Behavior Analysts' Use of Treatments for Individuals with Autism: Trends within the Field

Abstract

Previous surveys revealed the majority of certified behavior analysts reported using applied behavior analysis (ABA) as a treatment for individuals on the autism spectrum. However, some certificants have also reported using treatments without evidence (Schreck et al. Behavioral Interventions, 31(4), 355–376, 2016; Schreck & Mazur Behavioral Interventions: Theory & Practice in Residential & Community‐ Based Clinical Programs, 23(3), 201–212, 2008). The field of ABA has undergone many changes in the last five years. This survey evaluated trends in the use and variables influencing the use of autism treatments over that time. Results indicated that study participants (N = 921 BCBA-Ds, BCBAs, BCaBAs, and RBTs) were significantly less likely to report current use of ABA and some unestablished treatments (e.g., DIR Floortime, sensory integration therapy) than participants in 2016 (Schreck et al. Behavioral Interventions, 31(4), 355–376, 2016). Participants frequently cited persuasion by others as an influence for their treatment selections. Because behavior analysts’ use of unestablished treatments may be detrimental to client outcomes and the reputation and success of the field of ABA, future research is needed to identify methods for increasing behavior analysts’ use of empirically supported treatments.

In 2008, Schreck and Mazur surveyed 469 certificants of the Behavior Analyst Certification Board (BACB), including board certified behavior analysts (BCBAs) and board-certified assistant behavior analysts (BCaBAs), about their beliefs and use of treatments for individuals on the autism spectrum. They found that at least one participant reported the use of each intervention presented, including those that were not empirically supported (e.g., auditory integration training) or known to cause harm (e.g., facilitated communication). Likewise, in a follow-up study, Schreck et al. (2016) found that a statistically significant number of BACB certified behavior analysts of all levels (N = 848 BCBAs, BCaBAs, board certified behavior analysts-doctoral [BCBA-Ds]) used treatments without sufficient empirical support (e.g., Treatment and Education of Autistic and Communication Handicapped Children [TEACCH], sensory integration therapy). A small percentage of participants (up to 5.5%) reported using ineffective/harmful treatments including facilitated communication/rapid prompting method and gluten-free casein-free diets. In addition to reporting use of nonempirically supported treatments (NESTs), some participants ranked NESTs (e.g., sensory integration therapy, facilitated communication/rapid prompting method) as the most effective treatment for individuals on the autism spectrum. According to the results of these studies, a subset of certified behavior analytic practitioners believed that NESTs were the most effective for and were using these treatments in the care of individuals on the autism spectrum.

Evidence-based practice has been defined as a model comprised of three pillars: empirical support, client values and context, and the expertise of the professional (Slocum et al., 2014). Certified behavior analysts are required by the Ethics Code for Behavior Analysts to use all of these pillars when making treatment decisions (BACB, 2020; Code 1.05, 1.06, 2.01, 2.09, 2.13, 2.14). The use of NESTs violates behavior analysts’ ethical commitments to maximize client benefits, minimize risk of harm, and use scientifically validated interventions that align with the principles of behavior analysis (BACB, 2020; Code 2.01, 2.14, 2.15). Use of NESTs may also result in significantly poorer client outcomes (e.g., Howard et al., 2005; Howard et al., 2014). Previous comparison has indicated that purely behavioral interventions resulted in greater increases in cognitive abilities, language, and adaptive skills for preschool-aged children on the autism spectrum than intensive and nonintensive eclectic interventions (Howard et al., 2005). Long-term follow up found maintenance of these gains including higher scores on standardized assessments of cognition, language, and adaptive skills for those who received behavioral interventions than for their peers in the eclectic group, with individuals in the behavioral intervention group being more than twice as likely to score in the average range (Howard et al., 2014). These studies highlight the importance of behavior analytic practitioners implementing empirically supported treatments (ESTs) for their clients on the autism spectrum.

Recently, the BACB increased educational and experiential requirements for behavior analyst certification (BACB, 2012, 2017). These educational changes included increases in coursework hours and revisions to the ethical code (BACB, 2020, 2012, 2017). The number of BACB certificants across all certification levels (BCBA, BCaBA, BCBA-D and registered behavior technician [RBT]) has exponentially increased over the last five years (BACB, n.d.). As of April 1, 2022, more than 72% of certificants practiced in the area of autism (BACB, n.d.). As the field evolves, RBTs outnumber other behavior analytic certificants and provide a significantly higher proportion of direct care and treatment implementation. Although BCBAs and BCBA-Ds must supervise RBTs, a substantial amount of their day-to-day treatment implementation remains independent (i.e., as much as 95% of behavior analytic services are unsupervised).

With the many changes to the field of ABA (i.e., the increased presence of RBTs, increased number of overall certificants, and revisions to certification requirements), certificants’ use of ESTs and the variables related to their use of ESTs and NESTs must be ascertained. The purpose of this study was to replicate and extend the previous studies conducted by Schreck and colleagues (Schreck et al., 2016; Schreck & Mazur, 2008) to examine behavior analysts’ use of empirically supported treatments. Specifically, we wanted to understand how one pillar of evidence-based practice, scientific evidence, impacted practitioners’ clinical decision-making. In this study changes were made to: (a) reflect changes in treatment popularity and (b) add RBTs to the participant pool. Statistical analyses were also used to provide a comparison between current data and data from previous research (Schreck et al., 2016) to identify trends within the field.

Methods

Participants

Participants were BACB certified individuals (N = 921) holding BCBA-D (n = 38, 4.1%), BCBA (n = 475, 51.6%), BCaBA (n = 22, 2.4%), or RBT (n = 386, 41.9%) certifications. The majority of participants reported identifying as female (n = 822; 89%) and the most reported age group of participants was 26–30 years old (n = 180; 20%). All participants had to report treating at least one individual with autism in their career to complete the survey. Across their careers, the greatest percentage of BCBA-Ds and BCBAs reported treating 50 or more individuals with autism, whereas the greatest percentage of RBTs and BCaBAs reported treating 11–20 individuals with autism. Additional demographic information separated by certification level is shown in Table 1.

Table 1.

Demographic Variables by Percentage of Participants at Each Certificate Level

Demographic variable		BCBA-D (n = 38)	BCBA (n = 475)	BCaBA (n = 22)	RBT (n = 386)
Age	Under 20 years old	0	0	0	2
	21–25 years old	0	3	18	29
	26–30 years old	5	20	9	22
	31–35 years old	16	25	18	11
	36–40 years old	11	18	27	7
	41–50 years old	22	18	14	17
	51–60 years old	22	11	0	9
	60+ years old	24	7	14	3
	No response	0	< 1	0	0
Gender	Male	24	11	5	8
	Female	74	89	95	92
	Choose not to disclose	0	< 1	0	< 1
	Other	0	0	0	1
	No response	3	< 1	0	0
Highest degree obtained	High school diploma	0	0	0	16
	Bachelor’s degree	0	< 1	50	61
	Master’s degree	0	95	50	22
	Doctoral degree	97	4	0	1
	No response	3	< 1	0	0
Undergraduate major	ABA	5	5	28	6
	Psychologya	63	58	56	47
	Special education	21	12	0	4
	Speech language pathology	3	2	5	3
	Education—other	8	10	18	7
	Occupational therapy	0	< 1	0	1
	Social work	0	4	0	3
	Other	16	27	32	26
	No response	0	< 1	0	17
Graduate major	ABA	50	66	73	51
	Psychologya	50	22	18	29
	Special education	24	29	36	19
	Speech language pathology	3	1	9	1
	Education—other	3	11	0	10
	Occupational therapy	0	< 1	0	1
	Social work	0	1	9	2
	Other	8	9	0	22
	No response	0	< 1	0	0
BCBA training	Certificate program	24	30	68	-
	Bachelor’s program	0	< 1	14	-
	Master’s program	34	68	18	-
	Doctoral program	39	1	0	-
	No response	3	1	0	-
Number of supervisors	1	45	32	55	-
	2–3	37	52	41	-
	4–5	13	13	5	-
	Other	3	2	0	-
	No response	3	< 1	0	-
Number of years certified	Under 5	5	44	55	75
	5–10	29	28	36	8
	11–20	50	9	0	0
	Over 20	3	0	0	0
	No response	13	19	9	17
Other licenses/ certifications held	Psychology	32	6	14	7
	Counseling	0	3	0	1
	School psychology	13	2	0	1
	Speech language pathology	3	1	0	1
	Occupational therapy	0	< 1	0	1
	Social work	0	2	0	1
	Other	32	22	23	10
	None	29	62	64	74
	No response	5	7	0	6
Primary area of practice	Psychology	26	2	0	14
	Counseling	0	1	0	4
	School psychology	0	3	0	0
	Speech language pathology	0	1	13	1
	Occupational therapy	0	0	0	3
	Social work	0	< 1	0	0
	Behavior analysis	59	79	88	69
	Other	11	13	0	7
	No response	4	1	0	4
Current place of practice	School district	11	26	14	16
	Advocacy organization	0	2	5	2
	Autism school	5	9	18	14
	Private practice	37	28	50	35
	Agency	29	41	32	42
	Other	34	14	18	11
	No response	3	1	0	1
Currently treating individuals with ASD	Yes	87	93	95	95
	No	11	7	5	4
	No response	3	< 1	0	<1
Number of individuals with ASD treated in career	1	0	0	5	3
	2–5	0	2	0	16
	6–10	0	4	9	22
	11–20	3	9	36	24
	21–30	8	17	14	14
	31–50	8	22	9	11
	50+	79	46	28	9
	No response	3	<1	0	0

The table displays the percentage of participants who selected each response out of the number of participants that had access to the question (this varied based on skip and display logic in the survey.) Some questions allowed for multiple selections (e.g., practice site, other licenses held) and therefore percentages may add up to more than 100

^aPsychology undergraduate and graduate major included respondents who selected counseling psychology, developmental psychology, clinical psychology, general psychology, and school/educational psychology

Autism Treatments Survey

The survey consisted of a consent page, demographics, treatment use and variables related to use, treatment rankings, and variables related to each treatment (a copy of the survey can be obtained by contacting the first author). The demographic section (20 questions) included questions related to age, educational level, and certification status. Responses to questions determined further questions; thus, the number of questions depended upon participant answers. Access to further sections of the survey was dependent upon indicating BACB certification status and treatment of at least one individual with autism.

The next section of the survey contained questions directly related to specific treatment use and variables related to use. The survey included 31 treatments selected and revised from Schreck et al. (2016; see procedures for survey development). The name and a brief description of each treatment (see Table 2 for a list of the 31 treatments and their corresponding descriptions) was followed by options to indicate treatment use (i.e., currently use by myself, currently use in collaboration with other professionals, used in the past by myself, used in the past in collaboration, used under the direction of my BCBA supervisor [currently or in the past], never used). If participants selected any option indicating treatment use, they were asked to: (a) indicate their frequency of treatment use; (b) rate the sources that influenced their selection of the treatment (e.g., online sources, academic/research journals, colleagues/coworkers) on a five-point Likert Scale (from very influential to no influence); and (c) select the reasons they continued to use the treatment (e.g., positive feedback, interest from others, efficiency of use, effectiveness, research, reimbursement) or indicate that they no longer used the treatment (the influential variables included in the survey are presented in Table 3).

Table 2.

Included Treatments and Descriptions

Empirical Support	Treatment	Description
Established	ABAa	• Use of principles and procedures of behavior analysis to improve lives • Behavior itself is the primary focus • Increase, maintain, and generalize behaviors, teach new skills, and reduce interfering behaviors
	PECS	(Picture Exchange Communication System®) • Alternative/augmentative communication system using picture exchanges • Language skills are taught over six progressive phases • Protocol uses specific prompting and reinforcement strategies and includes systematic error correction procedures
	Social Stories	• Social learning tool that supports the safe and meaningful exchange of information between parents, professionals, and people with autism • Individualized stories written according to specific guidelines • Describes a situation in terms of relevant cues and common responses • Reflect on the individual’s perception of a situation
	Pivotal response training	• Naturalistic intervention model derived from ABA • Targets pivotal areas of development; motivation, responsivity to multiple cues, self-management, and social initiations • Specific procedures include child choice, task variation, interspersing maintenance and acquisition tasks, rewarding attempts, and the use of direct natural reinforcers • Implemented in the natural environment and emphasizes parent education
Emerging	Relationship Development Intervention	• Parents guide children to initiate and succeed in reciprocal relationships • Parents and caregivers taught to break down and gradually rebuild complex dynamic processes • Interactions embedded in daily routines and activities
	Music therapy	• Music is used within a therapeutic relationship • Treatments may include creating, singing, moving to, and/or listening to music
	TEACCH	(Teaching and Education of Autistic and related Communication-handicapped Children®) • Structured teaching and strategies can be adapted for children and adults of all ages • Individual classroom instruction is designed according to individual learning styles, skills, interests, and needs • Targets critical areas such as executive functioning, engagement, communication, and social skills
Unestablished	DIR Floortime	(aka DIR, Greenspan, Floortime) • Parent/therapist follows the child’s lead • Parent/therapist challenges the child to be creative and spontaneous • Parent/therapist expands interaction to include all or most of the child’s senses, motor skills, and emotions
	Rapid prompting method	(aka Text to Type, Supported Typing, Saved by Typing) • Service provider holds hands, wrists, or arms to help participant spell messages • Messages spelled on keyboard or a board with printed letters • Differs from independently typing or using computerized device
	SCERTS	• Enhances social communication between the parent and the child with ASD • Parents or teachers are taught to arrange the environment and create temptations for the child to initiate communication during daily routines
	Early Start Denver Model	• Fuses behavioral, relationship-based approach with developmental, play-based approach to create individualized and standardized intervention • Provided in the home by trained therapists and parents during natural play and daily routines
	Acceptance and commitment therapy	• A psychological intervention that uses acceptance and mindfulness strategies • Combines these strategies with commitment and behavior change strategies • Increases psychological flexibility
	Social Thinking	(aka Social Detective, Social Behavior Mapping, Superflex!, Garcia Winner) • Curriculum and tools that break down complex social concepts • Targets observation and interpretation of others’ perspectives, changing social behaviors, and reflection on how others’ feel • Specified frameworks, activities, strategies, vocabulary, and assessment techniques
	Gluten-free casein-free diet	• Eliminating foods which contain gluten, casein, or both gluten and casein • Gluten and casein are excluded from the diet for the purpose of changing behavior
	Holding therapy	• Caregiver holds the child very closely and very tightly while speaking in a comforting manner • Caregiver may not release the hold until the child “surrenders” and spontaneously looks into the caregiver’s eyes • Caregiver then returns the child’s gaze and exchanges affection
	Son-Rise	• Therapists believe that respect and deep caring is the most important factor impacting a child’s motivation to learn • Love and acceptance is a meaningful part of every teaching process • Techniques include joining in a child’s repetitive behaviors, utilizing a child’s own motivation, teaching through interactive play, employing a nonjudgmental and optimistic attitude, and placing the parent as the child’s most important and lasting resource
	Auditory integration training	• Service provider identifies sounds that participant is over- or under-sensitive to • High and low frequencies sounds presented via headphones • Over or under-sensitive frequencies completely or partially filtered from the music • Speech sounds are dilated, expanded, and then compressed as the student progresses
	Sensory integration therapy	(aka SIT, SI, Sensory Integrative Therapy) • Treatment aimed to improve attention and cognition, enhance the development of basic sensory integration processes, and decrease disruptive or repetitive behaviors • Uses selected activities that provide tactile, vestibular, proprioceptive, and/or other somatosensory experiences • Encourages adaptive responses • Activities may include brushing the body, compressing the elbows and knees, wearing a weighted vest, swinging, and spinning on a scooter board
	Chiropractic/ Craniosacral	• A human being’s nervous system is essential to health, and interference with this system impairs normal body functions and lowers the body’s resistance to disease • Therapists use gentle touch to balance the cerebrospinal fluid and the membranes and tissues surrounding the spine and brain • Improves central nervous system function and counteracts stress
	Hyperbaric oxygen	• Pressurized containers • Individuals enter and breathe an increased level of oxygen (24%–100% times the normal level) • Individuals experience an increased atmospheric pressure (up to 1.3 times normal pressure)
	Hippotherapy	• Therapy involving children interacting with horses • Purposeful manipulation of equine movement as a therapy tool • Engages sensory, neuromotor and cognitive systems to promote functional outcomes
	Complementary Medicine	(includes Anti-fungal, Essential oils, CBD oil, Acupuncture, Vitamin therapy, Bleach therapyb) • Broad domain of healing resources that encompasses all health systems, modalities, and practices • Does not include practices of the politically dominant health system • Includes all practices and ideas defined by users as preventing or treating illness or promoting health and well-being
Ineffective/ Harmful	Facilitated communication	(aka Text to Type, Supported Typing, Saved by Typing) • Service provider holds hands, wrists, or arms to help participant spell message • Messages spelled on keyboard or a board with printed letters • Differs from independently typing or using computerized device
	Chelation	• Use of a pharmacological agent that binds with toxic heavy metals in the bloodstream so metals may be excreted from the body • Aims to lower levels of mercury, lead, or other heavy metals in the body

^a The authors acknowledge that ABA is not a specific treatment; however, given the definition we provided of ABA, that highlighted features of treatments based on the science of behavior analysis rather than specific strategies, and the desire to compare our results to Schreck et al. (2016), who included ABA as a treatment, we chose to keep this treatment in the current study. ^b Bleach therapy was labeled as an ineffective/harmful treatment, all other complementary medicine treatments were categorized as unestablished. Participants were provided with the single definition of complementary medicine presented here and then prompted to select any complementary medicine treatments that they had used; however, individual definitions were not provided and therefore they are listed together in this table

Table 3.

Response Options for Variables Influencing Selection and Continued Use

Selection Variables	Continued Use Variables
Propaganda	Treatment feedback from clients’ parents is positive/supportive
TV/Movies	Treatment feedback from schools or teachers is positive/supportive
Newspapers/Magazines	Treatment feedback from clients is positive/supportive
Online Sources	Treatment interests parents of new clients
Research	Treatment is easy, cost effective, or efficient
Academic/Research Journals	Treatment research results are plentiful and high quality
Textbooks	Treatment is effective
Persuasion to Conform	Treatment has a solid scientific foundation
Colleagues/Coworkers	Treatment is covered by insurance companies
Instructors	Treatment provides business/financial expansion of my practice
Clients’ Parents	Treatment matches my understanding of autism’s causes
Employers/Supervisors	Treatment provides additional professional opportunities
Internship/Work Experience	Other
Workshops/Presentations	I have not continued using this treatment

Propaganda, research, and persuasion to conform were categories used by Schreck et al. (2016) and their use in the current study allows for comparison over time. Further, the uses of the terms propaganda and persuasion to conform are based on a technical conceptualization, and are not employed as a judgement on the appropriateness of the influence of these variables (i.e., we are not suggesting persuasion to conform is wrong). Propaganda refers to the manipulation of variables intended to elicit an emotional effect or evoke a particular behavior (Skinner, 1953). TV/movies, newspapers/magazines, and online sources all have a particular perspective and are intended to convince consumers to engage in behavior that is relevant to that viewpoint (e.g., share information with others, engage in endorsed treatments). Likewise, persuasion to conform connotes the impact of our social environment. Reinforcement is widely available for behaving in the way that others do, and nonconformity is regularly punished (for a more thorough discussion of the impact of the social environment, see Baum, 2017; Skinner, 1953); therefore, this is intended to capture the class of social reinforcers and punishers available for engaging or not engaging in specific autism treatments

After questions related to each of the used treatments, participants were asked to rank the three autism treatments that they perceived to be most effective. Participants then rated variables related to treatment choice (e.g., cost of the treatment, previous success with the treatment, scientific foundation of the treatment) and selected variables related to treatment success (e.g., parent report of improvement, scores on assessment measures, single subject design procedures). Finally, participants were given the opportunity to participate in a raffle for a $25 Amazon gift card.

Procedures

Survey Development

The survey created by Schreck et al. (2016) was used as a reference in creating the present survey. Revisions to the 2016 survey included (a) inclusion of new treatments based on contemporary relevance (e.g., Social Stories, Early Start Denver Model [ESDM], and bleach therapy); (b) elimination of old treatments based on contemporary irrelevance (i.e., no longer a popular treatment per consensus from the authors); (c) combining similar treatments (e.g., discrete trial instruction was considered a prevalent ABA technology and craniosacral therapy was encompassed under chiropractic); and (d) dividing treatments that were previously combined (e.g., facilitated communication and rapid prompting method). Face validity was obtained through review from five master’s or doctoral level behavior analysts with at least 10 years of experience in the autism and ABA field.

After determining the 31 treatments, updated brief descriptions of each treatment were created using descriptions from certifying bodies (e.g., BACB for ABA), recognized training or treatment centers (e.g., ESDM Training Program at University of California-Davis MIND Institute for Early Start Denver Model), or multiple sources (e.g., Association for Science in Autism Treatment [ASAT], n.d.; Foxx & Mulick, 2016; peer-reviewed articles). If an adequate and concise definition could be found in one of these sources, it was used directly. If not available, then a combination of sources was used to develop an accurate and brief description.

Because treatment research support may have changed since Schreck et al. (2016), treatments were reclassified into one of four categories based on the current level of scientific support: established, emerging, unestablished, and ineffective/harmful. Two of the authors reviewed treatment classifications on the ASAT website (ASAT, n.d.) and the National Standards Project (NSP; National Autism Center, 2015). In the event a treatment was reviewed by only one of the two sources, the classification was based on the single reporting source. If the ASAT and NSP classifications were consistent (e.g., both defined the treatment as established), the treatment was classified as such (e.g., established). If the ASAT and NSP classifications were inconsistent (e.g., unestablished and emerging), then the classification that indicated more support for the treatment was used (e.g., emerging versus unestablished). The only exception to this method was bleach therapy. This treatment was labeled as untested and unacceptably risky by ASAT and was not evaluated by the NSP; however, the treatment was identified as ineffective/harmful by the authors based on documented cases of physical harm and death following use (Food & Drug Administration, 2014; Zadrozny, 2019). Any disagreements in classification by the authors was resolved by having a third author review the information provided by these two sources, discuss the findings, and make a final determination. Following identification of the treatments, their descriptions, and classifications, the survey was developed using Qualtrics (https://www.qualtrics.com).

Survey Implementation

Following Institutional Review Board approval, the survey was sent out through the BACB listserv to 46,971 certificants across certification levels (i.e., BCBA-D, BCBA, BCaBA, and RBT). A total of 14,159 (30.18%) certificants opened the email with 1,153 (8.14%) of those individuals clicking the link within the email. A total of 1,009 responses were received, which equates to 7.12% of those individuals who opened the email. Responses were only included in the study if the participant responded to at least one question about autism treatment. Therefore, of the 1,009 certificants who responded to the survey, 921 were included as participants in the present study.

Analyses

Current Use of Treatments

The percentage of participants at each certification level currently using a specific treatment was calculated by dividing the number of participants who reported that they used the treatment by the total number of participants who responded to the question and multiplying by 100. A participant was considered to use a treatment if they reported currently using the treatment independently or in collaboration with other professionals. The percentage of participants that used each treatment was also calculated for the data from Schreck et al. (2016) using the same method described above for the present study. Statistical analyses were then conducted to compare the results from Schreck et al. (2016) with those of the current study. A Mann Whitney U test was performed to assess differences between groups from the two studies at each certification level (i.e., BCBA-D, BCBA, and BCaBA). Because RBTs were not surveyed in Schreck et al. (2016) they were excluded from the comparative analysis.

Variables Influencing Initial Selection and Continued Use of Specific Treatments

To calculate the percentage of participants who were influenced by each variable in their selection of each treatment, the total number of variables scored as very influential and influential were divided by the total number of participants who rated the variable and multiplied by 100. The percentage of variables influencing participants’ continued use of a treatment was calculated by dividing the total number of participants who selected that variable when asked, “Why do you continue to use this treatment?” by the total number of participants who reported continued use of the treatment and multiplying by 100.

Treatment Rankings

The following procedure was used to determine the top autism treatments believed to be most effective at each certification level. First, the number of times each treatment was selected for each rank (i.e., most effective, second most effective, and third most effective) was counted. Second, the total treatment selections at each rank were weighted. Treatments identified as the top-ranking treatment (i.e., most effective) were multiplied by 3, treatments identified as the second most effective treatment were multiplied by 2, and treatments identified as the third most effective were multiplied by 1. The weighted scores for each treatment were then summed and the treatments receiving the five highest scores for each certificate level were reported.

Results

Current Use of Treatments

All participants were required to respond to the question about treatment use for each treatment in order to continue through the survey. The number of participants who responded to the use of treatment questions at each certification level varied due to survey attrition. The initial question about treatment use (i.e., ABA) included a sample size of 38 BCBA-Ds, 475 BCBAs, 22 BCaBAs, and 386 RBTs. The final question about treatment use (i.e., vitamin therapy) included a sample size of 31 BCBA-Ds, 394 BCBAs, 13 BCaBAs, and 259 RBTs. See Table 4 for percentages of treatment use by certification level.

Table 4.

Use of Autism Treatments

Treatment	BCBA-D			BCBA			BCaBA			RBT
	2016 (n = 124)	2021 (n = 38)	Change	2016 (n = 643)	2021 (n = 475)	Change	2016 (n = 83)	2021 (n = 22)	Change	2021 (n = 386)
Established
ABA	98.39	84.21	-14.18**	98.44	95.14	-3.30**	95.18	77.78	-17.40*	84.36
PECS	68.97	62.50	-6.47	64.62	64.36	-0.26	55.13	38.46	-16.67	52.58
Social Stories	-	38.71	-	-	50.89	-	-	27.27	-	33.82
Pivotal response training	-	23.33	-	-	34.10	-	-	20.00	-	28.77
Emerging
Relationship Development Intervention	-	3.13	-	-	4.76	-	-	6.25	-	12.93
Music therapy	2.61	3.13	0.52	3.25	3.84	0.59	5.13	25.00	19.87*	14.55
TEACCH	25.66	12.50	-13.16	20.10	11.30	-8.8***	19.74	0.00	-19.74	10.04
Unestablished
DIR Floortime	16.38	3.13	-13.25	15.98	4.23	-11.75***	21.79	5.88	-15.91	20.91
Rapid prompting method	-	3.13	-	-	2.57	-	-	6.25	-	9.06
SCERTS	-	6.45	-	-	2.28	-	-	0.00	-	5.91
Early Start Denver Model	-	6.45	-	-	8.21	-	-	0.00	-	8.47
Acceptance and commitment therapy	-	16.13	-	-	15.27	-	-	23.08	-	5.31
Social Thinking	-	9.68	-	-	15.65	-	-	7.69	-	10.00
Gluten-free casein-free diet	1.80	3.23	1.43	2.84	2.45	-0.39	6.67	0.00	-6.67	4.55
Holding therapy	0.00	0.00	0.00	0.18	0.24	0.06	0.00	0.00	0.00	3.75
Son-Rise	1.80	0.00	-1.80	0.36	0.24	-0.12	1.33	0.00	-1.33	7.17
Auditory integration training	2.54	0.00	-2.54	1.61	2.07	0.46	1.23	11.11	9.88	10.39
Sensory integration therapy	24.68	9.38	-15.30	18.06	11.33	-6.73**	5.26	0.00	-5.26*	19.61
Chiropractic/Craniosacral	0.00	0.00	0.00	0.72	0.24	-0.48	1.33	0.00	-1.33	2.60
Hyperbaric oxygen	0.00	0.00	0.00	0.18	0.00	-0.18	0.00	0.00	0.00	0.37
Hippotherapy	-	0.00	-	-	0.25	-	-	0.00	-	1.92
Anti-fungal	-	0.00	-	-	0.25	-	-	0.00	-	0.00
Essential oils	-	3.23	-	-	0.25	-	-	7.69	-	6.56
CBD oil	-	3.23	-	-	1.27	-	-	7.69	-	2.32
Acupuncture	-	0.00	-	-	0.25	-	-	7.69	-	0.00
Vitamin therapy	-	3.23	-	-	0.00	-	-	7.69	-	0.77
Ineffective/Harmful
Facilitated communication/Rapid prompting methoda	3.42	2.63	-0.79	4.06	5.68	1.62	6.58	13.64	7.06	13.47
Facilitated communication	-	0.00	-	-	5.12	-	-	11.76	-	15.69
Chelation	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.74
Bleach therapy	-	0.00	-	-	0.00	-	-	0.00	-	0.00

Use for 2016 and 2022 is shown as percentage of respondents per question

Data from 2016 was calculated from the data previously published by Schreck et al. (2016)

^aFacilitated communication and rapid prompting method are presented as a combined category for the purposes of comparison with Schreck et al. (2016). Data are also presented for each treatment separately in the table because participants in the current survey were asked to respond to these treatments individually due to differing classifications of evidence for the two treatments

* p ≤ .05. **p ≤ .01. ***p ≤ .001

Established Treatments

There were four established interventions included in the survey (ABA, Social Stories, pivotal response training, and Picture Exchange Communication System [PECS]). Although the majority of participants indicated that they currently used ABA (BCBA-D = 84.21%, BCBA = 95.14%, BcaBA = 77.78%, RBT = 84.36%), 71 participants including BCBA-Ds (n = 6), BCBAs (n = 23), BCaBAs (n = 4), and RBTs (n = 38) reported that they did not currently use ABA. Of those 71 participants, 41 reported currently treating individuals on the autism spectrum and not using ABA for those cases. Of the nonusers of ABA, over half were certified at the RBT level (n = 38; 53.52%), whereas most users of ABA were certified at the BCBA level (n = 450; 64.19%). A smaller percentage of nonusers held a master's degree in ABA (n = 6; 42.86%) in comparison to users of ABA (n = 192; 79.67%). ABA users were more likely to report that they received supervision from four or more supervisors (13.45%) compared to nonusers (6.45%), and were more likely to identify ABA as their primary area of practice (n = 198; 78.57%) in comparison to nonusers (n = 12; 46.15%).

For the other established treatments, the majority of BCBAs and BCBA-Ds reported using PECS (BCBAs = 64.36%; BCBA-Ds = 62.50%) and the majority of BCBAs reported using Social Stories (50.89%). A lesser percentage of BCBA-Ds reported using Social Stories (38.71%) and lesser percentages of participants at the BCBA and BCBA-D level reported using pivotal response training (BCBA = 34.10%; BCBA-D = 23.33%). For most of the established treatments, a smaller percentage of BCaBAs and RBTs reported current use (PECS BcaBAs = 38.46%; PECS RBTs = 52.58%; Social Stories BcaBAs = 27.27%; Social Stories RBTs = 33.82%, pivotal response training BcaBAs = 20.00%) than BCBAs and BCBA-Ds.

Changes in the use of established treatments from 2016 to 2021 were calculated for ABA and PECS. Pivotal response training and Social Stories were not analyzed because Schreck et al. (2016) did not include these treatments. Across all three certification levels, there was a statistically significant decrease in the percentage of certificants that reported current use of ABA. This means that significantly fewer participants reported currently using ABA in the current study compared to 2016, and that these differences were greater than what would be expected from random variation within the group. Since 2016, PECS’s level of scientific support has changed from emerging to established (see ASAT, n.d.). Despite this change, the difference in the percentage of participants in the present study who reported currently using PECS was not statistically significant from the previous sample.

Emerging Treatments

For the three emerging treatments included in the survey (i.e., Relationship Development Intervention [RDI], music therapy, and TEACCH), the reports of treatment use varied among levels of certification. BCBA-Ds, BCBAs, and RBTs reported more use of TEACCH compared to BCaBAs (BCBA-D = 12.5%; BCBA = 11.30; RBT = 10%; BcaBA = 0%). A smaller percentage of BCBA-Ds and BCBAs reported use of RDI (BCBA-D = 3.13%; BCBA = 4.76%) and music therapy (BCBA-D = 3.13%; BCBA = 3.84%) than BCaBAs (RDI = 6.25%; music therapy = 25%) and RBTs (RDI = 12.93%; music therapy = 14.55%). Compared to the results from 2016 for emerging treatments (i.e., music therapy and TEACCH), a significantly higher percentage of BCaBAs used music therapy (+19.87%) and a significantly lower percentage of BCBAs used TEACCH (-8.8%) in 2021. No other significant differences in emerging treatment use were found.

Unestablished Treatments

For the 19 unestablished treatments included in the survey (see Table 4), few reached higher than 10% use across the certification levels. Acceptance and commitment therapy (ACT) was the most commonly used unestablished treatment by BCBA-Ds (16.13%) and BCaBAs (23.08%), and the second most commonly used by BCBAs (15.27%). The other treatments which 10% or more of participants at any certification level reported use of included DIR Floortime (RBT = 20.91%), Social Thinking (BCBA = 15.65%; RBT = 10.00%), auditory integration training (BcaBA = 11.11%; RBT = 10.39%), and sensory integration therapy (BCBA = 11.33%; RBT = 19.61%). Every unestablished treatment was reported to be used by at least one certified behavior analytic provider. Only three significant differences were discovered in the use of unestablished treatments between 2016 and 2021. These differences included decreased use of DIR Floortime (BCBA -11.75%) and sensory integration therapy (BCBA -6.73%; BCaBA -5.26%).

Ineffective/Harmful Treatments

For the three ineffective/harmful treatments (i.e., facilitated communication, chelation, and bleach therapy), only one was not used across all certification levels (i.e., bleach therapy). All other treatments were used by at least one level of certificants (e.g., chelation by RBTs; facilitated communication by BCBAs, BCaBAs, RBTs). Facilitated communication was reported to be used most commonly by RBTs (15.69%), BCaBAs (11.765%), and then BCBAs (5.12%). No significant changes in the use of ineffective/harmful treatments were reported from 2016 to 2021, including in the combined category of facilitated communication/rapid prompting method (facilitated communication and rapid prompting method were separated in the current study because of their different classifications as harmful/ineffective and unestablished, respectively, but were combined for the comparative analysis).

Variables Influencing Initial Selection and Continued Use of Specific Treatments

Participants who reported using a specific treatment, currently or in the past, were asked to indicate sources influencing their selection and continued use of that treatment. The variables reported by the majority of participants as influencing their selection and continued use of treatments at each level of evidence are displayed in Tables 5, 6, 7, and 8. The number of participants who identified variables influencing their use of a treatment varied because of an uneven distribution of participants across certification levels reporting use of each treatment and attrition across the survey. Consequently, the number of participants at each certification level reporting influential variables ranged from 1 to 437 per treatment. Therefore, the data should be interpreted with caution as some selections are indicative of variables influencing only a small number of participants.

Table 5.

Variables Influencing Selection and Continued Use of Established Treatments

	BCBA-D		BCBA		BCaBA		RBT
	Influence	% (n)	Influence	% (n)	Influence	% (n)	Influence	% (n)
Selection to use
ABA	Instructors	100% (31)	Academic journals	97.9% (434)	Academic journals	100% (19)	Employers/ Supervisors	92.8% (349)
					Instructors	100% (19)
					Presentations	100% (19)
PECS	Presentations	100% (28)	Colleagues	94.4% (391)	Textbooks	84.6% (13)	Employers/Supervisors	92.6% (229)
					Academic journals	84.6% (13)
					Employers/Supervisors	84.6% (13)
Social Stories	Work experience	84.2% (19)	Colleagues	87.4% (333)	Academic journals	90.0% (10)	Employers/Supervisors	85.7% (175)
Pivotal response training	Academic journals	94.4% (18)	Academic journals	92.0% (199)	Academic journals	100% (5)	Employers/Supervisors	86.7% (128)
					Work experience	100% (5)
Continued Use
ABA	Effective	100% (31)	Effective	91.3% (437)	Parent feedback	100% (19)	Effective	84.7% (346)
PECS	Effective	89.7% (29)	Effective	86.7% (392)	Effective	71.4% (14)	Parent feedback	77.6% (223)
Social stories	Interests parents of new clients	73.7% (19)	Parent feedback	73.4% (308)	Parent feedback	70.0% (10)	Parent feedback	70.5% (173)
					School feedback	70.0% (10)
Pivotal response training	Effective	76.5% (17)	Effective	81.2% (197)	Effective	100% (5)	Effective	71.4% (126)

Participants were asked to rate all variables that may have affected their selection to use a treatment from Not Influential to Very Influential, and were asked to select all variables that maintained their continued use of a treatment. Data for all variables is discussed in the article and is available from the first author on request. The table displays the predominant variable(s) (i.e., the variable(s) endorsed by the highest percentage of participants) reported for the selection and continued use of each treatment, as well as the percentage and corresponding number of respondents who endorsed that variable

Table 6.

Variables Influencing Selection and Continued Use of Emerging Treatments

	BCBA-D		BCBA		BCaBA		RBT
	Influence	% (n)	Influence	% (n)	Influence	% (n)	Influence	% (n)
Selection to use
Relationship Development Intervention	Colleagues	66.7% (3)	Colleagues	73.5% (34)	Textbooks	100% (2)	Employers/ Supervisors	84.8% (59)
					Academic journals	100% (2)
					Colleagues	100% (2)
	Clients’ parents	66.7% (3)			Employers/ Supervisors	100% (2)
					Work experience	100% (2)
Music therapy	Colleagues	100% (4)	Colleagues	80.0% (70)	Clients’ parents	75.0% (4)	Employers/ Supervisors	75.6% (82)
					Employers/ Supervisors	75.0% (4)
TEACCH	Work experience	75.0% (12)	Colleagues	83.9% (124)	Academic journals	100% (1)	Employers/ Supervisors	83.1% (59)
					Colleagues	100% (1)
					Instructors	100% (1)
					Employers/ Supervisors	100% (1)
					Presentations	100% (1)
Continued use
					Parent feedback	100% (1)
					School feedback	100% (1)
					Client feedback	100% (1)
Relationship Development Intervention	Parent feedback	100% (1)			Interests parents of new clients	100% (1)
	Client feedback	100% (1)	Parent feedback	56.0% (25)	Plentiful research results	100% (1)	Parent feedback	71.9% (57)
	Effective	100% (1)			Effective	100% (1)
					Solid scientific foundation	100% (1)
					Covered by insurance	100% (1)
					Business/Financial expansion	100% (1)
					Matches my understanding of autism’s causes	100% (1)
					Professional opportunities	100% (1)
Music therapy	Parent feedback	66.7% (3)	Client feedback	61.7% (47)	Client feedback	100% (3)	Client feedback	79.2% (77)
	School feedback	66.7% (3)
	Client feedback	66.7% (3)			Easy, cost effective, or efficient	100% (3)
	Effective	66.7% (3)
TEACCH	Effective	81.8% (11)	School feedback	70.5% (105)	School feedback	100% (1)	School feedback	72.7% (55)
							Effective	72.7% (55)

Participants were asked to rate all variables that may have impacted their selection to use a treatment from Not Influential to Very Influential, and were asked to select all variables that maintained their continued use of a treatment. Data for all variables is discussed in the article and is available from the first author on request. The table displays the predominant variable(s) (i.e., the variable(s) endorsed by the highest percentage of participants) reported for the selection and continued use of each treatment, as well as the percentage and corresponding number of respondents who endorsed that variable

Table 7.

Variables Influencing Selection and Continued Use of Unestablished Treatments

	BCBA-D		BCBA		BCaBA		RBT
	Influence	% (n)	Influence	% (n)	Influence	% (n)	Influence	% (n)
Selection to Use
DIR Floortime	Colleagues	100% (5)	Colleagues	72.7% (66)	No reported use		Employers/ Supervisors	82.9% (111)
Rapid prompting method	Online sources	100% (1)			Textbooks	100% (1)	Employers/ Supervisors	84.6% (52)
	Colleagues	100% (1)			Instructors	100% (1)
	Instructors	100% (1)	Academic journals	75.0% (16)	Employers/ Supervisors	100% (1)
	Clients’ parents	100% (1)	Colleagues	75.0% (16)	Work experience	100% (1)
	Employers/ Supervisors	100% (1)			Presentations	100% (1)
	Presentations	100% (1)
SCERTS	Textbooks	60.0% (5)	Colleagues	66.7% (27)	No reported use		Employers/ Supervisors	75.0% (28)
	Academic journals	60.0% (5)
	Colleagues	60.0% (5)
Early Start Denver Model	Academic journals	100% (6)	Colleagues	82.9% (82)	Employers/ Supervisors	100% (3)	Employers/ Supervisors	87.5% (48)
					Work experience	100% (3)
Acceptance and commitment therapy					Academic journals	100% (3)
					Colleagues	100% (3)
	Academic journals	100% (8)	Academic journals	92.1% (88)	Employers/ Supervisors	100% (3)	Employers/ Supervisors	77.8% (36)
	Presentations	100% (8)			Work experience	100% (3)
					Presentations	100% (3)
Social Thinking	Colleagues	66.7% (6)	Colleagues	83.5% (133)	Online sources	100% (1)	Employers/ Supervisors	84.8% (59)
					Textbooks	100% (1)
					Colleagues	100% (1)
					Instructors	100% (1)
					Employers/ Supervisors	100% (1)
					Work experiences	100% (1)
Gluten-free casein-free diet	Clients’ parents	100% (3)	Clients’ parents	89.5% (38)	No use reported		Clients’ parents	79.5% (39)
Holding therapy	No use reported		Academic journals	100% (1)	No use reported		Employers/ Supervisors	75.0% (16)
			Colleagues	100% (1)
			Clients’ parents	100% (1)
			Employers/ Supervisors	100% (1)
			Work experience	100% (1)
			Presentations	100% (1)
Son-Rise	No use reported		Clients’ parents	87.5% (8)	No use reported		Employers/ Supervisors	86.7% (30)
Auditory integration training			Colleagues	84.6% (26)	Academic journals	100% (3)	Employers/ Supervisors	87.5% (56)
	Academic journals	50% (2)			Instructors	100% (3)
	Colleagues	50% (2)			Employers/ Supervisors	100% (3)
					Work experience	100% (2)
Sensory integration therapy	Colleagues	75.0% (8)	Colleagues	83.7% (92)	Academic journals	100% (1)	Employers/ Supervisors	88.0% (92)
					Colleagues	100% (2)
					Employers/ Supervisors	100% (2)
Chiropractic/ Craniosacral	No use reported		Clients’ parents	100% (4)	No use reported		Clients’ parents	58.3% (12)
Hyperbaric oxygen	No use reported		Clients’ parents	100% (4)	No use reported		Clients’ parents	75.0% (4)
Hippotherapy	Clients’ parents	100% (2)	Clients’ parents	63.6% (11)	Instructors	100% (1)	Clients’ parents	70.0% (20)
					Employers/ Supervisors	100% (1)
					Work experience	100% (1)
Anti-fungal	No use reported		Clients’ parents	66.7% (6)	No use reported		Clients’ parents	100% (3)
Essential oils	Online sources	100% (1)	Clients’ parents	100% (8)	Online sources	100% (2)	Clients’ parents	54.6% (22)
	Textbooks	100% (1)			Textbooks	100% (2)
	Academic journals	100% (1)			Academic journals	100% (2)
	Colleagues	100% (1)			Colleagues	100% (2)
	Clients’ parents	100% (1)			Instructors	100% (2)
	Employers/ Supervisors	100% (1)			Clients’ parents	100% (1)
	Work experience	100% (1)			Employers/ Supervisors	100% (2)
	Presentations	100% (1)
CBD oil	Academic journals	100% (2)	Clients’ parents	87.5% (16)	Academic journals	100% (2)	Clients’ parents	52.9% (17)
	Colleagues	100% (2)
	Work experience	100% (2)
Acupuncture	No use reported		Academic journals	100% (2)	No variables reported		No use reported
			Clients’ parents	100% (2)
Vitamin therapy	Academic journals	100% (1)	Client’s parents	100% (13)	No variables reported		Clients’ parents	66.7% (6)
	Colleagues	100% (1)
Continued Use
DIR Floortime	Parent feedback	66.7% (3)	Parent feedback	67.6% (37)	No variables reported		Parent feedback	75.8% (99)
	Client feedback	66.7% (3)
	Effective	66.7% (3)
Rapid prompting method	School feedback	100% (1)	Parent feedback	76.9% (13)	Parent feedback	100% (1)	Effective	67.9% (53)
					School feedback	100% (1)
					Client Feedback	100% (1)
					Solid scientific foundation	100% (1)
					Matches my understanding of autism’s causes	100% (1)
SCERTS	Parent feedback	40.0% (5)	Parent feedback	61.9% (21)	No use reported		Effective	82.1% (28)
	School feedback	40.0% (5)
	Client feedback	40.0% (5)
	Interests parents of new clients	40.0% (5)	Effective	61.9% (21)
	Effective	40.0% (5)
Early Start Denver Model	Parent feedback	80.0% (5)	Effective	70.9% (79)	Parent feedback	100% (2)	Parent feedback	80.4% (46)
	School feedback	80.0% (5)
	Effective	80.0% (5)
Acceptance and commitment therapy	Effective	87.5% (8)	Effective	79.5% (83)	Parent feedback	100% (3)	Parent feedback	63.3% (30)
					Client feedback	100% (3)
					Effective	100% (3)
Social Thinking	Parent feedback	50.0% (6)	Parent feedback	73.6% (110)	Client feedback	100% (1)	Parent feedback	68.3% (60)
	School feedback	50.0% (6)
	Client feedback	50.0% (6)			Easy, cost effective, or efficient	100% (1)
	Interests parents of new clients	50.0% (6)
Holding therapy	No use reported		Effective	100% (2)	No use reported		Client feedback	86.7% (15)
Son-Rise	No use reported		Parent feedback	100% (3)	No use reported		Client feedback	73.3% (30)
							Effective	73.3% (30)
Auditory integration training	Discontinued use				Parent feedback	100% (3)	Parent feedback	70.8% (48)
			Parent Feedback	46.2% (13)	Interests parents of new clients	100% (3)
			Effective	46.2% (13)	Effective	100% (3)
Sensory integration therapy	Parent feedback	100% (5)	Parent feedback	56.8% (74)	Client feedback	100% (2)	Parent feedback	74.7% (83)
Chiropractic/Craniosacral	No use reported		Parent feedback	50.0% (2)	No use reported		Parent feedback	60.0% (10)
			Interests parents of new clients	50.0% (2)
			Other	50.0% (2)
Hyperbaric oxygen	No use reported		Interests parents of new clients	50.0% (2)	No use reported		Parent feedback	66.7% (3)
			Other	50.0% (2)
Hippotherapy	Client feedback	100% (2)	Parent feedback	80.0% (5)	Parent feedback	100% (1)	Parent feedback	87.5% (16)
			Client feedback	80.0% (5)			Client feedback	87.5% (16)
Anti-fungal	No use reported		Effective	66.7% (3)	No use reported		Effective	100% (1)
Essential oils	Parent feedback	100% (1)	Interests parents of new clients	66.7% (3)	Parent feedback	100% (2)	Parent feedback	59.1% (22)
	School feedback	100% (1)			School feedback	100% (2)
	Client feedback	100% (1)			Client feedback	100% (2)
	Interests parents of new clients	100% (1)			Easy, cost effective, or efficient	100% (2)
	Professional opportunities	100% (1)
CBD oil	Parent feedback	100% (1)	Parent feedback	70.0% (10)	Parent feedback	100% (2)	Parent feedback	70.6% (17)
	School feedback	100% (1)
	Client feedback	100% (1)
	Interests parents of new clients	100% (1)			Client feedback	100% (2)
	Professional opportunities	100% (1)
Acupuncture	No use reported		Client feedback	100% (1)	No variables reported		No use reported
			Effective	100% (1)
			Solid scientific foundation	100% (1)
Vitamin therapy	Other	100% (1)	Parent feedback	66.7% (6)	No variables reported		Parent feedback	83.3% (6)

Participants were asked to rate all variables that may have impacted their selection to use a treatment from Not Influential to Very Influential, and were asked to select all variables that maintained their continued use of a treatment. Data for all variables is discussed in the article and is available from the first author on request. The table displays the predominant variable(s) (i.e., the variable(s) endorsed by the highest percentage of participants) reported for the selection and continued use of each treatment, as well as the percentage and corresponding number of respondents who endorsed that variable

Table 8.

Variables Influencing Selection and Continued Use of Ineffective/Harmful Treatments

	BCBA-D		BCBA		BCaBA		RBT
	Influence	% (n)	Influence	% (n)	Influence	% (n)	Influence	% (n)
Selection to use
Facilitated communication	No use reported		Colleagues	78.2% (46)	Online sources	100% (2)	Employers/ Supervisors	85.6% (90)
					Textbooks	100% (2)
					Academic journals	100% (3)
					Instructors	100% (2)
					Clients’ parents	100% (1)
					Employers/ Supervisors	100% (2)
					Work experience	100% (3)
Chelation	No use reported		Clients’ parents	100% (6)	No use reported		Clients’ parents	83.3% (6)
Bleach therapy	No use reported		No use reported		No use reported		No use reported
Continued use
Facilitated communication	No use reported		Parent feedback	83.9% (31)	Parent feedback	100% (3)	Effective	69.0% (87)
					Plentiful research results	100% (3)
					Effective	100% (3)
					Solid scientific foundation	100% (3)
					Matches my understanding of autism’s causes	100% (3)
Chelation	No use reported		Parent feedback	66.7% (3)	No use reported		Parent feedback	100% (5)
			Other	66.7% (3)
Bleach therapy	No use reported		No use reported		No use reported		No use reported

Participants were asked to rate all variables that may have impacted their selection to use a treatment from Not Influential to Very Influential, and were asked to select all variables that maintained their continued use of a treatment. Data for all variables is discussed in the article and is available from the first author on request. The table displays the predominant variable(s) (i.e., the variable(s) endorsed by the highest percentage of participants) reported for the selection and continued use of each treatment, as well as the percentage and corresponding number of respondents who endorsed that variable

Established Treatments

Selection to Use

Across certification levels, variables reported to be most influential in selecting established treatments were related to persuasion to conform and research. Across all participants, influence to choose established treatments came from colleagues/coworkers and employers/supervisors (more than 75%) and from internship/work experiences and instructors (more than 55%). In particular, RBTs were primarily influenced by employers/supervisors in the selection of all established treatments (more than 85%). Academic/research journals influenced more than 84% of BCBA-Ds, BCBAs, and BCaBAs in the selection of ABA, pivotal response training, and PECS. Although BCaBAs reported academic/research journals predominantly influenced their selection of Social Stories (90.0%), this source was far less influential on BCBA-Ds and BCBAs (<62%).

The overall trends from 2016 to 2021 indicated that influential variables for the established category (despite changes in the included treatments) remained largely unchanged, with academic/research journals and colleague/coworker influence ranking as the highest variables. With that said, in Schreck et al. (2016), academic/research journals were the highest ranked influential variable for the selection of ABA, whereas in 2021, colleague/coworker influence was the highest ranked variable. When comparing results between 2016 and 2021 data, the most notable differences in the variables influencing the selection of established treatments were an increase in online sources (ABA +16.9%; PECS +14.1%), employers/supervisors (ABA +15.7%; PECS +11.7%), and clients’ parents (ABA +11.2%).

Continued Use

Across all certification levels, treatment effectiveness was reported as the most influential variable maintaining use of established treatments for 2016 and 2021 with the exception of Social Stories. In the current study, parent feedback primarily influenced continued use of Social Stories for BCBAs, BCaBAS, and RBTS (70%+) while BCBA-Ds were most influenced by new client interest (73.7%). Additionally, parent feedback influenced the majority of BCaBAs in their continued use of ABA (100%) and RBTs in their continued use of PECS (77.6%). Notable differences between 2016 and 2021 data were changes in the influence of positive client feedback (ABA +12.4%), insurance coverage (ABA +24.7%; PECS +11.5%), professional opportunities (ABA +14.3%), and opportunities for business/financial expansion (ABA -10.6%).

Emerging Treatments

Selection to Use

For emerging treatments, persuasion to conform predominantly influenced treatment decisions across certification levels. Very few BCBA-Ds and BCaBAs reported influential variables for emerging treatments, so overall results are more reflective of BCBAs and RBTs. BCBAs identified colleagues/coworkers as the most influential variable across all emerging treatments whereas RBTs identified employers/supervisors. In 2021, all participants across certification levels, who selected music therapy, tended to be persuaded more by colleagues/coworkers than by clients’ parents compared to 2016. The influence of clients’ parents in the decision to use music therapy decreased by 15.3% from 2016 to 2021. Additional changes in influence from 2016 to 2021 for music therapy included increases in the influence of colleagues/coworkers (+12.3%), employers/supervisors (+22.9%), internship/work experience (+17.06%), instructors (+27.4%), online sources (+10.2%), academic/research journals (+17.3%), and textbooks (+11.2%), and a decrease in the influence of newspaper/magazines (-14.1%).

Continued Use

Continued use of emerging treatments, across certification levels, was predominantly maintained by positive feedback from parents (RDI = 68.7%; music therapy = 62.0%), clients (music therapy = 73.6%; RDI = 57.8%), and school personnel (TEACCH = 70.2%; music therapy = 46.5%). Consistent with selection to use, very few BCBA-Ds and BCaBAs reported variables influencing their continued use of emerging treatments. Changes from 2016 to 2021 included decreases in the influence of parent feedback (music therapy -17%), effectiveness (TEACCH-14.3%; music therapy -11.4%), and ease, cost effectiveness, and/or efficiency (TEACCH -15.9%), and increases in client feedback (music therapy +15.6%) and solid scientific foundation (music therapy +13.8%). Consistent with the current study, Schreck et al. (2016) found the continued use of TEACCH was largely influenced by positive feedback from school personnel. On the other hand, in 2016, music therapy was found to be primarily maintained by positive feedback from parents rather than clients, as in the current study.

Unestablished Treatments

Selection to Use

Across certification levels, the decision to use unestablished treatments was most frequently influenced by persuasion to conform. BCBAs identified colleagues/coworkers or clients’ parents as one of the most influential variables for the selection of each unestablished treatment except ACT, which was predominantly influenced by academic/research journals. RBTs were most influenced by clients’ parents or employers/supervisors in the selection of each unestablished treatment. As with emerging treatments, few BCBA-Ds and BCaBAs reported variables influencing the selection of unestablished treatments. Consistent with the current study, Schreck et al. (2016) also found persuasion to conform predominantly influenced selection of unestablished treatments. Some notable differences between the current study and Schreck et al. (2016) included the selection of Son-Rise (clients’ parents -28.2%; employers/supervisors +34%), holding therapy (academic/research journals -68.7%; colleague/coworkers -47.1%; employers/supervisors +26.5%), and auditory integration therapy (colleagues/coworkers +29.8%).

Continued Use

The variables most frequently reported to influence the continued use of unestablished treatments were parent feedback, client feedback, and the perceived effectiveness of the treatment. These variables were highly influential in the continued use of the most commonly used unestablished treatments (i.e., ACT, Social Thinking, sensory integration therapy, auditory integration training). Specifically, positive feedback from parents and/or clients primarily influenced continued use of Social Thinking, sensory integration therapy, and auditory integration training for BCBAs, BCaBAs, and RBTs. Treatment effectiveness was identified by BCBA-Ds, BCBAs, and BCaBAs as the most influential variable maintaining use of ACT (more than 79%). These results are not unlike those reported by Schreck et al. (2016) who found parent feedback to be the primary influence in the decision to continue using unestablished interventions. Again, this comparison is primarily based on reports from BCBAs and RBTs in the current study. Additionally, because the unestablished treatments were used less frequently, the data on influential variables is based on a small subsample of participants.

Ineffective/Harmful Treatments

Selection to Use

Since BCBA-Ds did not report use of any ineffective/harmful treatments and no participants reported use of bleach therapy, influences for these categories could not be obtained. Persuasion to conform was the primary source influencing the decision to use the other ineffective/harmful interventions (i.e., facilitated communication and chelation therapy). Both BCBAs and RBTs identified clients’ parents as the predominant influence in the decision to use chelation therapy (more than 83%). BCBAs’ selection of facilitated communication was primarily influenced by colleagues/coworkers whereas RBTs identified employers/supervisors as more influential. Comparisons between the influences to use ineffective/harmful treatments in 2016 and 2021 could only be conducted for facilitated communication because chelation was not reported to be used by participants in the 2016 study. Variables influencing the selection of facilitated communication in 2021 were similar to those reported in 2016, although increases across all variables related to persuasion to conform were observed in the current study. Consistent with unestablished treatments, the influences reported in the current study are based on a relatively small number of participants from specific certification levels.

Continued Use

Parent feedback was the primary variable influencing the continued use of the two ineffective/harmful treatments utilized (facilitated communication = 71.1%; chelation = 87.5%) across certification levels. While parent feedback was the primary variable maintaining continued use of chelation for BCBAs and RBTs, it should be noted that BCBAs reported using chelation in the past (not currently) yet identified this variable as influencing their continued use. Thus, the information reported may be indicative of the variables maintaining continued use prior to discontinuation. Parent feedback also predominantly influenced continued use of facilitated communication for BCBAs and BCaBAs, whereas RBTs were primarily influenced by the perceived effectiveness of the treatment. Comparison of data from 2016 to 2021 for facilitated communication demonstrated a decrease in the influence of treatment effectiveness (-9.7%), and increases in parent feedback (+19.5%) and client feedback (+28.9%).

Treatment Rankings

Across all certification levels, ABA was ranked as the most effective autism treatment, with more than 95% of participants ranking the treatment as their first choice. PECS was consistently ranked as the second most effective treatment across certification levels. The third through fifth ranked treatments varied across certification levels. However, ESDM and pivotal response training were each ranked in the top five for all certification levels except BCaBAs. Social Stories ranked in the top five by two certification levels (i.e., BCaBA and RBT). Only one certification level (i.e., BCaBAs) ranked a harmful/ineffective treatment as one of the top five most effective autism treatments (i.e., facilitated communication ranked fifth). Table 9 shows the five treatments ranked as most effective by participants at each certification level and the percentage of participants at each level that selected that treatment as the most effective.

Table 9.

Treatment rankings

Ranking	BCBA-D		BCBA		BCaBA		RBT
	Treatment Rank	First Choice	Treatment Rank	First Choice	Treatment Rank	First Choice	Treatment Rank	First Choice
1	ABA	100.00	ABA	97.67	ABA	100.00	ABA	95.72
2	PECS	0.00	PECS	0.26	PECS	0.00	PECS	0.39
3	TEACCH	0.00	Pivotal response training	0.00	PEAKa	0.00	Social Stories	0.00
4	Early Start Denver Model	0.00	Early Start Denver Model	1.55	Social Stories	0.00	Pivotal response training	1.17
5	Pivotal response training	0.00	Acceptance and commitment therapy	0.52	Facilitated Communication	0.00	Early Start Denver Model	0.39

% First Choice indicates the percentage of participants at the certificate level that selected the intervention as the most effective treatment

^aPEAK was not included as a treatment in the survey; however, it was inadvertently included in the drop-down list for treatment rankings

Discussion

The current survey identified some encouraging and some concerning trends related to behavior analysts’ beliefs and use of autism treatments. Encouragingly, across all certification levels, the participants in this study ranked ABA as the most effective and PECS as the second most effective autism treatment. This displays that, when provided with treatment options, respondents across all certification levels appear to be aware of, and value, treatments supported by research evidence for the treatment of autism. Furthermore, comparisons between 2021 and 2016 (Schreck et al., 2016) indicated that across the three previously surveyed certification levels (i.e., BCBA-D, BCBA, and BCaBA), the percentage of participants using some unestablished autism treatments has significantly decreased (i.e., DIR Floortime for BCBAs, and sensory integration for BCBAs and BCaBAs). However, no change in the percentage of use from 2016 to 2021 were found for the majority of unestablished and ineffective/harmful treatments included in the 2021 survey. In addition, all NESTs (e.g., facilitated communication, chelation, auditory integration training), except for bleach therapy, were reported to be used by at least one participant in 2021.

Comparisons of 2016 and 2021 data showed that ESTs had not replaced the decreased use of NESTs. In fact, the 2021 data showed a statistically significant decrease in the percentage of certificants at each level (i.e., BCBA-Ds, BCBAs, and BCaBAs) using ABA compared to 5 years ago (Schreck et al., 2016). Specifically, across these certification levels, almost 6% of participants reported not using ABA at all. The significant decrease in the use of ABA and no change in the use of other ESTs indicates some possible concerns. If BACB certificants are accurately reporting their decreased use of ESTs, then poorer client outcomes could be associated with these practitioners and, relatedly, ABA-based interventions (Howard et al., 2014). These associations could negatively impact broader community perceptions of ABA.

The survey construction could partially explain the reported decreased use of ABA in 2021 compared to 2016. Participants could complete the survey if they treated individuals on the autism spectrum historically, even if they did not do so currently. Thus, those who served as administrators or professors could indicate they no longer used ABA to treat individuals with autism because they do not technically provide clinical services. However, since a proportion of participants (5.31%; n = 41 [BCBA-D = 1, BCBA = 6, BcaBA = 4, RBT = 30]) reported currently serving individuals on the autism spectrum while also reporting they did not currently use ABA, this survey construction variable cannot explain all results.

Relatedly, some may argue that practitioners who reported that they are not currently using ABA should have been removed from the survey results. In order to participate in the current survey, participants had to report that they held a credential from the BACB. Thus, these individuals are representing themselves as behavior analytic professionals while not currently using ABA. We believe it is important to include the data of these individuals in our results, as other behavior analysts and the field of ABA will continue to be associated with their actions if they are identifying themselves as BCBA-Ds, BCBAs, BCaBAs, or RBTs.

Another survey construction variable that may have affected the results was the wording of specific items. Some questions appeared to be misunderstood by several respondents. For example, certain participants appeared to interpret treatment use questions outside of the scope of the questionnaire. One participant reported that CBD oil was used to treat arthritis, a medical condition that is unrelated to autism. While some treatments may be medically validated for particular co-occurring conditions (e.g., gluten-free, casein-free diet for celiac disease), it is unknown if participants were using these treatments for these appropriate reasons. When participants indicated that the treatment was used to treat a co-occurring medical condition, rather than autism, their responses were excluded.

Similarly, although the word use was specifically defined in the survey (i.e., “used, in this context, means you actually engaged in implementing the procedure”), some participants typed in responses that indicated that they did not directly implement the treatments (e.g., “Related service providers I work with use SI [sensory integration] with my students”). These responses were recoded. However, it is unknown if other participants who did not type in responses also reported to use treatments that they had only observed. Despite this possibility, some typed responses clearly indicated that participants actively engaged in harmful/ineffective treatments. For example, one participant commented on their participation in hyperbaric oxygen, stating, “I was exposed and use to have to go into it with the client. It was not a pleasurable experience. Nor did I see any benefits from the use.” Concerningly, although the participant did not see the intervention as a contextual fit for the client, nor did the treatment have empirical support, the participant still actively engaged in the use of hyperbaric oxygen with the client.

In addition to interpreting use, it is possible that some participants lacked knowledge of the terminology (e.g., facilitated communication versus functional communication) and therefore may have responded in ways inconsistent with the treatments that were specifically defined. This may be problematic for the survey results, but more importantly, this is problematic for the field of ABA. Ensuring practitioners of behavior analysis are familiar with the terminology needed to effectively communicate with other ABA practitioners, nonbehavioral colleagues, clients, and their families remains necessary for successful service implementation.

Specifically relevant to this concern was that the BCaBAs in this study ranked facilitated communication as the fifth most effective autism treatment. It is unclear if these individuals mistook facilitated communication for functional communication. Regardless of the rationale for this choice, for at least two reasons it is concerning that the surveyed group of BCaBAs ranked an ineffective/harmful treatment so highly. First, BCaBAs must work under the supervision of a BCBA (BACB, 2022b). BCBAs overseeing the work and training of BCaBAs are responsible for ensuring their knowledge of harmful/ineffective treatments to prepare them to discuss therapeutic options with families and clients. BCBA supervisors are further tasked with “guiding the development of [BCaBAs’] behavioral case conceptualization and problem-solving and decision-making repertoires” (BACB, 2022b, p. 41), including teaching BCaBAs to make educated decisions about treatment selections. Second, as soon as BCaBAs are certified, they are eligible to begin supervising RBTs. BCaBAs will be called upon to make treatment decisions not only for themselves but also for the staff that they supervise. As the reach of the BCaBA may go beyond their own work with clients, it is imperative that BCaBAs have a knowledge of ESTs.

Across certification levels, demographic variables associated with nonusers of ABA included limited diversity in supervision experiences, graduate-level training in other disciplines, and prioritization of other areas of practice. For BCBAs and BCBA-Ds, participants holding master’s degrees outside of ABA were less likely to use ABA. These data appear supportive of the BACB’s decision to limit behavior analytic certification to those receiving a master’s degree or higher from an approved behavior analytic program starting in 2032 (BACB, 2022a). Future research should strive to better understand the correlation between field of master’s study and the use of ESTs that was found here. It may indicate that a master’s in behavior analysis could insulate against use of NESTs in the future, that individuals already focused on the use of ESTs are more likely to enter into a master’s degree program in ABA, or that behavior analysis programs are teaching students about particular packaged ESTs either in combination with or in the absence of an evidence-based practice model. As such, further evaluation of the correlation between master’s-level instruction in behavior analysis, the use of ESTs, and the process of evidence-based practice are merited.

Specific to RBTs, the responses within this survey highlight a potentially different set of concerns. RBTs must work under the supervision of a BCBA, BCaBA, or uncertified individual with training in a related area and expertise in behavior analysis (BACB, 2021). Moreover, the RBT task list does not include treatment selection, plan development, or caregiver training within an RBT’s scope of practice (BACB, 2018). While the BACB does allow supervisors to use their “discretion to determine if [the RBT] can competently perform activities outside of the task list” (BACB, 2021, p. 17), it is likely fair to assume that the majority of RBTs should not be taking on these higher-level decision-making tasks, and it is clear that they must be supervised if allowed to do so. As such, RBTs’ decisions about treatment use may be highly influenced by their supervisors, rather than their belief in a treatment’s efficacy (Leaf et al., 2016).

According to the findings of the current study, RBTs’ selection of treatments across all levels of scientific evidence was primarily influenced by employers/supervisors (18 treatments). Moreover, RBTs frequently reflected that their use of NESTs was not their decision but rather the decision of their supervisors. These statements included, “Many ineffective treatment modalities are preferred by my supervisors because they appeal to parents. They do not seem responsive to science-based treatments; they want to appear gentle, humane, and ‘normalized’ in comparison to peers;” “Supervisor wanted me to continue to use it;” and “It is what my supervisor wants me to do.” These comments substantiate the claim that some supervisors are recommending the use of NESTs, and thus training RBTs, who work directly with clients, in the use of these NESTs. As such, concerns related to RBTs in the current study can be conceptualized as a broader issue related to supervision and the supervisors overseeing the RBT participants.

It has been asserted that the 40 hrs of training time required for RBT certification is not sufficient (Leaf et al., 2016). Though more training may be supportive for individual RBTs who were given the ability to make treatment decisions (through the discretion of their supervisor) and chose to utilize NESTs, the current data suggest that recommendations to improve RBTs’ use of ESTs should focus more heavily on training supervisors. It appears that further training (i.e., beyond the 8-hr initial and 3 hrs of ongoing supervision training; BACB, 2022c) is necessary to prepare practitioners to supervise scientifically validated autism treatment. Supervisors must be skilled in analyzing the effectiveness of treatments and collaborating with families and colleagues, as well as knowledgeable about ESTs and NESTs for the populations with whom they work. Further, supervisors must be competent in efficacious training methods to develop these same skills in their supervisees. Competency assessments for supervisors may be needed to evaluate their proficiency in these important skills.

A limitation of the current survey was that collaboration with other professionals and supervision were not options for variables influencing the continued use of treatments. Future studies should include these options to provide all practitioners, and RBTs in particular, the opportunity to indicate when collaboration with nonbehavioral colleagues or directives from supervisors were primary reasons for continuation of a treatment. Another limitation of the survey construction was the presentation of treatments in a fixed order. The consistent order likely contributed to the large differences in response rates between treatments, and the sequence of presentation (with treatments across evidence levels presented in a semi-random order) could have impacted participant responses. Future researchers should construct surveys in a format that allows for randomization of question order. An additional limitation is related to the definitions of procedures in the current study. Although we used primary sources (e.g., BACB for ABA) whenever possible, some procedures were defined based on secondary sources (e.g., ASAT) and, therefore, definitions may not be broadly accepted representations of the treatments. Relatedly, for consistency with the previous study, ABA was conceptualized as a specific treatment, rather than a scientific approach encompassing many technologies. It is possible that some practitioners who engage in scientific evaluation of procedures (arguably a defining feature of our science), responded that they did not “use ABA” because they do not use treatments commonly associated with ABA services. Future researchers should make efforts to discuss ABA as a science, while evaluating practitioners’ use of interventions based on this scientific approach.

As was discussed previously, evidence-based practice requires the integration of empirical support, client values and context, and professional expertise (Slocum et al., 2014). The data from the current study allowed us to most thoroughly understand the relationship between treatment use and empirical support, particularly when scientific evidence aligned with or took priority over the other pillars. While our intention is not to suggest that scientific evidence is more important than the other pillars, the data from the current study suggest that there are some certified behavior analysts who may not be relying as heavily on scientific evidence as a pillar of evidence-based practice when making decisions about the use of treatments for individuals on the autism spectrum.

Balancing the pillars of evidence is challenging, because these pillars may not always align (e.g., escape extinction to treat the behavior of food selectivity has empirical support; however, it may conflict with family values.) From our perspective, the use of ineffective/harmful treatments indicates an imbalance among the three pillars of evidence-based practice, with more reliance on clinical expertise and/or client preference than empirical support. If a participant reported use of facilitated communication, for example, we have empirical studies demonstrating that this intervention is ineffective (versus unestablished). We know it does not work and is, therefore, never in the client’s best interest. This would mean that they are neglecting the available scientific evidence when making the decision to use that treatment or, minimally, that the other pillars took priority (or perhaps other variables took precedence, such as reimbursement for certain treatments, employment opportunities, or organizational requirements).

In comparison to Schreck et al.’s (2016) findings, in the current study there was a notable increase in participants reporting that their treatment decisions were influenced by persuasion rather than empirical support. This may be another indicator that some behavior analytic practitioners are relying more heavily on client/caregiver preferences, clinical expertise and experiences, and recommendations from colleagues rather than empirical support when making treatment decisions. Certificants reported persuasion by others (e.g., employers/supervisors, colleagues/coworkers, parents, clients) as the most influential variable to select and continue to use NESTs. As discussed above, client values and contextual fit is an important component of evidence-based practice and, therefore, persuasion from others is a vital consideration in treatment decisions. Further, persuasion to conform is not inherently problematic and can sometimes lead to the use of ESTs (e.g., ABA for BCBA-Ds; PECS for BCBAs). However, an evidence-based practice model should rely on a balanced consideration of variables. Participant responses indicated that in this sample of behavior analysts, there were some who did not appear to be balancing research with other variables when making treatment decisions. Consequently, changes to our current training standards may be necessary.

Determining if an intervention is empirically supported is a complex skill set that requires contacting multiple sources of evidence (see Reed & Reed, 2008) and evaluating intervention suitability to the current context (e.g., setting, client age, and diagnosis). Specific changes to training may be needed to develop this skill set in new practitioners (e.g., practice in identifying examples of ESTs and NESTs). Students of behavior analysis should be taught to systematically review the literature and the importance of staying relevant with research in their area of practice, including research outside of behavior analysis (e.g., special education autism research). In addition, practicing and future behavior analysts should access resources (e.g., NSP, ASAT) that can help them stay abreast of changes in treatment effectiveness. Accessing these resources may be particularly important for practicing behavior analysts working with individuals on the autism spectrum, who may have large caseloads and limited time to thoroughly evaluate the literature on all autism treatments. Having current information about NESTs and ESTs related to one’s area of practice is imperative to effectively communicate with and support clients and their families.

In cases in which treatments requested by caregivers or other professionals are not ESTs but may be emerging or nonharmful treatments, the practitioner may review the available evidence and consider the intervention’s potential success in the given context. In this case, behavior analysts must possess the strong analytical skills necessary to conduct experimental evaluations of unestablished treatments (see Bowman et al., 2021). Processes for evaluating the scientific evidence and contextual fit of requested treatments have been provided within the behavior analytic literature (e.g., Brodhead, 2015; Newhouse-Oisten et al., 2017; Schreck & Miller, 2010). Both future and current practitioners are encouraged to use these established models to support their decision-making processes.

It is certainly possible that practitioners who identified as using NESTs in this study, may already be undergoing this type of clinical treatment analysis. However, as participants did not consistently report evidence of effectiveness as an influential variable in their choice to continue using treatments, this is impossible to conclude. In theory, a participant currently engaged in experimental evaluation of a NEST may have indicated persuasion to conform as their rationale for continued use; unfortunately, we think it is unlikely that we captured each of these practitioners in the exact moment they were engaging in such experimental evaluation. It is the ethical responsibility of behavior analysts to use “treatments that are based on scientific evidence” (BACB, 2020, Code 2.14, p. 12) and a core characteristic of our discipline is the analysis and control of variables affecting behavior change (Baer et al., 1968, 1987). Therefore, it is imperative that behavior analysts utilize scientific evaluation through their own primary research and/or the existing literature when determining treatments to use with individuals with autism (Schreck & Miller, 2010). Furthermore, more salient reinforcement for the use of ESTs and punishment for the use of NESTs by supervisors and the BACB may be needed to support maintenance of these skills once they have been established.

After determining empirical support for a treatment, practitioners then need to effectively communicate about ESTs and NESTs with families and other professionals. As such, graduate programs may need to devote more time to training future practitioners to engage in productive problem-solving processes and compassionate conflict with families and clients who may be considering or requesting the use of NESTs. Respectfully supporting clients and families in understanding NESTs can avoid unpleasant interactions and treatments that may be ineffective or even harmful to clients. Compassionate skills have been well-researched in other fields of study (e.g., Beach et al., 2006; Hojat et al., 2011) and are receiving more attention in the field of ABA (e.g., Rohrer et al., 2021; Taylor et al., 2019). However, the data from the current study indicate that further research is likely needed on the effective training of behavior analysts to simultaneously be collaborative and compassionate, and incorporate research evidence.

Participants’ compassion could be an additional variable that influenced their reported use of ESTs in the current study. A recent movement, in opposition to ABA, has emerged from various groups that believe ABA has been harmful to clients and that autism should not be treated (Kupferstein, 2018). Some behavior analytic professionals possibly underreported their use of ABA and overreported their use of other treatments in light of these claims. These clinicians may have felt uncomfortable with being associated with treatments perceived as harmful. Future research should be conducted to determine how the neurodiversity movement and positions against ABA and treatment for those on the autism spectrum have affected the way behavior analysts discuss their profession, collaborate with others, and use ESTs. If behavioral professionals stop using behavior analytic treatments and include NESTs as a concession, this likely will be detrimental to client outcomes and could further deteriorate perspectives about the field of ABA.

The results from this study were compiled from a relatively small proportion of certified behavioral professionals, and it is possible that practitioners who engage in NESTs may have been more likely to respond to the current survey in order to provide a rationale for their treatment choices. However, even if this potential bias did exist, even one behavioral professional reporting the use of any of the ineffective/harmful treatments presented in this study causes serious concern (Schreck et al., 2016). To ethically protect consumers and stakeholders, preserve the reputation of the science and its practitioners, and uphold the efficacy of EST, considerably more research, education, and dissemination on scientifically supported approaches to treatment is needed.

Author Contributions

All authors contributed to the study conception and design of the survey. Material preparation, analysis, and writing were performed by Kimberly Marshall, Kristin Bowman, Lisa Tereshko, and Victoria Suarez. The first version of the manuscript was compiled and edited by Kimberly Marshall, later versions were edited by Kimberly Marshall and Kristin Bowman. All authors read and approved the final manuscript.

Funding

Partial financial support was received from the Autism Partnership Foundation.

Data Availability

The datasets generated during and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical Approval

Approval for the current study and use of the data from Schreck et al. (2016) were approved by Institutional Review Boards at Endicott College and Penn State University Harrisburg, respectively.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Conflicts of Interest

The first six authors have no competing financial or nonfinancial interests to declare. Justin B. Leaf earns small royalties from behavior analytic commercial products and trainings.