Closing the gap between actual and expected outcomes
Behavior analysts and other ABA autism service industry stakeholders need to band together, put their tools to best use, and get back on mission to saving the world (Chance, 2007; Skinner, 1971) by building organizations that deliver high-quality services with the interdisciplinary application of behavior analysis (including Organizational Behavior Management and Culturo-Behavioral Science), quality concepts and tools, advances in technology (e.g., Cox & Jennings, 2024; Sosine & Cox, 2023), and research on the variables that influence service quality in ABA autism service settings.
Summary. Criticisms of applied behavior analysis (ABA) autism services and inadequate workforce preparation to meet the demands for those services suggest the industry has reached a turning point. One in which we must course correct with a greater focus on quality assurance. However, research on quality assurance in ABA autism services organizations and its controlling environmental variables lags far behind the proliferation of ABA autism services. This five-part blog series offers a compass and a call to action for behavior analytic practitioners to band together in pursuit of a more robust scientific approach to understanding the environmental variables that influence ABA autism service quality. An ABA quality research agenda focused on ABA service delivery processes and their outcomes, is proposed. The agenda guides behavior analysts to publish quality control studies and establish a research base leaders can draw from to design evidence-based quality assurance systems that deliver high-quality services and compensate for inadequate industry safeguards for quality. Managers for quality in ABA organizations can implement this action plan to begin systematically designing and implementing robust quality assurance systems that deliver high-quality services with quality planning, control, and improvement; beginning with validation of processes for controlling behavioral intervention quality.
Since the 1950s (e.g., Ayllon & Michael, 1959), behavior analysts have been hard at work translating Behavior Analysis research into the practice of Applied Behavior Analysis (ABA). The most prominent and successful application of ABA is ABA therapy for individuals with autism spectrum disorder and related developmental disorders[1]. ABA assessment and intervention is the leading empirically supported approach to the treatment of autism. An industry dedicated to this work has proliferated around the United States and continues to expand around the world (e.g., Kelly et al., 2023; Malott, 2004). Despite increased access to ABA services for more people with autism, the industry has reached a turning point in which it must more objectively and verifiably demonstrate its value with evidence-based quality assurance.
Quality assurance is defined herein as, “all the planned and systematic activities implemented within the quality system that can be demonstrated to provide confidence that a product or service will fulfill requirements for quality” (ASQ, n.d.), the main purpose of which is to, “serve people who are not directly responsible for conducting operations, but who have a need to know – to be informed as to the state of affairs, and hopefully, to be assured that all is well” (Juran, 1995; p. 627). Those people include the clients, consumers, behavioral technicians, clinical supervisors, funders, and others impacted by an ABA service organization’s activities.
The purposes of this five-part blog series are two-fold. Part one presents evidence of industry-wide problems such as the rise of ABA criticism in research, the recent major increase in private equity investments in ABA autism service organizations, the inadequacy of current extra-organizational safeguards for quality, and a lack of research on the variables that influence ABA autism service quality. Parts two through five offer behavior analysts who are responsible for the quality of their organization’s services, and aspiring ABA service quality professionals, a four-step research agenda they can adopt or support to accelerate research on evidence-based quality assurance in ABA service delivery settings.
A Turning Point
Criticisms of ABA Practice in Research
ABA therapy for autism is widely recognized and accepted around the country by highly trusted sources (e.g., Centers for Disease Control and Prevention, 2022; Eunice Kennedy Shriver National Institute of Child Health and Human Development, 2021). For several decades since the first publication of our flagship journal (e.g., Baer et al., 1968; Baer et al., 1987) behavior analysts have conducted extensive research leading to a robust empirical arsenal of behavioral interventions that analysts can apply to improve the lives of autistic people through modifications of the environment (e.g., Cooper at al., 2020). Yet, criticisms of ABA services for individuals with autism are prevalent and easy to come by in the news, social media, and peer-reviewed research.
ABA therapy for individuals with autism has been described by neurodiversity activists (see Leaf et al., 2022) and some researchers (e.g., Gorycki et al., 2020; Shkedy et al., 2021) as harmful or abusive. Researchers have claimed it causes post-traumatic stress disorder (e.g., Kupferstein, 2018[2]). Claims about behavior analysts engaging in ableism and harmful practices that force autistic people to camouflage and mask behaviors characteristic of autism are published. Although recent research suggests rigorous empirical support for such claims are absent from the scientific literature (e.g., Leaf et al., 2023). Recent critical examination of published studies on interventions for autism suggested the literature (including behavioral interventions) lacks social validation, that outcome measures are too narrow, conflicts of interest are rarely disclosed, bias is running rampant, and adverse events associated with research are likely underreported (Bottema-Beutel et al., 2023). Others have concluded ABA therapy for autism is unethical from a bioethics standpoint (e.g., Wilkenfeld & McCarthy, 2020). Autistic voices describing ABA therapy experiences as threatening to their identity (e.g., McGill & Robinson, 2021) and traumatic (Anderson, 2022) have also been reported. Opponents of ABA therapy for autism have repeatedly referenced old, outdated, and today unethical studies conducted decades ago on behavioral interventions referred to as conversion therapy to strengthen or support claims that ABA therapy is harmful. Behavior analysts have responded in the literature to that unfortunate history (e.g., Conine et al., 2021).
Private Equity Investment and ABA Quality
Research on the impact of private equity (PE) firms’ involvement in the ABA autism services industry is emerging, and as a result, poorly understood. All PE firms are probably not “created equally” and logically we must assume there are a portion of PE firms focused both on the mission to deliver quality care AND the return on investment. Demonizing an entire group of people is wrong and we shouldn’t stand for it.
However, research from outside the field suggests PE firms in general represent a serious threat to healthcare businesses, including increased risk of financial stress and bankruptcy, and offers suggestions about what policy makes can do about it (Scheffler et al., 2021). Over the past few years, PE investment in the ABA autism services industry in particular has generated considerable controversy. Articles published by the press online reporting adverse effects of PE investment on ABA autism service quality are accumulating (e.g., Bannow, 2022; Fry, 2022).
PE ownership is now the predominant financial structure of for-profit organizations in the ABA autism services industry today (e.g., Batt et al., 2023; Fry, 2022). Put simply, PE firms use money pooled from investors to acquire and take control of an ABA service organization for the sole purpose of increasing the resale value of the organization and selling it for the most profit possible, typically within four to seven years (Morris et al., 2024). The PE firm is compensated through fees and a percentage of the resale profits. Potential benefits of PE ownership of ABA service organizations are (a) the original owners can receive compensation for selling the organization, (b) the infusion of capital that could help the organization achieve its mission, (c) the possibility of expanding services, and (d) a willingness to focus on the long-term value of the organization which can take pressure off the organization in the short-term (Morris et al., 2024). Yet there are risks of PE ownership such as (a) a potential shift to a profit-over-patient culture in which quality is neglected to focus on growth, (b) less freedom for practitioners to make decisions that impact their jobs in important ways such as caseload and professional development resources, (c) increased operational strain and fluctuating work conditions, (d) and cost-cutting measures such as layoffs (Morris et al., 2024). Although not discussed in that paper, another risk of PE ownership is a pattern of premature promotion of behavior analysts to positions of power, authority, and influence in the organization; not based on their performance or skills per se, but rather to fill new positions that rapidly become available as a result of a breakneck pace of operational growth.
A report published on June 21, 2023, by Batt and colleagues of the progressive Center for Economic and Policy Research, suggests PE investments in ABA organizations have been destructive (Batt et al., 2023). To understand the impact of PE on the autism services industry, the researchers conducted focused case studies on 12 major PE owned ABA autism service organizations that employed roughly 30,000 people at 1,300 locations around the country (Batt et al., 2023). Evidence in the report suggests patterns of activity demonstrated by these organizations and their PE firms with specific implications at the industry, organizational, and clinical levels. At the industry level, the researchers concluded that PE firms dominate the autism service market and that their activities are restructuring and consolidating smaller ABA organizations in ways that dramatically reduce competition and gives them leverage to demand higher reimbursement rates. At the organizational level, through buying and selling ABA organizations roughly every four years, PE firms drove high employee turnover, decreased financial stability, and loaded providers with debt. At the clinical level, evidence from the case studies suggests that PE firms lowered staffing, training and supervision levels, increased clinical staff turnover, pressured clinicians to use cookie-cutter treatment plans and bill excessively for clients who would otherwise thrive at a lower level of intensity (i.e., fewer hours per week). One of the ABA organizations studied by the researchers showed that after partnering with a major PE firm, the organization rapidly expanded from 5 locations to 162 locations in four years (Batt et al., 2023). Those data beg the question of whether and how an ABA organization growing at that rate operationally can simultaneously develop quality assurance systems and clinical expertise sufficient to protect and meet the needs of patients. Overall, it is hard not to conclude that PE has and will continue to play a major role industry-wide in shaping the quality of ABA autism services.
The Batt et al., 2023 report made numerous other notable discoveries as well. According to the report, PE firms have dominated the autism services market since the mid-2010s, most of which exploited ABA organizations by buying them out, consolidating organizations into national chains, and driving growth rapidly to turn a high profit. Eighty-five percent of all mergers and acquisitions in the autism services industry between 2017 and 2022 were completed by PE firms with little behavioral health expertise. Additionally, few PE firms have possessed expertise in the field of ABA autism service delivery but nevertheless took control over clinical decision making through care management practices. For example, the researchers explain that a major PE firm bought out a large ABA provider in 2018, but ultimately closed over 100 ABA autism services sites and bankrupted the organization by June of 2023.
Extra-Organizational Safeguards for Quality
There are many extra-organizational influences on service quality that might be expected to serve as safeguards against risks of harm to consumers and clients or low-quality services generally. These influences include but are not limited to practitioner certification (Behavior Analyst Certification Board®; see Linnehan et al., 2023 for a historical perspective), university coursework accreditation (Association for Behavior Analysis International®), ABA organization accreditation (e.g., Autism Commission on Quality®), licensure laws, a robust ethics literature (e.g., Bailey & Burch, 2016), and numerous behavior analytic professional organizations around the United States (e.g., Florida Association for Behavior Analysis®). Yet, the issues the ABA autism services industry faces highlight the need for (a) additional extra-organizational safeguards for quality that can help generate clear evidence of widespread and objectively verifiable high-quality services and fieldwork supervision experiences, (b) more protection for ABA providers against destructive financial pressures, (c) a behavioral quality research base to support empirical approaches to quality assurance, and (d) an adequate workforce to deliver verifiably high-quality services industry-wide.
For example, the Association for Behavior Analysis International (ABAI®) accredits graduate programs to control the quality of education (i.e., practitioner preparation) in behavior analysis. Between 2013 and 2020, the BACB’s first-time behavior analyst certification pass rates were higher for accredited than nonaccredited programs (Dubuque & Kazemi, 2022). However, of the more than 700 graduate ABA course sequences verified by ABAI, as of December 2nd 2023, only 25 universities had accredited master’s programs and only 10 had accredited doctoral programs (ABAI®, n.d.). These data suggest most behavior analysts receiving a graduate education today do not receive their education from a university which has demonstrated implementation of a graduate course sequence in behavior analysis that meets ABAI’s minimum quality standards for accreditation.
First-time behavior analyst certification exam pass rate data serve as one quality indicator of behavior analysts entering the field to practice ABA (Dubuque & Kazemi, 2022). Based on publicly available data between 2013 and 2020, Dubuque and Kazemi concluded that there is much room for improvement and suggested, among other things, that quality control over supervision fieldwork experiences is a vital next step in controlling the quality of certified behavior analysts entering the workforce. In 2022, of the 7,179 students who completed the BACB’s behavior analyst certification exam, only 55% of first-time test takers passed. These data suggest that in 2022, graduate programs in behavior analysis as an extra-organizational influence on the quality of ABA autism services failed to adequately prepare almost half of prospective practitioners to enter the workforce with the basic knowledge-based skills needed to practice independently and competently. In other words, despite the proliferation of behavior analysis graduate programs around the country, and presumably increased numbers of students completing graduate coursework in behavior analysis, access to high-quality education in behavior analysis as indicated by high first-time test taker pass rates is inadequate to meet the demand for high-quality ABA service providers in the ABA autism service industry.
Additionally, thousands of ABA autism service organizations around the country have sought accreditation of their organization as one approach to promoting the quality of their services. Accreditation offers benefits such as participation in a process of evaluating the extent to which an organization adheres to best practices and meets rigorous standards, it may offer stakeholders some assurances that a high-quality service will be delivered, a framework for continuous improvement, increased risk mitigation, and positive culture change (Kazemi, 2023). But accreditation is no substitute for a robust internal quality assurance system. Disadvantages of accreditation may include that it can be cost prohibitive for some organizations (e.g., fees, and the time and labor investment), exposing internal workings to external auditors may be uncomfortable and disruptive to daily operations, accreditation does not reflect the dynamic nature of quality over time because it is only a “snapshot in a moment in time and [misses] day-in and day-out activities for specific clients or staff” and the requirements of standardization may be perceived as overly restrictive (Kazemi, 2023). Additionally, research is needed to understand the extent to which accreditation processes have a positive impact on the contingencies that control cultural practices underlying high-quality ABA services and outcomes. Research suggests there is a lack of consensus on the definition of quality and therefore a lack of empirical research on the variables that control quality in ABA service settings (Silbaugh & El Fattal, 2022b). As a result, ABA autism service providers lack a robust empirical foundation of behavior analytic research on quality management, assurance, and control (e.g., Juran, 1986) from which leaders can draw to develop new organizations or improve existing ABA autism service organizations.
Implications Beyond ABA Autism Services
There are many other issues plaguing the ABA autism services industry that go beyond the scope of this paper such as data suggesting that the prevalence of autism continues to rise (e.g., Centers for Disease Control and Prevention; n.d.) but the ABA autism services industry continues to lack enough qualified behavior analysts to meet the demand (Strully Jr., 2023; Yingling et al., 2022; Yingling et al., 2021a; Yingling et al., 2021b). Existing extra-organizational institutions established to promote high-quality services provided by behavior analyst practitioners have admirably played a necessary and important role in our success. Nevertheless, the convergence of the evidence provided suggests that the ABA autism services industry has reached a turning point on the issue of quality. And the stakes include but go far beyond the future of the ABA autism services industry and the autistic population.
The behavior analytic view of relations between behavior and environment as revealed by our research is a cultural variant that may or may not ultimately survive through cultural selection. As mostly radical behaviorists (Skinner, 1976) we outright reject the explanatory fictions (i.e., mentalistic pseudo-explanations; Dillenburger & Keenan, 2023) and teleological explanations for behavior that people have used for thousands of years, with poor effect, to solve behavior problems. As an alternative to the failure of blaming, shaming, or treating others’ character or personality as causes of socially significant behavior problems, which underlies war, divorce, child abuse, and other persistent social problems (Friman, 2021), we have developed a technology for changing and improving socially significant human behavior entirely by modification of the environment. The technology works and has the potential to help address a myriad of global societal problems (e.g., Sadavoy & Zube, 2022) and socially significant behaviors (Heward et al., 2022). Given the widespread visibility of ABA autism services, it will only increase our chances of establishing applications of our technology and the Circumstances View of behavior on a larger scale if the ABA autism services industry can get quality right.
A Call to Action
Behavior analysts and other ABA autism service industry stakeholders need to band together, put their tools to best use, and get back on mission to saving the world (Chance, 2007; Skinner, 1971) by building organizations that deliver high-quality services with the interdisciplinary application of behavior analysis (including Organizational Behavior Management and Culturo-Behavioral Science), quality concepts and tools, advances in technology (e.g., Cox & Jennings, 2024; Sosine & Cox, 2023), and research on the variables that influence service quality in ABA autism service settings.
If researchers can start to address the behavior analytic quality assurance gap in the literature, ABA organizations may be better equipped to adequately protect practitioners, funders, service recipients, and society in general from risks associated with low-quality ABA service delivery experiences. We can strengthen the defensibility of ABA autism therapy in response to its critics. We can more effectively communicate the value of behavior analysis to the world with quality assurance systems that deliver increasingly better clinical outcomes for consumers. And we can better prepare future generations of behavior analysts for high-quality ABA service delivery.
The ABA autism service industry and ABA researchers have already started to take quality more seriously. For example, some researchers have started to address claims of ABA malpractice and harm directly through research on behavioral interventions and responses to flawed scientific articles (Leaf et al., 2018). Some ABA autism service organizations have started to report publicly on their quality metrics, and this is a step in the right direction. But when organizations publish quality metrics, data validating the process underlying those metrics are typically not made publicly available, which limits interpretations of the quality data organizations report. Metrics published with validation data on behavioral service delivery processes with empirical support can help consumers discern between real quality assurance and quality assurance data hand-picked for advertising and recruitment purposes in the same way that treatment integrity and interobserver agreement data increase the believability of behavioral intervention data and clinical decision making.
The remainder of this blog series presents four steps of a research agenda and a call to action for more robust scientific management of ABA service quality grounded in universal principles of managing for quality (i.e., quality planning, control, and improvement) and published experimental evaluations of the variables that influence quality outcomes of common operational and clinical processes in ABA autism service organizations.
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[1] It is acknowledged that ABA service organizations also provide services to individuals without autism and individuals with autism and comorbid conditions and diagnoses. For the remainder of this paper, for simplicity, the author refers to “ABA autism service organizations” because the autistic population is the primary population served by behavior analysts in practice.
[2] Readers are encouraged to see Leaf et al., 2018 for a critical analysis of the study’s major methodological problems.