The autism therapy industry faces a systemic shortage of experienced board-certified behavioral analysts (BCBAs).
This pain point is forcing autism therapy organizations to think long and hard about how to find, keep and expand the impact of what few experienced clinicians, especially BCBAs, they need as leaders.
Regardless of setting or type, the bottom line for all of these efforts is the need to significantly invest in clinicians or otherwise not have them in an organization. If an organization can’t find or develop these types of leaders, its growth will stall.
“We’re such a young field still, and many BCBAs don’t have five years of experience,” Brett Blevins, CEO and founder of Commonwealth Autism Care, told Autism Business News while attending the 2024 Autism Investor Summit in Los Angeles. “You have to be willing to allocate your budget and invest your dollars in your people, into their development.”
As of 2023, the Behavior Analyst Certification Board (BACB) has certified 66,339 BCBAs. Most of them, about 47%, are aged 34 years or younger. Meanwhile, 88% identified as female and 73% identified as white.
By comparison, about 20% of the registered nurse workforce is aged 34 or younger, according to the Health Resources & Services Administration.
Applied behavior analysis (ABA), the primary intervention of the autism therapy industry, is similarly growing at a dizzying pace. There were about 2.5 times as many BCBAs in 2023 as there were five years before, BACB data show.
And yet, for all the growth, the demand eclipses what the market can supply. An analysis of job postings shows that there were a total of 65,300 unduplicated job postings for BCBAs in 2023, according to a recent report by the BACB and Lightcast. There are likely enough jobs for every BCBA in the industry to change jobs, assuming that all BCBA certificants are active in the workforce. The data from BACB does not indicate what percentage of clinicians are active.
Independent of age, about 44% of BCBAs have held their certifications for five years or less, according to an analysis of BACB data.
“Even with a rising number of clinicians, you have a group of professionals that are struggling to keep up with the need for these services,” Tiffanie Moore, BlueSprig Pediatrics’ chief clinical officer, told ABN in an interview. “And as such, it’s critical that organizations establish systems that allow for support, mentorship, and professional growth within.”
Coming into the field, new BCBAs need support to translate clinical training into practice. Even as they progress, the young BCBA clinician workforce needs help coming into their own as leaders. This is necessary to overcome the growing pains of career progression that’s forced to accelerate to some degree because of the demands the industry and organizations place on BCBAs.
Adam Abramowitz, head of health care and co-founder of the investment bank Intrepid Investment Bankers, told ABN that autism therapy organizations find that some clinicians aren’t attracted to managerial roles.
“Some are saying that the clinical talent they promoted to take on more responsibility are coming back and saying, ‘I don’t want this job, I want to be quote-unquote demoted and go back to my old role,’” Abramowitz said. “When you’re a manager or leader, you have to be willing to have tough conversations and push people, help them improve and grow, and focus the organization.”
Hiring BCBAs for growth
It’s not possible to operate an autism therapy company without competing for talent in the job market. Historically, wages for all staff, especially BCBAs, have been elevated as a result of supply-demand imbalances within the workforce and the inflationary pressures on households’ pocketbooks. This makes the job market heavily slanted in favor of employees, meaning employers need to go out of their way to win over BCBAs.
“I think recruiting is the wrong word to use: Honestly, what you guys are doing is sales,” Sarah Trautman, board member of Apollo Behavior and founder of STE Consultants, said during a panel discussion at the Autism Investor Summit. “You need to have a really strong offer. You need to be solving the problem that they have. You need to understand what they need and give it to them.”
BCBAs often know that they are in high demand and will act in their self-interest. Often, especially if they are earlier in a career, they will chase higher salaries. But with the market as it is, several organizations are shelling out top-dollar salaries and signing bonuses. So, highly sought after professionals then become much more discerning when it comes to non-financial benefits such as education and mentorship.
“BCBAs are looking for organizations that they believe have the resources to support them,” Moore said. “If you think about what BCBAs are looking for, they want a manageable caseload. They want to be empowered — to have influence on the organization’s policies and things that impact their day-to-day.”
Several sources told ABN that the best BCBAs are ambitious in many ways. They hold themselves to high clinical standards and are eager to expand access to ABA. They also recognize the role their work has within the context of the business’ success. This can be further supported by fostering a sense of camaraderie among their co-workers to help cope with the stresses and challenges of working with patients and families of those with autism.
“Culture is something that, we say, is not about pizza parties,” Mordechai Meisels, CEO and founder of human services provider Chorus Software Solutions and founder and chief clinical officer of Encore Support Services, told ABN. “It’s about making sure that our clinical teams get the proper, not only support and resources, but acknowledgement.”
Finding BCBAs that would fit well in a growing organization and want to have a hand in that growth can be extremely difficult. This makes de novo growth all but impossible. In recent years, a less favorable deal market has forced many growing autism therapy companies to focus on de novo growth.
“The most important thing is like building a market around a person rather than having a market and then trying to find the right person because that makes all the difference,” Tommy Spiegel, vice president at investment bank Provident Healthcare Partners, told ABN. “If you have a business-minded, seasoned BCBA, building a market around them is huge.
“As I talk to groups, there are obviously issues finding those people. They’re a diamond in the rough.”
Growing your own supply
Apart from the potentially time- and capital-intensive effort of recruiting experienced BCBAs, the only other option for autism therapy providers is to hold onto and train BCBAs into leaders. While it may be the only option, it doesn’t have to be so seemingly limiting. And it doesn’t have to be if a business has systems that enable and reward ambition.
“I personally love beginners — they’re enthusiastic, they’re motivated, they’re excited, they’re not burned out,” Meisels said. “It becomes ever more important to create frameworks, training, and materials that can actually help them and get them up to speed. … If you can’t find older [clinicians], you won’t be able to make the clinicians you have more experienced without creating experiences for them. In a way, you are in control because they’re gaining experience through you.”
Meisels said Encore Support Services created a 75-page “playbook” and asynchronous training program with CEU credits for BCBAs. The program includes training for new BCBAs as they are onboard with the company. It also includes training that covers soft skills and leadership principles. Encore Support Services also conducts monthly mini-reviews to recognize accomplishments and support progress.
Several sources said that setting out clear guidelines and job descriptions help make the transition into leadership smoother. So does making clear expectations about a clinicians caseload. Approaches range from eliminating dedicated clinical case loads altogether and focusing on overseeing and coaching others to balancing managerial responsibilities and maintaining a diminished case load.
In a larger organization, corporate resources could include multidisciplinary clinical committees or, in the case of BlueSprig, “grand rounds” meetings where several clinicians discuss challenges in care. These resources give support to clinician leaders at all levels of leadership, Moore said.
Going out of your way to support younger BCBAs may lead to unexpected opportunities. A younger workforce is more likely to move or have other major life changes that take them away from their job. For example, investing in a young BCBA that wants to move closer to family could be retained and help the company grow by opening a clinic in a new market.
“You probably have more talent in-house than you realize,” Spiegel said. “I think people like to step up to the plate when you give them more responsibility.”
