Behavior technicians (BTs), as a clinical role, are a necessary but potentially problematic part of the autism therapy industry.
Sky-high average turnover numbers, compressing payer rates and overall wage inflation make hiring and retaining these care providers the defining challenge of the space. But several factors limit providers’ ability to shift to alternative models — without radical change.
Typically, the autism therapy industry requires a relatively small cohort of master-level or higher clinicians (behavioral analysts) to develop individualized treatment plans for a relatively much larger group of technicians to execute in practice. On the basis of scale alone, the industry is largely reliant on BTs to administer care.
Children in the U.S. are more frequently being diagnosed with autism, and providers across the U.S. tell Autism Business News that this leads to a massive mismatch between patient demand and the supply of autism therapy services. The most recent research from federally backed sources indicates that 32.2 out of every 1,000 eight-year-old children in the U.S., or 1 in 31, have been diagnosed with autism spectrum disorder — a 17% increase to the previous estimate.
On top of that, applied behavior analysis (ABA) itself is a relatively high-hour, high-intensity intervention. Twenty hours of therapy a week is typical, and, in some cases, 40 hours of therapy is well within the realm of possibility.
“Most of our clients are 15 to 30 hours of direct therapy a week, and that might beg the question of if the [behavior analyst] could do it all,” Jessica Zawacki, director of research for ABA Centers of America, told ABN. “The answer is, ‘Sure.’ … But on that larger scale, if we did that model, it’s going to be slow, it’s going to be very siloed, and it’s going to be crazy expensive when it comes to reimbursement rates.”
The rate at which behavior technicians turn over in the autism therapy industry is also a major expense.
Publicly available data paint very different pictures of what the industry’s typical levels of annual BT turnover look like. According to data from the autism- and IDD-focused B2B software firm CentralReach, average annual employee turnover is about 90%, with the largest provider organizations (those with over $30 million in revenue) seeing 103%, much of that being driven by behavior technician turnover. Other data from the Behavioral Health Center of Excellence show that annual turnover totaled 65% among organizations it polled.
Overall, employee turnover has been a huge challenge for autism therapy organizations. In some cases, it played a part in high-profile industry stumbles.
Still, the necessity of care delivery on a one-on-one basis allows for individualized adaptation of care, potentially leading to desired care outcomes. Brett Blevins, chief development officer for Already Autism Health, said that he thinks the current behavior technician-behavior analyst model is still worth it.
“There’s still a lot of great things going on, a lot of progress being made for individual learners, but it does come with its challenges, and that makes it difficult to operate at any scale,” Blevins told ABN.
Blevins maintains that there are only enough behavior analysts to support a fraction of autism patients, let alone patients with other primary diagnoses such as ADHD or substance use disorder.
“Without technicians, there’d be so many more individuals not being served,” Blevins said.
The evolving role of behavior technicians
There has been a significant evolution in the expectations of behavior analysts in the last several years. Earlier on in the autism therapy industry’s history, behavior analysts had a much more wide-ranging consultative role that required direct engagement with the child, but also a significant amount of training and support for the other members of an individual’s circle of support, Blevins explained.
That included teachers, parents and other caregivers. That simply doesn’t match what the industry is and does today, Blevins said.
Angela West, chief clinical officer and co-founder of Behavioral Framework, told ABN that behavior analysts in 2025 don’t expect to provide as much direct services as they did in the past.
“It would be really difficult to find any behavior analyst willing to do direct work anymore,” West said. “It’s just not done anymore.”
What’s more, having a technician and an analyst working with a patient could help better generalize the skills developed in therapy outside of the session, according to West.
Challenging cost-benefit analyses for employers and employees alike lie at the heart of the behavior technician issue.
On the front end, several payers and local governments require BTs to receive a certification from a professional accreditation body before they can treat and bill patients. Although other certification bodies exist, the largest and most prominent in the autism therapy field is the Behavior Analyst Certification Board (BACB). The certification standards of the BACB, other credential-awarding entities and provider organizations only require technicians to have a high school diploma. This belies the competence and fortitude required to become and stay a behavior technician.
Getting prospective behavior technicians trained and certified can often create an administrative nightmare for employee and employer alike, West said. While the certification process for the BACB’s registered behavior technician (RBT) certification only requires 40 hours of training, it is still a phase for which provider organizations have to dedicate time and resources with no prospect of getting paid. In some circumstances across the industry, technicians may have to pay their way to become certified professionals.
“People just give up because it’s so complex and it’s not worth it for the amount of money they’re making,” West said. “And it’s also a difficult job. It’s physically demanding. It’s emotionally demanding. … It’s so complex — the amount of hand-holding we do just for our technicians through just the red tape and all the administrative work.”
In some circumstances, payers and local regulators will allow non-certified BTs to treat patients. Occasionally, these exceptions apply only to technicians pursuing certifications. Overall, trying to match up patients, the patients’ payer requirements for billed services and the certification status of technicians makes trying to find workarounds administratively untenable, West said.
Understanding what’s survivable
Relatively low rates from payers for the services provided by technicians is also a major retention problem.
In addition to the lower payer rates compressing employee wages, the fee-for-service paradigm of nearly all behavioral health means that patient cancellations take money out of the provider’s and the employee’s paycheck as well. Some providers seek to support the lack of pay by paying for all or part of the missed session while the technician completes other work.
The lack of consistency in work and the resultant lack of consistency of pay drive many out of the industry despite their competency or their potential career trajectory.
“That’s something that the payers have yet to address, setting a rate that encompasses the overhead that’s in the industry, that allows for technicians to be offered 40 hours a week and a livable wage,” Blevins said.
The challenge of hiring and retaining through the earliest stage of a technician’s career takes up so much attention that it often challenges the ability of providers to address burnout. Much of the burnout comes from the non-clinical aspects of the job, Zawacki said.
“I think those who genuinely love what they do and love the changes [therapy brings] find that part is survivable,” Zawacki said. “Then you have the post-session, which is the outside-the-session stuff. It’s the canceled session. There’s the travel time and the cost of a vehicle. Paperwork is the bane of everyone’s existence, and ABA paperwork is endless.”
But given the fee-for-services and regulatory paradigm of behavioral health and the systemic challenges that make and keep behavior technician work challenging, there is often little that individual providers can do to fundamentally change circumstances. To some extent, the industry has normalized burnout.
“We are handing out umbrellas in a hurricane and saying, ‘Good luck,’” Zawacki added.
Even so, some providers see a different way forward. For example, the digital health provider AnswersNow providers services that are focused on behavior analyst care provided directly to families that seeks to limit the overall hours of care by centering parent
Jeff Beck, the company’s founder and CEO, told ABN that the bulk of new diagnoses of autism are for those with low-intensity symptoms that are not well-served by the high-hour, early intervention model that is the norm.
The industry “started as a very intense service 40 years ago with far fewer level 1 autism kids, now the fastest growing [group], making this model dated,” Beck told ABN.
While his organization doesn’t employ RBTs, he has a much grimmer assessment of what makes it difficult to retain RBTs than others who commented for this article: “They are driven to the ground in the name of billable and treated like a cog,” Beck said.
