This is an exclusive BHB+ story
Staffing has long been the No. 1 challenge for autism services operators. The supply and demand disparity has led to long waitlists for care and frustrated parents.
However, some providers are now looking to empower frustrated parents by giving them a larger role in their child’s care. The industry has recently seen growth in parent-led Applied Behavior Analysis (ABA) services, where parents essentially function as live-in registered behavior technicians (RBTs).
“We’re giving them a toolbox of skills where they can practice with their kiddo daily. So, in the morning, when they’re getting them ready for school, they’re using applied behavior analysis and all of the skills that an RBT or a BT would use,” Dr. Mitze Burnett, founder and CEO of Burnett Therapeutic Services, told me at the Autism Investor Summit. “It’s really done in the natural environment, and it’s more of a way to support the family. And I love this because, as you know, we have a shortage in the field of RBTs and BTs, so this is almost a step in between. Let’s get services going ASAP for the family.”
Napa, California-based Burnett Therapeutic Services offers clinic-based ABA services, mental health therapy and other behavioral health services.
On the surface, I think it just makes sense. Providers are desperate to find RBTs and can help circumvent long waitlists for parents by training them to deliver care. The care is also provided in their natural environment and can be an excellent add on.
On the flip side, parents of children with autism already have a high care burden. In addition to their traditional caregiver role, these parents often schedule appointments, advocate for their child’s services and coordinate with schools. Many question if it’s fair to put an additional therapy role on parents.
As a new parent with one typically developing child, if a provider suggested that I provide 40 hours of service to her, I would ask: When exactly would this happen? In the two hours between when I finish work and her bedtime – the time already consumed with dinner, a bath and the basic rhythms of family life? Numbers aren’t working out. My concern is for working parents, who may have to choose between a career and a child’s care plan.
Still, if it’s done as a supplement to traditional care, I could see real value in having those skills to share.
In this week’s exclusive BHB+ Update, I will explore:
– The role of parents in ABA therapy
– The question of payment for parent-led ABA services
– The controversy of parent-led ABA
The training
Becoming a registered behavioral health technician takes approximately 40 hours of training. The number of hours is relatively low compared to other health-adjacent positions, which lends itself to the idea of parent-led therapy. It’s worth noting that RBTs are all overseen by a master-level BCBA.
Whereas it would be laughable to suggest that a parent should obtain a registered nursing or medical degree to care for their child. While I do admittedly call the pediatric nurse hotline for every single rash on my child, they just patiently wait on the line instead of sending me nursing school applications.
Still, parent education is key in all pediatric services. Many parents also want to better understand how to care for their child.
“Families need options, and we need to have more than one ABA delivery model,” Dr. Doreen Samelson, chief clinical officer for the nonprofit Catalight, told my colleague Chris Larson. “If you look at those extra [recruiting] costs, which can be hard for agencies to bear, and balance that with parent-led ABA, you can pull down the costs. You can also increase access.”
While it may be unrealistic for a parent to devote tens of hours to ABA therapy a week, the model and insights could help everyday life for parents and children.
“I’ve had several parents say that at the end of our time together, ‘I definitely want my kids to get one-on-one services,’” Ashley Simmons, BCBA for Easterseals of North Georgia, told BHB. “‘But I now know how to interact with my kid, how to engage, how to deal with the tantrums and restrictive or repetitive behaviors I didn’t feel equipped to deal with before.’”
Paying parents
Let’s face it, parents, especially those of children with complex needs, do a lot of unpaid work. Adding on a task like parent-led therapy could be one more of those unpaid tasks.
However, ideas to pay caregivers for their time have begun to circulate. It’s already happening in other areas of health care. Take the home health care space, for example, in some states if a person with a disability receives Medicaid, a family member or friend may be eligible to receive compensation as a paid caregiver.
At least one ABA startup was also considering a similar model. Forta Health raised $55 million to help parents become RBTs and pay them for their services to their children. The San Francisco-based startup also provided an AI-backed tech stack to support parents and other clinicians who oversaw the therapy.
While parent training is often encouraged by industry groups, parent accreditation and payment for caring for their own children remains a controversial topic. For example, the Behavior Analyst Certification Board told its members that parents acting as their child’s RBT violated the organization’s code of ethics.
And Forta’s initial business concept has changed. In August of 2024, just months after its funding round, the company pivoted and no longer paid parents to become RBTs for their child.
The payment question of parent compensation is difficult. On one side, there are certainly ethical complications regarding a parent’s ability to provide a therapeutic intervention for their own child.
On the other hand, parent education and informal training may be most beneficial to affluent parents who have the luxury of time and resources to consistently engage in parent training programs and ABA techniques with their children. Meanwhile, less affluent parents may have to work multiple jobs and have less time to devote to practicing ABA techniques. Compensation could help level the playing field.
In terms of the future of parent-led therapy, in my opinion, the best way of looking at it isn’t parent-led therapy or working with an RBT; it’s probably an “and.” Parent education is critical in most areas of pediatric behavioral health and autism services are no different.
But for the vast majority of families, expecting parents to take over care is unrealistic – especially if it’s uncompensated.
Companies featured in this article:
Burnett Therapeutic Services, Catalight, Easterseals of North Georgia
