chains of behaviors using forward or backward chaining with reinforcement can help the child learn to occupy themselves without electronic devices 1

Improving Social Communication:

• Given the child's inability to engage in reciprocal conversations beyond basic needs and never spontaneously sharing thoughts or experiences, ABA will explicitly teach social reciprocity and pragmatic language skills 4
• The child's lack of conventional gestures (never nodding for yes/no, no pointing to share interest) requires systematic teaching of nonverbal communication 1, 2

Critical Implementation Details:

• Initial cognitive and functional evaluations using measures like the VB-MAPP (Verbal Behavior Milestones Assessment and Placement Program) or ABLLS-R should be completed before starting to optimize therapy targets 1
• Parent training as co-therapists is essential for generalization across settings, particularly given the severe masking at school that exhausts all the child's energy 1, 4
• Combining ABA with any future medication (if aggression becomes severe enough to pose immediate safety risks) is moderately more efficacious than medication alone 3

Occupational Therapy (OT) - Essential for Sensory and Motor Challenges

Occupational therapy must be sustained long-term to address this child's severe sensory sensitivities, fine/gross motor challenges, and self-injurious skin picking. 1

Specific Benefits:

Sensory Processing:

• The child's severe tactile sensitivities (requiring only soft pants, unable to tolerate tags or hair accessories, keeping hair in front of face) require systematic desensitization protocols 1
• Light sensitivity finding environments "too light" and sun glare "more intense than typical" needs environmental modifications and coping strategies 1
• The unusual sensory responses noted from birth (oblivious to fire alarms despite normal hearing) indicate profound sensory processing differences requiring ongoing intervention 1

Motor Skills:

• Despite "really amazing handwriting" (a strength), the child has delayed motor milestones (crawling delayed, walking at almost 2 years, requiring support until 18-24 months) 1
• Nearly all individuals with PTEN-ASD (and ASD generally) have fine and/or gross motor challenges requiring sustained therapy even when difficulties appear improved, as a variable pattern of improvement and worsening has been observed 1

Self-Injurious Behaviors:

• The severe compulsive skin picking resulting in permanent scarring that required specialist consultation for a protective helmet represents a critical OT target 1
• OT can provide sensory substitution strategies and protective equipment recommendations 1

Important Caveat: OT should be sustained even when difficulties appear to have improved because variable patterns of improvement and worsening have been observed in cases like this 1

Counseling/Therapy - For Child and Family System

Individual therapy for the child and family therapy are both essential given the trauma created within the family system by years of aggressive behaviors. 1

For the Child:

Emotional Regulation:

• The child comes home "exhausted and tearful approximately 90% of the time" after masking at school, using "every ounce of energy and brain space" to appear compliant 1
• Cognitive behavioral therapy has shown efficacy for anxiety and anger management in higher-functioning individuals with ASD 4
• The child's threats of self-harm with knives and grabbing objects as if to throw them during dysregulation episodes require immediate therapeutic intervention 1

Processing School Masking:

• The extensive masking behaviors preventing effective learning despite appearing compliant need to be addressed therapeutically 1
• The child needs support developing authentic coping strategies rather than exhausting compensatory masking 1

For the Family:

Mother's Trauma:

• The mother is currently receiving therapy "partly due to the impact of the child's aggressive behaviors" - this must continue 1
• The siblings exposed to years of aggression (throwing objects at mother's head, punching, threatening with knives) likely need their own therapeutic support 1

Parent Training:

• Parents need specific training in behavior management techniques to support ABA implementation at home 1, 2
• The family's report that virtual behavioral services at a previous center were "ineffective as the child did not pay attention" suggests they need in-person, intensive parent coaching 1

Family Systems Work:

• The aggressive behaviors have "significantly impacted family functioning" and created a "traumatic environment" requiring family therapy to rebuild safety and connection 1

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How to Apply for DDA and DDI Programs

Developmental Disabilities Administration (DDA)

This child qualifies for DDA services based on the ASD Level 2 diagnosis requiring substantial support, with onset before age 18 and substantial functional limitations across multiple life areas. 1

Application Process:

Step 1: Gather Required Documentation

• The comprehensive autism diagnostic evaluation with ADI-R results (this current assessment) 1
• Medical records documenting developmental delays from birth (early intervention through Birth to Three program, occupational therapy for infants) 1
• School records showing standardized testing indicating "level one urgent intervention" needs 1
• Documentation of functional impairments in self-care (bowel accidents 3 times recently, inability to occupy self without screens), social functioning (surface-level friendships, no reciprocal conversations), and behavioral regulation (aggression requiring behavioral management services) 1

Step 2: Contact Your State's DDA Office

• Each state has a different DDA system - contact your state's developmental disabilities services agency (often within the Department of Health or Human Services)
• Request an application packet for developmental disabilities services
• Ask about expedited processing given the severity of behavioral challenges and safety concerns (aggression, self-injury, threats of self-harm) 1

Step 3: Complete the Application

• The application will require detailed information about the child's diagnosis, functional limitations, and support needs
• Include documentation of the "clinically significant impairment across multiple important areas of current functioning" noted in this evaluation 1
• Emphasize the substantial support needs: inability to function without screens, complete dysregulation when unavailable, aggression creating trauma for family members, masking exhausting all cognitive resources 1

Step 4: Assessment by DDA

• DDA will conduct their own functional assessment to determine eligibility and level of need
• They will evaluate adaptive functioning across communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work 1

What DDA Can Cover:

Behavioral Support Services:

• Intensive in-home behavioral intervention services (the 20-30 hours/week of ABA recommended) 1, 2
• Functional behavioral assessments and behavior support plans for the severe aggression 3
• Crisis intervention services for episodes of dysregulation with aggression or self-harm threats 1

Therapeutic Services:

• Speech/language therapy for the significant communication challenges (conversations limited to basic needs, no spontaneous sharing of thoughts) 1
• Occupational therapy for sensory sensitivities and motor challenges 1
• Physical therapy if needed for gross motor difficulties 1

Respite Care:

• In-home or out-of-home respite to provide relief for the family, particularly the mother experiencing trauma from years of aggression 1
• This is critical given the impact on family functioning and the mother's need for ongoing therapy 1

Family Support Services:

• Parent training and education in behavior management 1, 2
• Family counseling to address the trauma within the family system 1
• Sibling support services for the siblings exposed to aggressive behaviors 1

Community Support:

• Supported recreation and leisure activities to develop skills beyond screen use 1
• Social skills groups to address the surface-level friendships and inability to read social cues 4

Equipment and Assistive Technology:

• Augmentative/alternative communication devices if needed (given the limited functional communication) 1, 4
• Sensory equipment for the severe sensitivities (soft clothing, light-blocking materials, protective equipment for skin picking) 1
• Visual schedules, planners, timers to support organizational weaknesses 1

Case Management:

• A DDA case manager to coordinate all services and ensure the child receives comprehensive support 1

Developmental Disabilities Insurance (DDI) / Medicaid Waiver Programs

DDI typically refers to Medicaid waiver programs that provide additional services beyond standard Medicaid for individuals with developmental disabilities. 1

Application Process:

Step 1: Establish Medicaid Eligibility

• If not already enrolled, apply for Medicaid through your state's health insurance marketplace or social services office
• Children with disabilities may qualify even if family income exceeds typical Medicaid limits through "Katie Beckett" or similar waivers 1

Step 2: Apply for the Waiver Program

• Once Medicaid-eligible, apply for your state's Home and Community-Based Services (HCBS) waiver for developmental disabilities
• This is often called different names in different states (e.g., "DD Waiver," "Autism Waiver," "TEFRA")
• The application typically requires the same documentation as DDA (diagnostic evaluation, functional assessments, medical records) 1

Step 3: Functional Assessment

• The state will conduct a comprehensive functional assessment to determine waiver eligibility and service needs
• They will evaluate the level of support needed across all life domains 1

Important Warning: Many states have waiting lists for waiver programs that can be years long. Apply immediately even if you don't need services right now - you can decline services when your name comes up if circumstances have changed, but you cannot get services until you've been on the waiting list. 1

What DDI/Waiver Programs Can Cover:

Intensive Behavioral Services:

• The 20-30 hours per week of ABA therapy recommended for this child 1, 2
• In-home behavioral support services targeting the severe aggression and dysregulation 3

Therapeutic Services:

• Speech/language therapy beyond what insurance covers 1
• Occupational therapy for the severe sensory sensitivities and self-injurious skin picking 1
• Mental health counseling for the child and family 1

Personal Care Services:

• Assistance with activities of daily living given the functional impairments (bowel accidents, inability to occupy self independently) 1

Respite Care:

• Both in-home and out-of-home respite to provide family relief 1
• This is particularly critical given the mother's trauma and need for ongoing therapy 1

Environmental Modifications:

• Home modifications to create sensory-friendly spaces (lighting adjustments for light sensitivity, quiet spaces for dysregulation) 1
• Safety modifications given the aggression and self-harm threats 1

Assistive Technology:

• Communication devices for the limited functional communication 1, 4
• Organizational supports (visual schedules, timers, planners) for the working memory and processing speed deficits 1

Transportation:

• To and from therapeutic appointments and community activities 1

Supported Employment (Future):

• When age-appropriate, job coaching and supported employment services 1

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Critical Action Steps for This Family

1. Apply for Both DDA and DDI/Waiver Programs Immediately:

• Do not wait - even if there are waiting lists, get on them now 1
• The severity of this child's needs (Level 2 ASD, substantial support required, safety concerns from aggression and self-harm threats) may qualify for expedited processing 1

2. Coordinate with the School:

• Use this diagnostic evaluation to push for an appropriate IEP that acknowledges the masking behaviors and provides actual support rather than assuming the child is fine because they appear compliant 1
• The school counselor's 50-minute conversation about needing this assessment for IEP planning suggests they recognize the need - follow up immediately 1

3. Prioritize Safety:

• The aggression toward mother (throwing objects at her head, punching, threatening with knives) and self-harm threats require immediate behavioral intervention 3
• If aggression becomes severe enough to cause physical harm or prevents participation in behavioral interventions, medication (risperidone or aripiprazole) may be needed as an adjunct to behavioral therapy 3

4. Address the Screen Dependency:

• The "complete dysregulation" when screens are unavailable and inability to occupy self independently is a critical target for ABA intervention 1, 2
• This is functioning as a maladaptive coping mechanism that must be systematically replaced with functional alternatives 4

5. Support the Entire Family:

• The mother's ongoing therapy must continue, and consider therapy for siblings exposed to years of aggression 1
• Respite care through DDA/DDI is essential to prevent caregiver burnout and allow the family to heal 1