Culture and Language Inclusion in the Practice of Applied Behavior Analysis: Next Steps for Improving Outcomes for Autistic Clients

Abstract

As applied behavior analysis (ABA) is widely prescribed as an intervention for autistic children, ABA practitioners must have a thorough understanding of the impact of language and culture on the individuals and families they serve. The twin purposes of this article are to discuss cultural humility in ASD service delivery, and to provide an overview of practice parameters for the expansion of equity and inclusion. These efforts are guided by the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Readers will be provided with recommendations for incorporating culturally and linguistically appropriate services into training, practice, and supervision in ABA settings.

For healthcare services, including Applied Behavior Analysis (ABA)1, the direct recipient of services (i.e., “client”; Behavior Analyst Certification Board [BACB], 2020, p. 3) is, or rather, should be, at the center of their care system. As ABA is widely prescribed as an intervention for autistic children (Hyman et al., 2020), ABA practitioners must have a thorough understanding of the impact of language and culture on the individuals and families served (Dennison et al., 2019). In the pages that follow, we do not recommend clinicians strive to become an expert on every possible client population. On the contrary, providers in the field would be well-suited to support the client’s perspective as paramount, seeking to understand their values, experiences, and culture. As such, to render appropriate services in this context, ABA providers must consider their personal positions in time and space (Sànchez, 2010), and consistently engage in a process of ongoing reflection, assessment, and action (Miller et al., 2019).

We are adding our voices to the recent calls for change in ABA (Mathur & Rodriguez, 2021; Miller et al., 2019; Pritchett et al., 2021; Veneziano & Shea, 2022) and we offer this work as an initial step, situated within a larger set of action steps, which will improve outcomes for individuals and families who seek ABA services because of an ASD diagnosis. Similar to Pritchett et al. (2021), our aim is to affect functional as opposed to topographical change, in a manner that motivates our colleagues to reflect, connect, and act (Miller et al., 2019). The twin purposes of this article are to discuss cultural humility in ASD service delivery, and to provide an overview of practice parameters, for the expansion of equity and inclusion, guided by the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (U.S. Department of Health & Human Services [DHHS], 2016).

Introduction to the National CLAS Standards

Originally drafted as a set of 14 standards in 2001, the The Office of Minority Health released an updated version of the National CLAS Standards in 2013 to improve quality of care, eliminate health disparities, and advance equity in health-care settings (Aggarwal et al., 2017; DHHS, 2016). To achieve these aims, the National CLAS Standards provide guidance to health-care systems in the following three areas:

• Governance, Leadership, and Workforce—In addition to hiring professionals from diverse cultures and providing training on cultural inclusion, programs must ensure policies are constructed in a way that honors the linguistic needs and various cultures of those requesting service;

• Communication and Language Assistance—Programs must offer services, written forms, and documents in preferred languages to promote understanding and information sharing; and

• Engagement, Continuous Improvement, and Accountability—Programs must create culturally and linguistically appropriate goals, partnerships, processes, and quality assurance standards (DHHS, 2016).

A handout containing the 15 standards, along with resources and guides for implementation, is available on the Think Cultural Health webpage at HHS.gov.

The Role of Culture in ABA

While hospitals (Diener, 2021) and behavioral health agencies (Aggarwal et al., 2017) are implementing and evaluating the National CLAS Standards with their respective client populations, Miller et al. (2019) sets the context in ABA by providing a rationale for culturally and linguistically appropriate service delivery. The racial and ethnic demographics of the United States are shifting, and as a result it is imperative that ABA professionals deliver care with intention and humility (Miller et al., 2019). In a time of systemic reflection, failure to consider culture, across systems of care, not only violates our ethical standards, it also perpetuates a system of disproportionality within the ABA industry, and in the larger health care context in the United States.

Culture can be described as the languages, customs, and knowledge of a group of people, an array of characteristics woven delicately into the intricate tapestry of a person’s existence. Culture cannot be encompassed simply by checking a box on an intake form, nor can it be summed up in a sentence or glossed over in a 1-hr competency course. Long-term, sustainable change requires a multifaceted approach that moves individuals from contemplation to action. Our collective actions will not only advance our science but will ultimately improve outcomes for the communities we serve.

To add additional clarity to an increasingly complex set of issues, we provide the following definitions of diversity, equity, and inclusion (DEI), as endorsed by the DEI Special Interest Group (SIG), an affiliate of the Association for Contextual Behavioral Science (Luo, 2019). The definitions the SIG endorses were informed by terms used at the University of Houston, the Independent Sector, the University of California at Berkeley, and America Healing, a racial equity initiative of the W. K. Kellogg Foundation.

Diversity—Psychological, physical, and social differences that occur among any and all individuals. Diversity includes all the ways in which people differ, encompassing the different characteristics that make one individual or group different from another, including but not limited to: race, ethnicity, national origin, religion, socioeconomic status, education, marital status, language, age, gender, gender identity and expression, sexual orientation, mental or physical ability, veteran status, genetic information and learning styles. Our definition also includes diversity of thought: ideas, perspectives, and values. We recognize that individuals affiliate with multiple identities. A diverse group, community, or organization is one in which a variety of social and cultural characteristics exist.

Equity—The guarantee of fair treatment, access, opportunity, and advancement for all while at the same time striving to identify and eliminate barriers that have prevented the full participation of marginalized groups.

Inclusion—Authentically bringing traditionally excluded individuals and/or groups into processes, activities, and decision/policy making in a way that shares power.

In psychological research, authenticity is an essential component of well-being, operationally defined as the “unobstructed operation of one’s true or core self in one’s daily enterprise” (Goldman & Kernis, 2002, p. 3). We believe all ABA professionals serving individuals and their families should honor the many ways in which people differ, in addition to actively working towards equity for clients and staff. We also believe ABA professionals who operate within systems of privilege, with access to power, should engage in activities that create pathways for clients and staff to also access privilege and power, on a daily basis, especially when those decisions or policies directly affect members of marginalized groups.

Researchers have explored the impact of a practitioner’s culture on their behavior and delivery of therapeutic services (Fong et al., 2016) and made the case for culturally responsive care in ABA (BACB, 2020; Beaulieu et al., 2018). We recognize culture affects biases, interpretations of behavior, and responses to others, and our aim is to take this base of knowledge and apply it further in practice standards, ethical codes, training, and continuing education, in particular for the practice of ABA. The following section includes a brief discussion of recent relevant literature, centered on disparities in access to care among autistic children.

Disparities in Access to Care

Although health equity is the standard for which various health-care systems should strive, much work remains to be done regarding equity in ABA service delivery, particularly when providing services to individuals and families affected by an ASD diagnosis. As evidenced by our clinical experiences and review of extant literature, briefly summarized below, children of color are disproportionately absent in normative data on rates of diagnosis, access to services, and service penetration in medical treatment of ASD.

A growing body of research compares health disparities among culturally diverse communities and the majority White population throughout the United States, and these systemic issues have been brought to the forefront in recent months. On May 29, 2020, the American Public Health Association (APHA, 2020) declared racism to be an ongoing public health crisis that demands immediate attention and action. Researchers have recently named institutional racism as a barrier faced by Black caregivers of autistic children, during the diagnostic process and when navigating ASD-related services (Čolić et al., 2021). Additional research is needed to document the experiences of other culturally and linguistically diverse families seeking ASD-related services and supports, and add these voices to the extant literature. In addition, we encourage ABA organizations to implement the recommendations offered by Levy et al. (2021) to actively dismantle racist policies and practices across all levels of the ABA industry.

For nearly 2 decades, Mandell and colleagues have sounded the alarm, bringing attention to the cultural exclusion of children of color, particularly Black autistic children, from high-quality services, across systems of care (Jones & Mandell, 2020; Mandell et al., 2009; Mandell et al., 2002). In more recent research, the National Survey of Children with Special Health Care Needs has documented additional health-care disparities. The researchers found the following:

1. White autistic children were more likely to receive coordinated care and have access to family-centered care than non-White children (Doshi et al., 2017).

2. Autistic children, particularly those who are Latinx or Black, faced greater challenges in receiving high-quality health care (Magaña et al., 2012).

3. Compared with White children, Latinx autistic children had a consistent pattern of worse health-care access, utilization, and quality (Magaña et al., 2012).

4. Black and Latinx parents were significantly less likely than White parents to report that their providers spent enough time with their children and were sensitive to their family values (Magaña et al., 2015).

Research has also suggested that language barriers and immigration concerns have contributed to a lack of appropriate diagnostic and intervention services for Latinx children and therefore to their underrepresentation in autism diagnosis rates (Yingling et al., 2018). To advance the provision of inclusive services, all professionals within the ASD space should adhere to a shared set of cultural ethics and engage in ongoing self-reflection, with shared accountability, to create a pathway of openness for others (BACB, 2020). A culturally responsive clinician will be better positioned to discern the impact of culture on ASD symptom presentation (Bernier et al., 2010). Further, practitioners must incorporate this knowledge, attitude, and behavior in various aspects of treatment delivery and in the training and guidance they provide to registered behavior technicians (RBTs) under their supervision (BACB, 2020).

Recommendations for Practice Modifications

As an evolving field of behavioral health care, ABA could greatly benefit from a specific set of culturally and linguistically appropriate standards in line with those used in other mental and physical healthcare fields. The field of ABA suffers from gross underrepresentation from culturally diverse populations, as indicated by the latest demographic data published by the BACB (see Fig. 1).

Fig. 1.

This chart depicts data reported by certificants in their BACB accounts. These images were last updated on January 4, 2023. The results are as follows: White 69.16%; No Answer 4.56%; American Indian/Alaskan Native 0.28%; Asian 7.39%; Black 4.21%; Hispanic/Latinx 11.04%, and Native Hawaiian/Pacific Islander 0.37% (BACB, 2023)

It is our assertion that a lack of cultural diversity among ABA certificants (Beene, 2019) leaves room for perpetuation of the dominant culture’s values, practices, and beliefs, at best, and systemic injustices and irreparable harm to diverse populations, at worst. We agree with Fong et al. (2017)—we can no longer ignore the shifting demographics of the United States. We must create pipelines to increase the representation within our field, to serve increasingly diverse client populations who could benefit from well-trained, humble, responsive professionals who understand their unique linguistic and cultural needs.

The evidence base for the National CLAS Standards is building in health-care settings across the United States (Aggarwal et al., 2017; Barksdale et al., 2017) and researchers have developed tools evaluate adherence, in particular within behavioral health organizations (i.e., The Organizational Multicultural Competence Assessment [OMCA]; Delphin-Rittmon et al., 2021). The following table lists all 15 of the National CLAS Standards, along with an example of how these standards may be applied in ABA settings. We encourage readers to use the table as a guide to not only reflect on their own practices, but to create an action plan with reasonable timelines for implementation of these recommendations.

The authors also provide several recommendations (see Table 1) to bring ABA practice guidelines, such as the BACB Ethics Code for Behavior Analysts (BACB, 2020) and the fifth edition of the BCBA Task List (BACB, 2017), into alignment with the National CLAS Standards. Although the latest iteration of the Ethics Code does list cultural responsiveness as the final example of ways that BCBAs can “ensure their competence” (BACB, 2020, p. 4), there is work to be done to ensure BCBAs act in accordance with best practices related to culture and language inclusion. Although not included in our table, state departments of health that license ABA practitioners at all levels (i.e., behavior technicians, assistant behavior analysts, and behavior analysts) can also play a role by requiring evidence of cultural and linguistic training. Further, now that the Association for Behavior Analysis International oversees the approval of verified course sequences (VCS), now is the time to consider incorporation of cultural and linguistic course content in preparation of behavior analysts. However, such a change would require further revision of the BCBA fifth edition Task List, on which the VCS standards are based. Simple nondiscrimination statements will no longer suffice; quantifiable, systems-wide change requires multitiered, committed action (Akpapuna et al., 2020). As we know, social validity is a fundamental principle in ABA, both in research and applied settings (Wolf, 1978). Although Pritchett et al. (2021) posited that ongoing assessment of social validity would increase responsiveness to the “established and emergent values of the participant” in an empirical context (p. 4), we argue the same could be true in applied settings.

Table 1.

Proposed Modifications to Current ABA Practice Standards

Topic	Proposed Modification	Benefit	Relevant Standard
ABA Service Forms for Caretakers	All forms associated with the practice of ABA should be provided in any threshold language (a language identified as being the primary language of more than 30% of the population in the geographic area where services are being delivered). Forms should be provided to caregivers in their preferred languages, specifically any forms requiring consent.	Meet the informed consent requirement for service delivery (decision capacity, disclosure, and competency). Align with informed consent requirements in other fields of medical and mental health.	Ethics Code 2.08 Communicating about Services Ethics Code 2.11 Obtaining Informed Consent Ethics Code 2.16 Describing Behavior-Change Interventions Before Implementation
The Use of Translators	Certified or designated fluent staff should communicate with caregivers in their preferred languages. If staff are not available, the use of a language line should be required for critical information exchanges, assessments involving caregivers, and family guidance/caregiver training. In addition, practitioners should provide information on language availability for caregivers and facilitate timely access to resources.	Provide more professional communication exchanges, invite more active caregiver inclusion in service delivery, and provide clinicians with more accurate information to inform decisions.	Ethics Code 2.08 Communicating about Services Ethics Code 2.11 Obtaining Informed Consent Ethics Code 2.16 Describing Behavior-Change Interventions Before Implementation
Cultural Responsiveness Training for RBTs	Specific culturally and linguistically inclusive training should be required for RBTs, and assessed as part of the RBT competency exam, and included in the RBT Ethics Code. This training should center the core CLAS principles and standards, with a specific focus on inclusion, treatment services, and communication.	Improve RBTs’ understanding of cultural inclusion, better equipping them to understand cultural implications for behavior and interventions.	RBT Task List (2nd Ed.) Section F. Professional Conduct and Scope of Practice RBT Competency Assessment RBT Ethics Code Section 2. Responsibility to Clients
Right to Culturally and Linguistically Inclusive Treatment	Client’s right to linguistically and culturally inclusive treatment should be included in the second section of the BCBA Ethics Code. Practitioners should factor in cultural presentations of behavior and should consider these factors in the clinical formulation of the case and any associated treatment.	Identify and respect the role of cultural inclusivity in treatment. Create a whole-person approach to the delivery of quality ABA services.	BCBA Ethics Code 2.01 Providing Effective Treatment BCBA 5th Ed. Task List Section 1(a)
Consideration of Culture and Language in Assessment		Allowing for the appropriate assessment of the complete individual better informs treatment. Openly and professionally obtaining information relevant to the assessment from caregivers allows for more insight. Providing accurate information to caregivers builds rapport and engages them in the therapeutic process.	BCBA Ethics Code 2.13 Selecting, Designing, and Implementing Assessments

We add our voice to the calls for change within the field, in particular related to culture and language inclusion in ABA (Beaulieu, 2018; Fong et al., 2016; Fong et al., 2017; Wang et al., 2019). The implementation of these recommendations would position ABA as a more inclusive service, with improved outcomes and more equitable treatment. Weighing behavioral presentation in the context of culture would benefit the overall treatment of an individual and could potentially assist in the continued development of diagnostic and treatment frameworks (Bernier et al., 2010). The recommendations are interconnected, with each category lending strength to the next (see Fig. 2).

Fig. 2.

Interconnected concepts for excellence in linguistically and culturally appropriate ABA. This figure is a circle, with four equal quadrants, with two arrows circling around the center, to illustrate the interconnectedness of four concepts: Code of Ethics, Training & Task List, Continuing Education, and Practice Standards

The Impact of Recommendations on ABA Practice

Bringing ABA into compliance with the minimum standards of large-scale health-care providers requires an examination of the impact of language and culture on day-to-day practices within the profession. Prior to obtaining consent for assessment and services, a care provider should deliver all documents, forms, and other communication in the client and family’s primary language. This may require the use of qualified translators, sign language interpreters, Braille materials, or other accommodations for individuals with hearing, vision, or other impairments. Failure to do so could jeopardize the legal and ethical requirement to obtain informed consent and could also result in the omission of key variables that could have a detrimental impact on service delivery. When ABA service providers collect relevant cultural information from the individual and families at intake and throughout the assessment process, the client has the opportunity to learn skills that increase their participation in family events, religious and community organizations, and activities that are in alignment with their values.

The Impact of Recommendations on Preparation, Training, and Supervision of ABA Service Providers

Training of ABA service providers at all levels of credentialing must be inclusive of relevant cultural information and its historical context, including impacts, current implications, and applications to practice (Conners et al., 2019). Standards must move beyond basic cultural competency training and instead focus on cultural responsiveness and cultural humility, giving honor to the uniqueness of individuals and their experiences. Mathur and Rodriguez (2021) have developed a competency assessment checklist for behavior analysts, which serves as a tangible outcome of the shift that is occurring within our field. Although we agree that current practitioners in the field have a personal responsibility to act, we are also arguing for systems-wide change that would affect preparation of certificants in the field, at all levels (Mathur & Rodriguez, 2021).

At the entry level, the authors recommend that skills related to diversity and inclusion be evidenced during initial and renewal RBT competency assessments required by the BACB. The current RBT competency assessments contain a section on professionalism that includes four interview questions related to client dignity, professional boundaries, supervision requirements, and clinical direction. How simple would it be to add a question, such as: “Cultural Responsiveness—Provide examples of culturally responsive actions you can engage in during sessions” to a competency assessment? This would bring the RBT competency assessment into alignment with the updated BCBA Ethics Code (1.07), which states behavior analysts “evaluate biases of their supervisees and trainees, as well as their supervisees’ and trainees’ ability to address the needs of individuals with diverse needs/backgrounds” (BACB, 2020, p. 9). This question could serve as a prompt to discuss the specific needs of families served by the ABA provider, while also exploring the knowledge, skills, awareness, and attitudes of the practitioner, prior to formal interaction with clients and families Table 2.

Table 2.

Examples of CLAS Standards in an ABA Context

Domain	CLAS Standard	ABA Examples
Principal Standard	1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.	Honor the values, beliefs, and cultural practices of the families served, giving them a role in treatment and in the delivery of services Enhance caregiver participation by incorporating skills that are meaningful for the family unit Teach the client to participate in family cultural events and traditions
Governance, Leadership, & Workforce	2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.	Develop and promote health equity leaders from within the organization Recruit and retain culturally and linguistically diverse workforce and board, at all levels within the organization Promote an environment of inclusion and governance that is reflective of the cultures and abilities of clients served Policies and hiring practices should align with CLAS standards and be culturally inclusive Provide comprehensive training on cultural inclusion, upon hire, and throughout the year Build training programs that are linguistically and culturally inclusive Performance appraisals and associated training plans should reflect CLAS Standards
Communication & Language Assistance	5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.	Obtain information on the cultural demographics of the area All marketing, outreach content, and legal/service forms should be in threshold languages where services are provided Provide access to qualified translators (ideally staff within the agency), at no cost to the family Contract for language service lines and make such services available to caregivers for all assessments, family engagement, and communication
Engagement, Continuous Improvement, & Accountability	9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations. 10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.	Create meaningful partnerships with key community stakeholders Allow these stakeholders to provide input in development of new policies and procedures Solicit feedback from community stakeholders on existing practices Encourage and allow for mentorship opportunities Promote a culture of volunteerism with local community agencies Provide pro bono, sliding scale, or government-funded services to families who do not have private insurance Ensure HR policies are culturally and linguistically inclusive

To support the ongoing development of a culturally responsive workforce, Table 2 provides additional recommendations for supervisors. Conners and Capell’s (2020) recent book serves as an excellent resource for building foundational knowledge related to multiculturalism and diversity in ABA, including six chapters focused on specific diverse populations. Cultural immersion experiences (i.e., interaction with a culture different than one’s own), which have been a research-informed component of graduate counseling programs for over 25 years, can also provide opportunities for RBTs to connect with local artisans, leaders, and community organizers to learn from others while also exploring their own cultural identities (Pope-Davis et al., 1997).

Culturally relevant training standards at the university level must also be required for BACB-approved course sequences and undergraduate and graduate programs that prepare students for credentialing as BCBAs and BCaBAs. Conners et al. (2019) provided a thorough analysis of gaps in didactic training and fieldwork experiences for a sample of 575 certificants from the United States and countries across the globe (N = 575; 86.26% from the United States). The findings revealed a need for more comprehensive training on multiculturalism and diversity issues, both in coursework and during field experiences. The authors recommended university programs incorporate multicultural content within the supervision course that is required by the fifth edition of the BCBA Task List (Conners et al., 2019). However, we would like to take this a step further and recommend a 3-credit hour course on multicultural issues in ABA, along with evidence of cultural and linguistic diversity training across the curriculum, for all VCSs (Conners & Capell, 2020). Najdowski et al. (2021) have developed a critical framework that will serve us well to implement across all graduate training programs in ABA. This would ensure practitioners obtain high-quality professional preparation on topics related to diversity, inclusion, language, and culture prior to sitting for certification exams. Beginning in 2025, the BCBA certification exam will include content on cultural humility and culturally responsive service delivery across four of the nine domains (BACB, 2022). Lastly, we are glad to note that the BACB® plans to require two DEI CEUs per certification period, beginning January 1, 2027, as indicated in their March 2022 newsletter (BACB®, 2023). We consider these actions as steps in the right direction.

Implications for Future Research

Additional research, using a wide range of methodologies, is needed to identify the impact of cultural responsiveness on client outcomes in ABA, in particular for autistic children of color, who have largely been excluded from systems of care. In an examination of ABA research through a social justice lens, Pritchett et al. (2021) conducted an analysis of 50 years of articles published in the Journal of Applied Behavior Analysis and reported several key takeaways. First, descriptions of the informed consent process were largely absent, or limited, at best. Second, the research questions were chosen by the analysts, not by the communities or individuals in the studies. Third, little to no demographic information was collected and reported. Fourth, few studies made mention of socially significant improvements in the lives of participants when the studies ended (Pritchett et al., 2021). It is sad that the call to action made by one of ABA’s founders 44 years ago still rings true today—“Well, if social validity is such a good thing, why haven’t we been doing more of it all along” (Wolf, 1978, p. 211).

Future studies could also examine the impact of culture and language inclusion for adult populations who often struggle to obtain diagnoses, limiting access to care. Intersectionality, or the relationship between several aspects of one's identity (e.g., class, sexual orientation, age, gender expression, religion), is also an understudied phenomenon in ASD research. Regarding practitioner preparation and staff development, research within the field of organizational behavior management (OBM) is needed to examine the impact of culture and language inclusion in the field of ABA, particularly for recruitment and retention of diverse practitioners. These are but a few of an endless number of implications for future research related to culture and language inclusion in ABA.

Discussion

The call for cultural sensitivity and responsiveness in health care has never been louder. To echo Pritchett et al. (2021), who called for a shift within the ABA research paradigm, we attest that “it is time” for true change in applied clinical settings. The true change we seek does require accountability; however, the application of our science must evolve from a mentality of simply checking off boxes, to instead adopting a living and breathing view of human identity (Pritchett et al., 2021). In ABA, ongoing pursuit of socially significant client outcomes should be our primary goal. The only way to reach this aim is by considering the whole person, and including culturally relevant practices across the entire system of care. Over time, we can co-create systems to measure the impact of these changes on access to high-quality care, and achievement of socially significant treatment goals (Mathur & Rodriguez, 2021).

ABA professionals must consider and fairly assess the complete identity of an autistic individual before services informed by cultural and language considerations can be applied. As caregivers are an integral component of the ASD pediatric community, their inclusion in service delivery must be considered and any needed linguistic accommodations must be made. ABA providers should consider establishing their own infrastructure to ensure that culturally sensitive services are delivered, by way of a top–down and bottom–up leadership structure. Bi-directional leadership allows for a diverse group of RBTs, BCaBAs, and BCBAs to advocate for cultural and language inclusion and provide essential guidance to an executive leadership team. The senior leadership team will ultimately take responsibility for facilitating and monitoring the essential inputs (e.g., staff training) and outputs (e.g., the production of pertinent policies, procedures, and standard operating procedures) that will result in organizational change. Finally, we encourage the creation and dissemination of universally adopted CLAS standards in ABA, spanning from practitioner preparation to practice.

All proposed practice modifications made in Table 2 can be implemented by an organization in the absence of guidelines issued by a governing body, in collaboration with other health-care providers who also serve the client and family. An interdisciplinary approach provides ABA practitioners with an opportunity to learn from other related disciplines who are further along the continuum. However, the indispensable corrective involves psychological flexibility and committed action at every level. More to the point, the voices that will guide organizational and operational change need to emerge from every direction. In particular, both institutional and grassroots initiatives are necessary. Many medical and behavioral health professions have adopted cultural standards of practice, and it is time for ABA to follow this path. Doing so would allow for the continued development of policies, training programs, guidelines, and treatment plans with the aim of delivering the highest quality of care and engagement. An exploration of cultural identity and its impact on ABA should begin in formal educational programs and continue to be present and woven throughout the learning lifespan of the professional. Cultural identity affects behavior in various ways and therefore must be considered across ASD systems of care. We can each do our part to promote true cultural and linguistic inclusion, and together, our efforts will have a lasting impact for the communities we serve.

Declarations

The authors also provide several recommendations to bring ABA practice guidelines, such as the BACB Ethics Code for Behavior Analysts (BACB, 2020) and the fifth edition of the BCBA Task List (BACB, 2017), into alignment with the National CLAS Standards.