EIBI Saves Up to $2,500,000

SUMMARY: Cost-benefit Estimates for
Early Intensive Behavioral Intervention
for Young Children with Autism

Research with children who have, or are at risk for, various disabilities has shown that effective early intervention can substantially reduce their need for specialized services later on. To be effective, however, Guralnick (1998) and Ramey and Ramey (1998) found that early intervention must be (1) comprehensive, (2) intensive, (3) extended over time, (4) individualized, and (5) delivered directly to children. Of course, such intervention is neither cheap nor easy, so it is important to determine how this kind of intervention is likely to pay off not only in benefits to particular children and families but also in financial savings.

Early Intensive Behavioral Intervention (EIBI)

Studies have demonstrated that intensive early intervention using the principles and methods of applied behavior analysis (ABA) can produce substantial benefits for many children with autism/PDD (Anderson et al., 1987; Birnbrauer & Leach, 1993; Fenske et al., 1985; Lovaas, 1987; McEachin, Smith, & Lovaas, 1993). Although there were some variations in procedures across studies, the interventions generally met the five criteria listed as essential by Guralnick (1998) and Ramey and Ramey (1998).

The interventions:

1. emphasized skill development through positive reinforcement;
2. started with an assessment of each child's current skills and deficits; instructional objectives, teaching methods, pacing, skill sequences, and reinforcers were all customized to the characteristics and needs of each child;
3. addressed all skill domains;
4. used frequent direct observation and measurement of individual performance to determine if progress was occurring, and adjust instructional methods accordingly;
5. included parents as co-therapists; and
6. were directed and supervised by individuals with postgraduate training in behavior analysis plus extensive hands-on experience in providing ABA intervention to young children with autism.

Among the studies published to date, the best outcomes – achievement of normal or near-normal functioning in all skill domains – were documented for children who received this kind of intervention for at least 30 hours per week year around for 2-3 years, starting before they reached the age of 6. In the longest and best documented study, Lovaas and colleagues (Lovaas, 1987; McEachin, Smith, & Lovaas 1993) found that 47% of the children receiving EIBI were able to function independently and successfully in regular classrooms. Another 40% or so made substantial improvements but continued to need some specialized intervention; and about 10% made minimal gains and continued to need intensive intervention. For a review, see Green (1996).

Cost-Benefit Analysis of EIBI

Given the emerging evidence on the effectiveness of EIBI, and the availability of detailed information about the costs of childhood and adult services for people with autism and related disorders, it is now possible to estimate the financial costs and benefits of EIBI. We conducted such an analysis using information from the state of Pennsylvania available to us at the end of 1996.

The major assumptions underlying the analysis were:

1. There is insufficient scientific evidence on which to base predictions about the likely outcome for any individual child.
2. In any group of children receiving EIBI, between 20% and 50% will achieve normal functioning and require no specialized services after entering elementary school. About 10% will make small gains and require intensive special education and adult services (minimal effect group). The remainder will make moderate gains and need nonintensive special education and adult services (partial effect group).
3. Without EIBI, most people with autism need lifelong special services.
4. The average annual cost of EIBI is estimated at $33,000 per child. The average duration is estimated to be three years.
5. Children who realize partial or minimal effects will use family support services to age 22, i.e. for 18 years.
6. During adulthood, those who achieve partial effects will use 18 years of Medicaid waiver (or equivalent) services and 15 years of supported work services.
7. During adulthood, of those adults for whom minimal effects are obtained, 80% will use waiver services for 20 years, 20% will use intensive community services for 23 years, and 40% will use supported work services for 15 years.

Calculating Projected Costs and Benefits

We summed the costs of all public entitlements to early intervention, education, family support, adult services, and Social Security benefits for people with autism. Then, we factored in earnings in adulthood using the 1996 median household annual income to estimate earnings by individuals who are diagnosed with autism or PDD as young children but achieve normal functioning by adulthood, and supported employment wages for those who do not.

Costs and savings were estimated for individuals who achieve normal range effects, partial effects, and minimal effects from EIBI and for differing proportions of groups of children with autism/PDD who achieve normal functioning (i.e., 20%, 30%, 40%, 50%). In the article we show projected present value, current cost, and cost with inflation. A great deal of additional information is provided regarding the exact methods used to project costs.

Summary of Results

Table 1 Estimated Net Costs and Savings of EIBI, Ages 3-55 years.