New survey data show that a significant portion of the board-certified behavior analyst (BCBA) workforce feels there is a key gap in how they are trained to dose hours for applied behavior analysis (ABA).

The survey, conducted by the tech company RethinkBH and inclusive of 390 responses from practicing BCBAs, finds that 80% do not have formal training in determining service hours. Instead, BCBAs are often trained on the job in the ways that their employers handle questions of dosing hours of therapy within the context of treatment planning. 

“Generally, I will say there is not much of a norm for this,” Jessica Jones, director of clinical operations for BrightBridge ABA, told Behavioral Health Business, speaking of the training process for BCBAs. “Most master’s programs that are for ABA, don’t really delve into this topic. For most clinicians, they are receiving training on this through their fieldwork, through mentorship, rather than grad school.”

There is the potential that BCBAs in training don’t get specific training from their mentors at all, adding that “if a behavior analyst is lucky, they get great mentorship, and they learn how to do it.” Jones is a BCBA and a licensed behavior analyst (LBA).

The survey report highlights this training as a gap in “one of the most critical decisions in client care.”

Yet at the same time, 57% of BCBAs surveyed felt equipped to make those determinations: 88% draw on an analysis of the child’s prioritized goals based on deficits and family objectives, 86% consider assessment results, while 42% consider the family’s availability for treatment.

The survey found that only 9% use “data-based software or technology” to help determine ABA hours.

“In practice, the determination of ABA therapy hours remains more of an art than a science,” the report states.

Angela Nelson, executive director of clinical services and a BCBA, notes that the combined industry-academia segment that trains and develops new clinicians is in a tricky spot. While standardization across the industry would simplify matters; ABA is often seen as most effective when it accounts for the heterogeneity of those with autism. Still, some new elements of training could be standardized, such as the most effective and vital criteria to use in developing assessments.

“A tenet of the field is individualization; we don’t want to make cookie-cutter assessments,” Nelson said. “That’s why this is so complicated.”

In the short term, clinicians and organizations could develop technologies that take into account all the data generated during the diagnosis and assessment process to customize therapy hours and then help adjust them based on care outcomes.

The relative youth of the collective BCBA field also complicates and exacerbates the issue of a lack of standardization and training regarding ABA hours. A review of certificant data from the Behavior Analyst Certification Board shows that about 32% of all BCBA certificates have been awarded in the last five years, while 71% have been awarded within the last 10 years. For perspective, about 32% of the registered nurse workforce has been a nurse for 10 years or less.

Jones said there is a risk of “overstandardization” as the industry seeks to resolve the lack of uniform training standards for developing ABA dosing for hours. She said that some organizations have tried to develop “dosing calculators” to be an aid to the BCBA workforce. 

“We run the risk of missing out on the individualization piece when ABA, at its core, needs to be individualized to make lasting and effective change,” Jones said.

Key constituents in the ABA industry could also step in to fill the gap and spur other entities, such as universities and provider organizations, into action. These include the BACB or trade associations like the Council for Autism Service Providers, Jones added.

Other data points from the report highlight the challenges the BCBA workforce faces. 

About 58% of respondents said that the stress they face in their role has led them to consider changing professions, while one-third reported operating under extreme stress for two years or more.

Top reasons for stress are varied: 39% cite a lack of personal time, while 37% report managing personnel as a top stressor.

The survey also found that BCBAs are increasingly required to act as leaders and administrators in their organizations. About half (53%) manage six or more people, while 37% report managing 10 or more people. More than half (61%) state that administrative burden interferes with their ability to provide direct care, while cumulatively BCBAs report spending 38% of their week on billable services that are not therapy. One-fourth of their time is spent on direct client care.

Many of these nonclinical actions in the autism therapy industry are still manual, the report states. Session notes (24%) and report/reauthorization writing (18%) were identified as the top tasks taking time away from client work.

“I think that the industry has demanded more and more of BCBAs,” Nelson said. “Over time, they’ve required BCBAs to be a jack of all trades, and it’s rare, I think, for someone to possess all of those skills and all of those talents. … It’s really quite incredible all of the types of skills we are expecting BCBAs to have.”