Individuals with autism demonstrate persistent differences in social communication and interactions as well as restricted, repetitive patterns of behavior, interests, or activities (American Psychiatric Association, 2013, 2022). Autism exists on a wide spectrum and there is a great deal of variation in how it affects individuals and their families. According to surveillance data reported by the Centers for Disease Control (CDC) (2023), childhood prevalence estimates of autism have increased dramatically over the last two decades from 1 in 150 in 2000 to 1 in 36 in 2020.
For decades, applied behavior analysis (ABA) has been widely recognized as an effective treatment for autism by numerous independent, government, scientific, and professional bodies (Larsson, E.V., 2021). Unfortunately, there are numerous barriers creating variability in service quality that are preventing patients from accessing the care they deserve, including, but not limited to, unqualified providers falsely claiming expertise in ABA (Dubuque, Yingling, & Allday, 2021); training programs failing to adequately prepare providers (Dubuque & Kazemi, 2022); poor distribution of qualified providers across the country (Yingling, Ruther, & Dubuque, 2022); low and variable reimbursement rates across funding sources (Maglione et al., 2016); overleveraged companies prioritizing profits over patient care (Batt, Appelbaum, Nguyen, 2023); inexperienced clinical providers working with minimal oversight (Behavior Analyst Certification Board [BACB], n.d.); and demand for services far outweighing the supply of qualified ABA providers (BACB, 2023).
Compliance with industry standards developed and enforced by a known and trusted accreditation body is needed to address these barriers. Alongside other quality control mechanisms (e.g., professional certification, licensure), accreditation can help stabilize the industry by promoting standards designed to address meaningful issues preventing access to quality ABA services.
Accreditation offers numerous benefits to individual organizations by verifying and keeping their focus on quality improvement, patient safety, risk mitigation, consumer satisfaction, and professional development. More importantly, widescale adoption of accreditation has the potential to benefit the industry by serving as a stabilizing force that fosters a culture of professionalism, ethical behavior, and continuous improvement. Unfortunately, while these benefits are significant, they may not be strong enough to incentivize the industry to invest the time and resources necessary to pursue accreditation on a large scale. Instead, widescale acceptance and adoption of accreditation is likely to be achieved only when financial and regulatory incentives are created that make it more expensive for organizations to opt out of accreditation than to opt in. Funders are uniquely positioned to create financial incentives to promote the widescale adoption of accreditation by recognizing trusted accreditation bodies. Recognition could come in multiple forms, including limiting access to funding streams, offering preferred rates, expediting the credentialing process, or eliminating administrative burdens for accredited organizations. Funders must be careful when they create financial incentives for organizations to pursue accreditation. Many ABA provider organizations have never gone through an accreditation process and will need adequate time to align their operations to industry standards. Creating incentives that require accreditation too quickly could serve to limit access to services instead of improving access to quality services. Fortunately, funders can mitigate this issue by giving enough notice to providers before these financial incentives are established to ensure organizations have enough time to prepare, apply, and participate in the accreditation review process.
For funder recognition to work, the relationship between funders, provider organizations, and accreditors must be mutually beneficial with appropriate checks and balances coming from all sides. This can be achieved by ensuring that funder concerns about quality, safety and efficiency are addressed within an accreditor’s standards and review process. Accreditation bodies can appropriately balance and incorporate standards that address funder concerns by relying on independent committees comprised of industry experts and representatives from the diverse groups involved in receiving, delivering, supporting and funding services. Accreditation bodies can also appropriately balance provider needs by partnering with state professional and consumer associations who are better equipped to understand the local service landscape and how accreditation can be most beneficial to the providers working within in it. Accreditation bodies can also work together with funders to help align their policies with industry standards, which ultimately should help reduce the administrative burden providers face when trying to comply with the patchwork of policy requirements across different funders.
For recognition to work, it is critical that funders ensure that they do not inadvertently recognize accreditation bodies with known and unknown financial conflicts of interest that compromise their ability to regulate the industry. For example, accreditors should not be involved in selling the organizations or services they regulate. Accreditation bodies perform an important societal function by setting and enforcing industry standards. When these bodies are structured as nonprofits they are better equipped to fulfill this function because they are created to serve the public good and are required to adopt additional safeguards to ensure they remain transparent, accountable, and trusted by the communities they serve. For example, nonprofit status helps ensure an accreditation body is not concealing its sources of financial support or any agreements made to secure that support from unknown sources. The integrity of an accreditor is not guaranteed by its nonprofit status; however, this status and the additional safeguards it brings are designed to help prevent financial conflicts of interest and unethical behavior.
Widespread adoption of accreditation for ABA service providers is an important step the industry needs to take to address the numerous barriers preventing families from accessing the care they deserve. Funders can help promote this adoption by creating financial incentives that encourage organizations to pursue accreditation from trusted nonprofit bodies.
The author is the Director of the Autism Commission on Quality (ACQ), a nonprofit accreditation body for organizations offering applied behavior analysis as a healthcare service to individuals and families affected by autism. ACQ is backed by the Council of Autism Service Providers (CASP), a known and trusted trade association with over 350 organizational members serving over 125,000 individuals with autism. More information about ACQ and CASP can be found at autismcommission.org and casproviders.org.
References
American Psychiatric Association. (2013). Neurodevelopmental Disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425787.x01_Neurodevelopmental_Disorders
American Psychiatric Association. (2022). Autism Spectrum Disorder. https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-AutismSpectrumDisorder.pdf
Batt, R., Appelbaum, E. & Nguyen, Q. T. (2023, June 21). Pocketing money meant for kids: Private equity in autism services. Center for Economic and Policy Research. https://cepr.net/report/pocketing-money-meant-for-kids-private-equity-in-autism-services/
Behavior Analyst Certification Board. (2023). US employment demand for behavior analysts: 2010–2022. Littleton, CO: Author
Behavior Analyst Certification Board. (n.d). BACB certificant data. https://www.bacb.com/BACB-certificant-data
Centers for Disease Control and Prevention [CDC] (2023, April 4). Data & Statistics on Autism Spectrum Disorder. https://www.cdc.gov/ncbddd/autism/data.html
Dubuque, E. M. & Kazemi, E. (2022). An investigation of BCBA exam pass rates as a quality indicator of applied behavior analysis training programs. Behavior Analysis in Practice, 15, 909-923. https://doi.org/10.1007/s40617-021-00660-x
Dubuque, E. M., Yingling, M. E., & Allday, R. A. (2020). The misclassification of behavior analysts: How National Provider Identifiers (NPI) fail to adequately capture the scope of the field. Behavior Analysis in Practice, 14(1), 214-229. https://doi.org/10.1007/s40617-020-00451-w
Larsson, E.V. (2021). Are applied behavior analysis (ABA) and early intensive behavioral intervention (EIBI) effective, medically necessary treatments for autism? A cumulative history of impartial independent reviews. Cambridge Center for Behavioral Studies. https://behavior.org/wp-content/uploads/2017/06/Larsson2021AreABAandEIBIEffectiveTreatmentsforAutismReviews.pdf
Maglione, M. A., Kadiyala, S., Kress, A. M., Hastings, J. L., O’Hanlon, C. E. (2016, January 11). Reimbursement rates for ABA, Medicaid, and commercial insurance. In TRICARE Applied Behavior Analysis (ABA) Benefit: Comparison with Medicaid and Commercial Benefits. RAND Corporation, 27-50. https://www.jstor.org/stable/10.7249/j.ctt1b67wmj.9
Yingling, M. E., Ruther, M. H., & Dubuque, E. M. (2022). Trends in geographic access to Board Certified Behavior Analysts among children with autism spectrum disorder, 2018 – 2021. Journal of Autism and Developmental Disorders. 52(12), 5483-5490. https://doi.org/10.1007/s10803-021-05402-0
