Low standards corrode quality of popular autism therapy - Spectrum

Rapid expansion:

Questions about qualifications have long been an issue for the field. In the 1970s, experts realized they needed uniform standards and a way to certify that therapists are qualified, says Gina Green, chief executive officer of the Association of Professional Behavior Analysts in San Diego, California.

In 1983, Florida pioneered the first state ABA certification program, and several other states adopted similar standards the following decade. In 1998, a behavior analyst named Jerry Shook, who worked at the Florida health department, created the national nonprofit Behavior Analyst Certification Board. The board developed credentials for a ‘board-certified behavior analyst’ (BCBA), which requires at least a master’s degree, and a ‘board-certified assistant behavior analyst’ (BCaBA), which requires a bachelor’s degree. They decided to develop a technician credential more than a decade later, Nosik says. In 2014, the board added an entry-level certification.

Alongside the credentialing efforts, the field has quickly grown in popularity, buoyed by a rise in autism prevalence. In the U.S., the ranks of BCBAs grew from fewer than 400 in 2000 to 16,000 in 2014, three-quarters of them working with autistic people, according to certification board data. By 2017, the board had anointed more than 34,000 RBTs worldwide. By October 2020, almost 83,000 people had received an RBT certification (and more than 42,000 had become BCBAs).

The swelling ranks of RBTs helped address a numbers problem, Warren says. A BCBA can directly serve only a small number of children. For example, at 20 hours a week per child, a BCBA can help only two children in a 40-hour week. With RBTs working under them, BCBAs can handle many more clients.

“When I have a child at 9 o’clock in the morning, I’m going to do something different at 9:10, because good ABA adjusts to the learner constantly.” Ronald Leaf

At the same time, state mandates for insurance coverage of ABA (all states now have them) have reshaped the industry, experts say, opening up the potential for greater profit for agencies that shift more hours and responsibility to RBTs. Whereas entry-level BCBAs earn about $60 to $80 per hour, according to several job postings, a typical RBT makes less than $20 per hour. At the same time, insurance companies reimburse ABA firms an average of $95 an hour for a BCBA, compared with an average of $65 an hour for an RBT.

Industry changes may have come with growing pains, as many RBTs have expressed concerns about their lack of supervision from BCBAs: Every year, 1,200 to 3,600 messages — from RBTs, BCBAs and families — pour into the ABA Ethics Hotline, which Bailey has run in one form or another for more than a decade. According to board regulations, RBTs should receive half an hour of direct supervision for every 10 hours of services (5 percent of their monthly hours). Supervisors also monitor therapy indirectly by reviewing daily progress notes, Green says. But the hotline regularly hears from RBTs who have not seen their supervisors in weeks, and sometimes months.

The hotline also hears from parents who are not happy with how RBTs interact with their children. One family installed a hidden camera, which showed their RBT repeatedly slapping their child in the face. “I hear from parents that say, ‘This person doesn’t seem to know what they’re doing.’ And then I hear from RBTs that say, ‘I wasn’t trained to do this; I’m not getting any help. I’ve only worked with, say, children with language problems, and now they’ve given me a teenager who’s aggressive,’” Bailey says.

RBTs regularly vent their frustrations on Reddit too. One reported having no in-person training and not knowing what to do with clients even after four months on the job. A case manager described a company that would “just hire anybody” and throw them into one-on-one situations with children without any supervision. Some children, the manager said, had not seen a supervising BCBA in six months. (None of the commenters responded to requests for interviews.)

Realistically, BCBAs could oversee a maximum of 5 to 10 RBTs at once (depending on who the clients are), given the time it takes to observe, provide feedback and complete paperwork, Bailey says. But many are assigned to manage 15 to 20 RBTs, he says, in part because there are too few BCBAs to go around: More than half of U.S. counties have no BCBAs at all.

RBTs can make choices that hurt families, says Catherine Lord, a clinical psychologist at the University of California, Los Angeles. Plenty of schools and agencies deliver high-quality ABA, she says, but she worked with one autistic child who was seeing 16 separate RBTs. None would commit to more than two hours a week, because they were paid hourly and if the client got sick or went on vacation, the RBT would lose that pay.

RBTs also sometimes leave clients if they feel unprepared and unsupported to handle that person’s difficult behaviors — a disruption that can hurt the client’s progress. When Shannon Des Roches Rosa’s high-support autistic son was 12, the family turned to an agency near their Silicon Valley, California, home. For the first couple of years, no technician the company sent lasted more than a few months. The family cycled through at least 10 technicians, says Rosa, who is senior editor of Thinking Person’s Guide to Autism.

“A lot of them didn’t have what it takes to work with a person who has a lot of autistic behaviors,” Rosa says. And the turnover and poor care took its toll. Rosa’s son was often miserable, which was stressful for Rosa. “Whenever there was a new therapist who arrived in the house, it was worse for me than having nobody there,” she says.

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