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    Teletherapy and Teletraining- A Solution to the Shortage of Qualified ABA Therapists to Meet the Demands of a Growing ASD Population

    Topics: Autism Treatment Options, Elementary (4-12), Teen (13-17), Young Adult (18-21), Adult (22+)

    Concern has been expressed regarding a shortage of qualified Applied Behavior Analysts and also about the quality of training available to such providers. 

    Distance Learning, also called remote learning, can help provide much needed therapy and services to autistic children and the therapists who work for them.

    The prevalence of Autism Spectrum Disorders has increased dramatically over time.  According to the Centers for Disease Control, the prevalence of ASD in the population is 1 in every 54 people (2020 data). Autism prevalence has increased 178% since 2000 when it was reported to be 1 in 150.

    How can families find high-quality treatment?  Who are the providers?  What kind of training do providers receive? What are the obstacles to training, and ultimately to treatment?  These topics will be explored in this article.

     

    What Kind of Treatment is Effective for ASD?

    Behavioral interventions have consistently been found effective in the treatment of Autism Spectrum Disorders (ASD)

    Interventions such as Applied Behavior Analysis (ABA) are founded on the premise that problematic behaviors can be addressed through targeted behavioral change.  Improved communication, social interaction, and decreased aggression are among the positive outcomes that ABA practitioners hope to achieve.  According to the Behavior Analyst Certification Board (BACB), “behavior analysis is the science of behavior, with a history extending back to the early 20th century. Its guiding philosophy is behaviorism, which is based on the premise that attempts to improve the human condition through behavior change (e.g., education, behavioral health treatment) will be most effective if behavior itself is the primary focus.”  Families have a range of options in terms of the types of ABA providers, and we’ll examine that next.

     

    Who provides ABA?

    Before we further explore access to high-quality ABA services, here’s a guide to some relevant acronyms and abbreviations, and what they stand for:

    • ABA: Applied Behavior Analysis/Analyst
    • BACB: Behavior Analyst Certification Board 
    • BCaBA: Board-Certified assistant Behavior Analyst (Bachelor’s Degree required)
    • BCBA: Board-Certified Behavior Analyst (Master’s Degree required)
    • BCBA-D: Doctoral-level Board-Certified Behavior Analyst
    • RBT: Registered Behavior Technician (High School Diploma or GED required)

    While the BACB was established in 1998 in order to provide quality control in training and to ensure that families received effective ABA services, the RBT designation has only been around since 2014.  With the increased demand for ABA providers as diagnoses of ASD increased, the BACB created the RBT designation in hopes of meeting that demand.  

    In order of the least-training-required-for-certification to the most-training-required, the hierarchy would be: 

    RBT--> BCaBA --> BCBA --> BCBA-D

     

    An RBT has completed a minimum of 40 hours of training, as opposed to the next level with a minimum of 4 years of academic study and supervised experience.  Additionally, in 2009, Nevada and Oklahoma became the first states to pass licensure laws for ABA providers; today there are 33 states with such licensure laws.  

    These laws specify the requirements that must be met in order to provide ABA services.  Professional licensure laws typically include specific academic course requirements, experience requirements, and supervision requirements before an individual can provide professional services.  These laws also detail consequences for malpractice, for practicing without a license, and for practicing beyond the scope of one’s license.

    While numerous studies have identified ABA as the treatment of choice for ASD, concerns have been raised regarding the quality of services provided, especially by RBTs who have the least amount of training.  As Melissa Nosik, deputy chief executive officer of the Behavior Analyst Certification Board, puts it:

     “ABA’s worth depends greatly on who is delivering it.” 

    ABA therapist for autism working with a student

    In other words, an individual may have completed the training required for certification, but that does not guarantee that high-quality services will be provided.  Nosik maintains that variation in treatment quality exists in many fields.  Regardless, it is wise to identify the level of training a provider has achieved in order to adjust your expectations accordingly.  There are scant data to support any benefits from ABA delivered by RBTs, perhaps due to a lack of research on this more recent pool of providers, but also due to the low level of training required for certification.

     

    Are there enough ABA providers to meet the demand?

    Let’s look at the number of persons who get certified.  As of April 1, 2021, the BACB reported the following numbers of certificants:

    • BCBA 45,915 (as compared to 8,582 in 2011)
    • BCaBA 4,885 (as compared to 1,597 in 2011)
    • RBT 96,607 (up from 328 in 2014)

    This data represents increasing numbers of certificants for each of the past 20 years, with few exceptions.  But is the greater supply of practitioners equal to the increased demand?  Even with these tens of thousands of certified providers, that is still not nearly enough to meet the increase in children with ASD diagnoses.  

    Other factors influence availability as well.  Some geographic areas, especially rural areas, may not have any providers at all. Overall, there is a significant shortage of providers in all states except Massachusetts. 

    In addition, some therapists with the proper training do not work with autistic children.  Roughly 73% of practitioners report working with the autism population; the remaining 27% are working in other fields.  Interestingly, only 61% of the RBT certificants reported working with the autism population, perhaps reflecting greater dissatisfaction with their work, for a variety of reasons we’ll explore below.  And more than half of U.S. counties have no BCBAs at all.  This is important because BCBAs provide required supervision to RBTs, an essential part of the training of RBTs and of ongoing practice in the field.

     

    What are the obstacles to training, certification, and provision of services?

    There are external factors regarding who gets trained, certified, and who is in the pool of potential candidates to work with an ASD child.  If one reviews the most recent US government’s Interagency Autism Coordinating Committee’s (IACC) strategic plan, you will see that a wide variety of agencies are doing great and wonderful things in research, early diagnosis, and preparation of school-based professionals to help children with autism.  However, the issue of availability of high-quality ABA therapists is not addressed at all.  And, we can’t equate quantity of providers with quality of services, nor with availability of providers to actually deliver ABA therapy.  

    Let’s explore some of the obstacles or problems that may contribute to the lack of adequate numbers of ABA providers.  Some of these issues may be causing RBTs, in particular, to leave the profession after completing credential requirements: 

    1. Feeling under-prepared for the actual work.  Quality control is left to colleges, universities, and other education providers; some RBTs have voiced that they have not received adequate training.

    2. Lack of appropriate supervision. Although specific supervision is required both pre- and post-certification, there are often not enough BCBAs to devote the hours necessary to supervising RBTs.  Supervision is essential to learning and growth, as well as to prevent harm to the client.  BCBAs or RBTs must travel to get the face-to-face supervision time.

    3. Feeling unsupported.  Without adequate training and supervision, RBTs sometimes feel “thrown to the wolves” in situations that are highly challenging, such as with aggressive teens.  In addition, family members of clients may be uninvolved or may have expectations that are not in line with the RBT’s training.

    4. Low pay.  ABA is intensive work, and RBTs may decide that it is in their best interests to work in situations that are less demanding for the pay received.  Over the past decades, state mandates for insurance coverage of ABA (all states now have them) have reshaped the industry, exposing a profit motivation for agencies that shift more hours and responsibility to RBTs. While such agencies bill insurance companies an average of $65 per hour for an RBT, that same RBT is earning less than $20 per hour.   Insurance companies reimburse ABA firms an average of $95 an hour for entry-level BCBAs, who earn about $60 to $80 per hour.  And of course, some families are able to pay privately for ABA services at a higher level than RBTs.

    5. Low satisfaction with work outcomes.  If someone is under-prepared for their work, it is not surprising when outcomes are disappointing.  Good intentions are wonderful, but a marginally trained ABA provider is unlikely to see the desired progress in their clients, which is discouraging to all involved.

    6. Lack of a path to advancement.  To advance in the ABA field, more training is needed.  Training is costly.  It often requires paying college tuition and fees, plus transportation (and time) to and from classes.  In the era of online courses, there is insufficient access for RBTs and not enough qualified instructors to go around. The same can be said for BCaBAs who would love to get more training, more supervision, and to advance in their careers.

    7. Time on the road.  ABA providers typically drive from home to home to conduct their sessions with clients.  Very infrequently services are provided via tele-health; thus a great deal of time is wasted in simply commuting from place to place.

    ABA therapist explaining something over teletherapyOur professional organizations are well-positioned to advocate for a higher quality of training, and access to training, for all levels of education required for ABA certification and licensure.  Many people are working behind the scenes to do just that.  

    Of note, telehealth options are increasingly being made available for a variety of medical and mental-health purposes and it appears that ABA is next in line.  Likewise, supervision of ABA professionals could effectively be offered via telehealth platforms to many more supervisees, eliminating the time-waster of driving around for one-on-one supervision appointments.  Teaching and training could reach many thousands more potential professionals who would like to become ABA providers, if offered via on-line platforms.  Having a high-quality trainer in one location, who can teach students in multiple locations (or at home) would serve to significantly increase options for receiving the training essential for certification and effective provision of ABA services.

     

     

    What can a parent do to find and to evaluate ABA services? 

    Autism Speaks provides an excellent free “tool kit” for parents that gives definitions of common ABA terms, and information on how to seek a provider.  According to psychologist Erica Kovacs, it is essential for you to be actively involved in your child’s ABA program.  There are steps you can take, detailed in her article on the Autism Speaks website (see link below).  

    Together, we can proactively evaluate service providers, and advocate for children with ASD to receive the most effective high-quality behavioral change services possible.  

    • This means encouraging institutions to create high-quality training programs that empower ABA providers to feel confident, competent, and well-prepared for their work.
    • It means helping workers gain access to training programs through scholarships, lower costs, and on-line training options.  
    • It means that appropriate supervision is provided to support workers.  And it may mean making changes to legislation that currently allows organizations to over-charge families for services, while under-paying workers who provide those services.

    Have you had experiences with autism and teletherapy this year? Positive or negative, we want to hear from you! Please share your experiences, questions, or ideas in the comments section below!

    Note: Stages Learning Materials is current building a new tele-therapy platform designed specifically for children with autism. Sign up for information and updates!

    Signe M. Kastberg

    Written by Signe M. Kastberg

    Signe M. Kastberg is a licensed mental health counselor with a PhD in Human Development. She taught and directed a Master’s degree program in Mental Health Counseling. She is a psychotherapist, consultant, author, certified in personality typology and is a board-certified clinical sexologist.