W
hen Terra Vance took a course to become a registered behavior technician (RBT) in 2015, she was trying to transition from a career as a teacher to one as a psychologist. To get the supervised hours she needed for her psychology license, she had taken a job working with mentally ill adults for a company in Lynchburg, Virginia.Instead, her employer told her the company had a backlog of autistic children and wanted her to help with that caseload. The employer paid for her to get the RBT certification, which would qualify her to deliver what many researchers consider the gold-standard autism therapy, applied behavior analysis (ABA), under supervision to these children.
Vance completed the online course — a series of videos followed by quizzes from a company called Relias — over a weekend. She was intent on learning the material, she says, but found out later that other students cut corners, letting the videos play while they did other things and looking up quiz answers on their phones. It was easy to pass: If you failed a quiz, you could just re-watch the video and take it again.
Vance had spent 14 years teaching English to middle- and high-school students, and she had developed a reputation for helping autistic students. (She was diagnosed with autism herself in 2017.) But when she started accompanying another RBT on home visits, she felt unprepared, she says. Extra training she received from her employer — on privacy, patient rights and restraint training — did not add to her confidence. No one taught her how to change diapers or adequately manage aggression, she says, which she would have found more useful.
Vance also quickly became skeptical of the kind of therapy she was being trained to deliver. For example, she shadowed a more experienced RBT at the home of a 10-year old boy with autism and intellectual disability who had memorized entire movie scripts. Vance recognized that he was communicating with humor and nuance by choosing lines to recite in various situations. But instead of engaging with him through movie lines, she was told by her supervisors to reward the boy with candy or cereal for following commands and completing trivial tasks, such as stacking blocks.
“They were missing so much about this amazing human by just saying he was like a 3-year old,” says Vance, who now heads NeuroClastic, a nonprofit blogging platform about autism. After a few weeks of working with the boy, Vance was laid off and her supervisor was fired, she says.
The sprawling industry that has coalesced around ABA is causing frustration for many — technicians, clients and experts alike. Plenty of therapists in a wide range of settings, including schools, homes and clinics, do ABA well, and plenty of studies support its value, says Zachary Warren, a clinical psychologist at Vanderbilt University in Nashville, Tennessee. But ABA’s worth depends greatly on who is delivering it. And as autism diagnoses and demand for ABA have risen over the past decade, how to ensure people are qualified to deliver the therapy effectively has become a point of contention.
Six years ago, the Behavior Analyst Certification Board, a nonprofit corporation that establishes professional credentialing standards for behavior analysts, created the RBT qualification, largely, they say, to ensure uniform standards for the technicians who increasingly do much of the frontline care. Compared with higher levels of certification that call for at least a college degree, these paraprofessionals need only a high school diploma, a 40-hour course, a background check, an in-person assessment and, starting in 2016, a written test.
The new qualification was followed by a surge in the number of people certified to deliver ABA. Critics, however, have challenged the standards for being too lax. It takes hundreds of hours of training over months to qualify therapists to work independently with children, they say. “Forty hours? You’ve got to be kidding me. Put another zero behind that and maybe that would be closer,” says Jon Bailey, an ABA expert at Florida State University in Tallahassee.
And it’s not just the credentials that have come under scrutiny. On-the-job coaching and supervision are supposed to make up for gaps in the training, but some RBTs find that the agencies they work for do not provide much of either. Technicians describe checked-out or overworked supervisors, little guidance and high turnover, which harms clients along with ABA’s reputation. “The RBT is the hands-on person,” Bailey says. “They should have a lot of training, because if they mess up, you’re messing with people’s lives. This is not like somebody burned a hamburger or something.”
Yet, critics say, the agencies that hire RBTs often rely on a vast pool of undertrained labor. These businesses collectively train and employ tens of thousands of RBTs to work with children. “It’s being treated as a money grab in many places,” Bailey says. He estimates that there are hundreds, if not thousands, of these companies in the United States. Some are profitable enough that they have become popular buys for private equity firms.
Some experts are calling for more stringent certification standards. Others in the field — including Melissa Nosik, deputy chief executive officer of the Behavior Analyst Certification Board — maintain that variation in treatment quality exists in many fields. Training requirements evolve, they say, and the system is doing its part to help meet the demand for qualified people to deliver ABA.
In the meantime, families and therapists are left in a tough spot. “If you have a kid with autism, you’re desperate to get those services, and I don’t think you’re willing to wait until we figure out all of the right things about training, fidelity and implementation,” Warren says. “You want services now, and you want to be able to have a workforce that can deliver that.”