Registered Behavior Technicians’ Training Experiences for Severe Problem Behavior: A Survey

Abstract

Registered Behavior Technicians (RBTs) are the primary paraprofessionals who deliver applied behavior analysis (ABA) services to individuals with autism spectrum disorder (ASD) under supervision of a Board Certified Behavior Analyst (BCBA). Effective training and supervision for RBTs providing ABA services is critical, especially for technicians working with children who exhibit severe behaviors. Recent research has assessed the needs of BCBAs working with individuals who exhibit severe problem behavior (Colombo et al., 2021). However, no research exists to identify the needs and ongoing training offered to the RBTs who provide ABA services to clients who exhibit severe problem behavior. Thus, the purpose of the current study was to survey RBTs for their initial training experiences and ongoing supports offered when working with clients who exhibit severe problem behavior. Results indicated that some RBTs reported appropriate initial and ongoing training, however, 13% reported receiving no initial training and 29% reported receiving no ongoing training when working with clients who engaged in severe problem behavior. In addition, 75% of RBTs reported sustaining an injury themselves and 36% reported their client sustained some type of injury. Suggestions for improvement for training RBTs working with this population and directions for future research are discussed.

Applied behavior analysis (ABA) is the application of principles of operant conditioning to improve socially significant behaviors (Baer et al., 1968). One of the largest areas of application of ABA currently is as a treatment for individuals with developmental disorders such as autism spectrum disorder (ASD). ABA uses an individualized and highly structured format of treatment that applies principles of operant conditioning to teach various skills as well as reduce maladaptive behaviors (Medavarapu et al., 2019). Meta-analyses and numerous individual studies have demonstrated the effectiveness of ABA procedures to reduce symptoms of ASD and other developmental disorders (Makrygianni et al., 2018; Miller & Lee, 2013; Sibley et al., 2023; Virués-Ortega, 2010).

Problematic Behavior

Individuals with developmental delays often exhibit problem behavior that can be a barrier to social/community inclusion and pose a safety risk. Rates of problem behaviors are higher for children with ASD and other intellectual developmental disabilities (IDD) when compared to typically developing peers (Fitzpatrick et al., 2016). According to Newcomb and Hagopian (2018), problem behaviors among individuals with ASD and IDD can include self-injurious behavior (e.g., head hitting, head banging, skin picking, and self-biting), aggression (e.g., hitting, scratching, biting, and kicking), pica (ingesting nonfood items), disruptive behavior (e.g., destruction and throwing items), and elopement (leaving a specified area without permission). A problem behavior might be classified as “severe” when it occurs regularly, causes harm to self or others, impedes developmentally appropriate participation in activities, and requires a higher level of care (Newcomb & Hagopian, 2018). The presence of severe problem behavior can negatively affect quality of life for the child, limit a family’s access to community resources, and can becomes costly if injuries and/or property destruction occurs.

A behavior analytic conceptualization holds that the presence of these problematic behaviors are a result of the contingencies of reinforcement in the environment that shape and maintain the behaviors, not a condition or syndrome within the client (Ala’i-Rosales et al., 2019). Behavior analysts working with individuals who exhibit such behaviors typically complete a functional behavior assessment (FBA) to identify the operant function that behavior serves. Once the function is identified, a behavior analyst can design individualized treatments based on the specific function(s) identified. Data are collected on the operationally defined target behaviors to monitor treatment effects and allow for changes throughout the behavior change program. Several meta-analyses have demonstrated that ABA interventions, especially those using function-based approaches, are successful in reducing problematic behaviors such as aggression (Brosnan & Healy, 2011; Chezan et al., 2018; Heath et al., 2015).

Training for Individuals Working with Clients Exhibiting Severe Problem Behavior

As mentioned, completing FBAs and designing intervention plans to are the responsibility of Board Certified Behavior Analysts (BCBA’s) overseeing cases with clients who exhibit severe problem behavior. Initial and ongoing training in a particular area (such as functional assessment) is one way in which practitioners can build competence. To better understand training experiences of BCBAs directing cases with problem behavior, Colombo et al. (2021) conducted a survey to identify current trends in the experience and training offered to BCBAs who manage cases with clients who exhibit severe problem behavior. Respondents were asked to report their personal demographics, company demographics, experience with severe problem behavior, and initial and ongoing training with severe problem behavior cases. A quarter of the respondents indicated they worked with three to five cases with clients who exhibited severe problem behavior and 27.5% reported 3–5 hr of ongoing support from others on initial cases with severe problem behavior. Approximately 68% of respondents reported receiving in-field clinical supervision for the assessment and treatment of severe problem behavior (Colombo et al., 2021). However, data also indicated that BCBAs reported often being assigned cases with severe problem behavior with limited initial and ongoing training/support. For example, 12.5% of respondents indicated they received no initial support on their first severe problem behavior case and 18.3% reported no ongoing support for their first case with severe problem behavior. A total of 30% of respondents reported 1–2 hr of ongoing monthly support on their first case with severe problem behavior. A total of 15.2% of respondents reported being trained in FA methodology one time and 18.4% reported they never received formal training in FA methodology at all (Colombo et al., 2021). The data collected in their survey demonstrated a need for more initial and ongoing support for BCBAs supervising cases with severe problem behavior.

Assessing the Needs of Registered Behavior Technicians

Researchers have only recently started to research the training needs and other variables affecting the performance of Registered Behavior Technicians (RBTs) implementing ABA services. RBTs are paraprofessionals who implement ABA therapy under the direction of the BCBA (Behavior Analyst Certification Board [BACB], n.d.-a). Luiselli et al. (2017) provided a questionnaire to 11 paraprofessional staff who completed the required training for the RBT credential to assess training needs. Areas of highest need were identifying components of written skill acquisition plans, implementing differential reinforcement procedures, and identifying extinction procedures, the latter two of which directly relate to the management of problem behavior. Novack and Dixon (2019) completed a review of published articles to identify predictors of job satisfaction, burnout, and turnover with behavior technicians. At first, 33 articles were identified in their review, of which 5 met inclusion criteria. Results of the review of these five articles indicated that greater satisfaction with supervision was associated with lower intention to turnover, greater levels of personal/professional support from a supervisor were correlated with higher job satisfaction, and high satisfaction with training was related to lower intention to turnover. Given the importance of RBTs in service delivery and lack of previous research, more information on the needs of RBTs implementing ABA services is needed.

Although the data from Colombo et al. (2021) provided insight on the training needs reported by BCBAs managing cases with severe problem behavior, they did not assess the needs of the RBTs who presumably implement the bulk of ABA interventions to treat problematic behavior(s). Understanding the type of ongoing training(s) and support(s) provided to RBTs working with individuals who exhibit severe problem behavior is important for the field of ABA and clients alike. Because RBTs are the primary paraprofessional providing ABA services, proper, efficient training for them is essential for treatments designed by BCBAs to be implemented correctly and safely for individuals displaying severe problem behaviors. Identifying the types of training and support, or lack thereof, provided to RBTs working with individuals with ASD and IDD who exhibit severe or challenging problem behaviors would help inform practices in the field and help supervisors better understand the needs of RBTs they oversee working in this population. Thus, the purpose of the current study was to extend the research of Colombo et al. (2021) by surveying RBTs working with individuals with severe problem behavior to gain insight into their training experiences working with this population.

Method

Participants

Participants were 142 RBTs who responded to an anonymous survey distributed through ABA related groups on Facebook and Reddit that were found using the search feature on the respective platform using terms related to the purpose of the study (i.e., ABA, applied behavior analysis, RBT support, ABA supervision.) to locate groups of RBTs. Responses to the survey were collected from February 18 to March 6, 2022. Participants had to indicate they were currently an RBT to start to survey. The survey was designed to be anonymous and did not allow respondents to take it more than once. Participation in the survey was not limited to any specific geographic area(s).

Instrumentation

A 28-item survey was created to assess for the training experiences of RBTs working with individuals with severe problematic behavior. Many of the training experience questions on the survey were adapted from those asked by Colombo et al. (2021). For the purpose of this survey, participants were informed that severe challenging behavior was defined as any behavior that reasonably may result in harm, damage, or threat to the safety of oneself, another person, or property—wherein the result of the behavior may be or has been incarceration or hospitalization. The survey was divided into four sections: (1) demographic information; (2) initial training for severe problem behavior cases; (3) ongoing training/support for severe problem behavior cases; and (4) case outcomes/cost benefits. In the demographic section, participants were presented with questions regarding RBT certification, gender identity, age, level of education, place of residence, setting of experience, experience with ASD, experience with severe problem behavior, and severe problem behavior topography. The second section assessed initial training and asked questions regarding training received prior to being assigned to a case with an individual who exhibited severe problem behavior. The questions pertained to staff comfortability, types of formal training received, and intervention plans for severe problem behavior. The third section presented questions about ongoing training received after staff began working with an individual who exhibited severe problem behavior. Questions assessed the amount of supervision per case, performance feedback received on cases, formal training offered while working on cases, and staff burnout. The final section asked about cost/benefits of services and inquired about possible outcomes of working with individuals who exhibited severe problem behavior such as staff and client work-related injuries and hospitalizations. See Appendix I for the survey items used in the current study.

Procedure and Data Analysis

The survey was distributed on two social media platforms (Facebook and Reddit) through a post with a link to an anonymous survey hosted through Youngstown State University’s Qualtrics website (www.qualtrics.com). The post itself contained an invitation to complete the survey, information on IRB approval, investigator contact information, and the hyperlink to the survey. Once directed to the survey site, respondents were presented an online consent form. If the respondents did not consent to participate, the survey ended. If they consented to start the survey, participants were directed to the demographics section. After the demographic section, respondents were asked about their experience working with individuals who exhibit severe problem behavior. Those respondents who indicated they were currently an RBT and had experience working with individuals who exhibit severe problem behavior completed the whole survey. On some items, participants were permitted to select multiple answers on some questions. On other questions, respondents could type in an answer, and on other questions participants were presented follow up questions to gain more information. Therefore, not all participants were presented the same type or number of questions. Data analysis consisted of calculating the percentage of respondents who endorsed a specific choice a given survey item out of the total responses obtained for that item. Percentages were computed using the automated tabulation in Qualtrics (under the “Results” tab) and Microsoft Excel software.

Results

Demographic Information

Of the 142 respondents that initially consented to participate and started the survey, 114 (80.28%) indicated they currently held the RBT credential and completed the survey. A total of 91 (84.26%) identified as female, 16 (14.81%) identified as male, and 1 (0.93%) identified as non-binary. A total of 39 (36.11%) respondents indicated they were between 18 and 25 years of age, 44 (40.74%) indicated they were between 26 and 33 years of age, 18 (16.67%) reported they were 34 to 41 years of age, 6 (5.56%) reported they were 42 to 49 years of age, and 1 (0.93%) indicated they were 50 to 57 years of age. A total of 68 (62.96%) respondents indicated holding an RBT certification for 2 years or less, 25 (23.15%) for 3–4 years, 11 (10.19%) for 5–6 years, and 4 (3.70%) for 7–8 years. A total of 47 (43.52%) of the respondents RBT work was indicated to occur in a clinic setting, 21 (19.44%) in a home setting, 17 (15.74%) worked in a school setting, 5 (4.63%) reported working in a community setting, and 18 (16.67%) reported working across mixed settings. Table 1 displays additional demographic information for respondents in the current study.

Table 1.

Demographic information

	N	Percentage
RBT Credential Status
Yes, hold the RBT credential	114	80.28
No, do not hold the RBT credential	28	19.72
Gender
Male	16	14.81
Female	91	84.26
Transgender	0	0.00
Nonbinary	1	0.93
Other	0	0.00
Age
18–25	39	36.11
26–33	44	40.74
34–41	18	16.67
42–49	6	5.56
50–57	1	0.93
Level of Education
High school or GED	19	17.59
Bachelors	66	61.11
Masters	22	20.37
Doctoral	1	0.93
Years Certified as an RBT
2 years or fewer	68	62.96
3–4 years	25	23.15
5–6 years	22	10.19
7–8 years	4	3.70
Place of Residence
United States	106	98.15
Other	2	1.85
Primary Service Setting
Clinic	47	43.52
Home	21	19.44
School	17	15.74
Community	5	4.63
Mixed	18	16.67
Years of Experience Working with ASD
Less than 1	14	12.96
1–3 years	44	40.74
4–6 years	34	31.48
7–9 years	8	7.41
10–12 years	3	2.78
13–15 years	2	1.85
15+ years	3	2.78
Age Range of Clients
3 years or younger	9	8.33
4–11 years	85	78.70
12–18 years	12	11.11
19–29 years	2	1.85

Characteristics of RBT Cases

A total of 90 (83.33%) respondents indicated they had experience working with clients who exhibited severe problem behavior and completed the survey items on their experience working with this population. Over 74% of respondents indicated working with either 1–2 or 3–5 clients with problematic behavior. When asked about the intensity of problem behavior they worked with, 26 (19.26%) of respondents indicated working with clients who exhibited behavior that posed no harm to self or others but disruptive to the environment (minimal harm). A total of 64 (47.41%) of respondents indicated working with clients who exhibited problem behavior that posed harm to self or others but could be redirected (moderate harm). A total of 45 (33.33%) respondents indicated working with clients who exhibited an intensity of problem behavior that often resulted in tissue damage to self or others and puts the client at risk of incarceration or hospitalization (severe harm). Lastly, respondents were asked which topographies of problem behavior(s) they had treated in the past. The three most common reported topographies were hitting (90.80%), biting (78.16%), and object throwing (74.71%). Table 2 lists additional characteristics reported by RBTs.

Table 2.

Characteristics of problematic behavior

	N	Percentage
Experience Working with Severe Problem Behavior
Yes	90	83.33
No	18	16.67
Number of Clients with Severe Problem Behavior
1–2	29	33.33
3–5	36	41.38
6–9	12	13.79
10–15	5	5.75
16–19	1	1.15
20 or more	4	4.60
Intensity of Severe Problem Behavior
Minimal harm  Moderate harm  Severe harm	26 64 45	19.26 47.41 33.33
Topography of Severe Problem Behavior
Hitting  Biting	79 68	90.80% 78.16%
Elopement  Object Throwing  Pulling others’ hair  Kicking  Scratching  Self-hitting  Pinching  Grabbing  Excessive screaming/yelling  Head butting  Self-biting  Breaking objects  Pushing  Spitting at others  Skin picking  Slapping  Ingesting objects/pica  Disrobing  Severe threats  Fecal smearing  Self-hair pulling  Licking and/or mouthing objects  Masturbating in public	64 65 47 59 63 64 49 51 62 42 44 46 43 42 29 38 24 34 21 21 16 41 13	73.56% 74.71% 54.02% 67.82% 72.41% 73.56% 56.32% 58.62% 71.26% 48.28% 50.57% 52.87% 49.43% 48.28% 33.33% 43.68% 27.59% 39.08% 24.14% 24.14% 18.39% 47.13% 14.94%
Topography of Severe Problem Behavior	N	Percentage
Body slamming  Grabbing others’ genitals  Excessive eating  Bowel or urine retention  Rumination  Rectal digging  Operant vomiting  Eye gouging/poking  Choking  Genital rubbing against others  Violent ideation  Harm to nonhuman animals  Fecal throwing  Coprophagia  Self-restraint  Self-cutting  Fire setting	14 7 14 15 15 12 8 9 10 8 8 5 5 4 1 3 0	16.09% 8.05% 16.09% 17.24% 17.24% 13.79% 9.20% 10.34% 11.49% 9.20% 9.20% 5.75% 5.75% 4.60% 1.15% 3.45% 0.00%

Initial Training

Table 3 displays responses for initial training (i.e., training experiences received prior to being assigned to a case) for severe problem behavior cases for the current study. A total of 12 (14.81%) respondents indicated always being asked if they were comfortable working a case with severe problem behavior before being assigned to work with client(s). On the other hand, 18 (22.22%) respondents indicated never being asked if they were comfortable working a case with severe problem behavior before being assigned. A total of 33 (20.89%) respondents reported receiving formal training in the form of overlaps with other technicians working with the same client or clients who exhibited severe problem behavior before being assigned to a case with a client who exhibited severe problem behavior. A total of 26 (16.46%) respondents reported receiving formal training in the form of overlaps with other technicians working with clients who did not exhibit severe problem behavior before being assigned to a case with a client who exhibited severe problem behavior. Table 3 also displays the number of session overlaps (sessions spent shadowing a more experienced technician) reported by RBTs. Individual meeting with a supervisor (18.35%) was the next most common training experience reported by technicians before being assigned to a case with a client who exhibited severe problem behavior. This was followed by group training (17%) and no training (13.29%, see Table 3).

Table 3.

Initial training reported by RBTs

	N	Percentage
Discussed Case Comfortability
Always	12	14.81
Very Frequently  Occasionally  Rarely  Very Rarely  Never	12 14 17 8 18	14.81 17.28 20.99 9.88 22.22
Type of Formal Training Before Case Assignment
Overlaps with other technicians working with the same client or clients who exhibited severe problem behavior	33	20.89
i. If yes, how many (1–2, 3–4, 5–6, 7+)
1–2 3–4 5–6 7+	15 11 3 4	45.45 33.33 9.09 12.12
Overlaps with other technicians working with clients who did not exhibit severe problem behavior	26	16.46
ii. If yes, how many (1–2, 3–4, 5–6, 7+)
1–2 3–4 5–6 7+	9 6 2 9	34.61 23.07 7.69 34.61
Individual (1 on 1) meetings with supervisor(s)	19	18.35
Group meetings with supervisor(s)	28	17.72
Discussion of research related on the problematic behavior	14	8.86
Provision of research without discussion	4	2.53
Other: ____________	3	1.90
I received no formal training prior to starting my cases.	21	13.29
Behavior Intervention Plan (BIP) for Severe Problem Behavior
Yes	70	86.42
No	9	11.11
Not sure	2	2.47
Formal Training on BIP Before Implementation
My supervisors who wrote behavior plans always provided me training on implementing the behavior intervention plan before implementing it with a client.	17	25.37
My supervisors who wrote behavior plans frequently provided me training on implementing the behavior intervention plan before implementing it with a client.	15	22.39
My supervisors who wrote behavior plans occasionally provided me training on implementing the behavior intervention plan before implementing it with a client	24	35.82
My supervisors who wrote behavior plans rarely provided me training on implementing the behavior intervention plan before implementing it with a client.	5	7.46
My supervisors who wrote behavior plans very rarely provided me training on implementing the behavior intervention plan before implementing it with a client.	2	2.99
My supervisors who wrote behavior plans never provided me training on implementing the behavior intervention plan before implementing it with a client.	4	5.97
Treatment Fidelity of BIP Frequency
Very Frequently	12	17.91
Frequently	21	31.34
Occasionally	9	13.43
Rarely  Very Rarely  Never  Not sure	4 6 9 6	5.97 8.96 13.43 8.96
Professional Crisis Management Training for Severe Problem Behavior
Yes, before I started working with clients who exhibited severe problem behavior	31	39.74
Yes, after I started working with clients who exhibited severe problem behavior	29	37.18
No, never.	18	23.08

Behavior Intervention Plan Training

A total of 70 (86.42%) respondents reported that their supervisor created a behavior intervention plan (BIP) to address severe problem behavior exhibited by the client. Of these, a total of 17 (25.37%) respondents indicated the supervisor who wrote the behavior plan always provided training implementing the BIP before implementing it with a client. A total 15 (22.39%) respondents indicated a supervisor frequently provided training and 24 (35.82%) respondents indicated a supervisor occasionally provided training implementing the BIP before implementing it with a client. Lastly, 11 (16.42%) respondents indicated a supervisor rarely, very rarely, or never provided training on the BIP before implementing it with a client. When asked about the frequency with which reliability/treatment fidelity on BIP implementation was taken by a supervisor, 33 (49.25%) respondents reporting a supervisor very frequently or frequently completed reliability or treatment fidelity and 9 (13.43%) reported a supervisor occasionally completed reliability or treatment fidelity data on the BIP implementation. On the other hand, 19 (28.36%) of respondents reported a supervisor rarely, very rarely, or never completed reliability or treatment fidelity data on the BIP implementation. When asked about the availability of crisis management training, 31 (39.74%) respondents reported they received crisis management training before starting to work with clients who exhibited severe problem behavior, 29 (37.18%) of respondents reported receiving this training after starting to work with clients, and 18 (23.08%) of respondents reported they were not provided crisis management training at all (see Table 3).

Ongoing Training/Support

Table 4 displays responses for ongoing training and support for severe problem behavior after work began on a case with a client who exhibited severe problem behavior. The majority (56.58%) of respondents indicated receiving between 3 and 5 hr of supervision per care per month. A total of 18 (23.68%) respondents indicated receiving 1–2 hr of supervision per case per month. Few respondents reported receiving more than 3–5 hr per month of supervision, with two (2.63%) respondents reporting their received no supervision on any cases with a client who exhibited severe problem behavior. When asked about the type of performance feedback they received, a majority of respondents indicated they either received only verbal feedback (42.11%) or a combination of feedback types (48.68%) from their supervisor. When asked about available ongoing training other than regular case supervision, 30 (31.91%) of respondents indicated receiving formal training in the form of in-office group meetings with a supervisor and 23 (24.47%) of respondents indicated receiving formal training in the form of in-office one-on-one meetings with a supervisor. A total of 28 (29.79%) respondents indicated receiving no ongoing formal training while working on cases with a client who exhibited severe problem behavior. A total of 25 (32.89%) respondents indicated that their supervisor discussed burnout or the effects of job-related stress while working with a client who exhibited severe problem behavior whereas 51 (67.11%) respondents indicated this conversation did not occur with their supervisor. For those who responded that their supervisor discussed burnout or the effects of job-related stress with them, 17 (68%) indicated that accommodations or changes were made to make it easier to provide services to the client and 8 (32.00%) indicated that no such accommodations or changes were made.

Table 4.

Ongoing training reported by RBTs

	N	Percentage
Hours per Month On-the-job Supervision per Case
No supervision on any of my cases	2	2.63
1–2 hr of supervision per case each month  3–5 hr of supervision per case each month  6–9 hr of supervision per case each month  10+ hr of supervision per case each month	18 43 7 6	23.68 56.58 9.21 7.89
Type of Performance Feedback
Only verbal feedback from a supervisor	32	42.11
Only written feedback from a supervisor	1	1.32
Only graphic feedback (graphs of your performance) from a supervisor	6	7.89
Some combination of different feedback
methods (i.e., verbal, and written feedback)	37	48.68
Formal Training While Working Severe Problem Behavior Case
In-office 1-on-1 meetings with supervisor	23	24.47
In-office group meetings with supervisor  Discussion of research related on the problematic behavior  Provision of research without discussion	30 11 0	31.91 11.70 0.00
I received no ongoing training when working with any clients who exhibited problem behavior	28	29.79
Other: _______________	2	2.13
Discussion of Burnout or Effects of On-the-job Stress
Yes	25	32.89
No	51	67.11
Accommodations or Changes for Burnout or Effects of On-the-job Stress
Yes	17	68.00
No	8	32.00

Case Outcomes/Cost Benefit

Table 5 displays responses for case outcomes and cost benefit questions for cases with severe problem behavior in the current study. A total of 57 (75%) respondents indicated they suffered a work-related injury when working with a client who exhibited severe problem behavior and 19 (25.00%) respondents they did not. For those who indicated they had suffered an injury, a total of 7 (12.28%) respondents indicated that they were hospitalized due to the work-related injury and 50 (87.72%) indicated they were not. For those were hospitalized, five (8.77%) indicated that they missed 1 week or more of work. A total of 28 (36.84%) respondents indicated that their client suffered an injury due to severe problem behavior while the respondent was working with them whereas 48 (63.16%) respondents indicated that their client(s) did not suffer any injury.

Table 5.

Case outcomes/cost benefits

	N	Percentage
Work-related Injury While Working with Severe Problem Behavior
Yes	57	75.00
No	19	25.00
Hospitalization Due to Injury
Yes	7	12.28
No	50	87.72
Absent 1+ week of Work Due to Injury
Yes	5	8.77
No	52	91.23
Client Injury While Working Case
Yes	28	36.84
No	48	63.16

Discussion

The purpose of this study was to extend Colombo et al. (2021) by surveying RBTs for their training experiences for working with clients who exhibit severe problem behavior. The results of the current study indicated that a majority of RBTs reported working with individuals who exhibit severe problem behavior. Further, a majority indicated their client exhibited behaviors that posed a risk of moderate or severe harm to themselves and/or others. When polled about their initial training, few respondents indicated they were regularly asked about comfortability with taking on cases with clients with intensive behavior management needs. Although some technicians did report overlap with other technicians prior to starting a case, over 13% reported no initial training prior to starting cases and only 18% reported individual one-on-one meetings with a supervisor prior to starting the case. Although many RBTs reported that their client was on a BIP, over a third of respondents reported only occasional training on the plan before implementation. Over 15% (combined) reported rare, very rare, or none as the frequency of training on their client’s BIP. Over 13% reported no ongoing measurement of treatment fidelity while implementing their clients BIP.

These data on initial and ongoing trainings offered to RBTs providing services to clients who exhibit significant challenging behavior are concerning for several reasons. First, assessing RBT comfortability when they are assigned a case with a client who exhibits severe problem behavior should be a logical first step supervisors should take to assess RBT competency prior to beginning work with clients who have significant behavioral needs. Not taking such a simple initial step unnecessarily increases the risk of negative case outcomes. For example, staff who lack experience working with clients who exhibit problem behavior might experience burnout and/or turnover more frequently. Even if the answer to the initial discussion is that a staff does not feel comfortable, such a discussion can assess training needs to help develop competence in the future. The high percentages of respondents who reported occasional or less frequent intensity of training on BIPs and treatment fidelity checks are not consistent with best practices in the field of ABA. Low-fidelity service delivery, where treatments are not implemented as designed, can lead to suboptimal treatment outcomes for the client and their families (see Fryling et al., 2012; Pipkin et al., 2010). RBTs, especially those working high need cases, require ongoing direction and supervision on implementing interventions from the BCBAs overseeing cases. It may be presumed that there is also an increased risk of negative outcomes and injury with low case supervision on cases with high intensity needs. In the current survey, three quarters of RBT respondents reported a work-related injury and over a third reported their client sustained an injury as well.

The type and frequency of ongoing training reported is also an area of concern. Over half of the respondents reported 3–5 hr per month of supervision. During a 4-week month, this amounts to an average amount of supervision fewer than 2 hr per week. This frequency of supervision may be acceptable for focused level services (e.g., limited behavior targets, social communication skills, self-care skills) but may be low for comprehensive level services with client(s) exhibiting significant problem behaviors. Although fewer than 2 hr of supervision is sometimes out of the control of BCBAs due to insurance approvals and related to case specifics, supervisors need to ensure they have adequate means to provide direction to technicians.

Although the largest percentage of respondents reported receiving various modalities of feedback, over 40% of RBTs reported only receiving verbal feedback from supervisors while working on a case with severe problem behavior. Supervision with only verbal feedback is not consistent with current research that has identified the most effective types of feedback as those consisting of multiple mediums (Sleiman et al., 2020). Section 4.08 of the Ethics Codes for Behavior Analysts requires “ongoing, evidence-based data collection and performance monitoring” during supervision (BACB, 2020, p. 15). Given the intensity of services and risks that can come with providing services to clients who exhibit significant problem behavior, behavior analysts need to sure the types of procedures used during supervision are appropriate for the needs of those they supervise and their clients. Other forms of feedback such as written and graphic can provide additional permanent product feedback that can be referenced in the future. Behavioral skills training, which involves modeling and rehearsal in addition to feedback, has been shown to be effective for teaching behavior management skills to teachers and other paraprofessionals (i.e., Slane & Lieberman-Betz, 2021) and could also be integrated into supervision.

Almost 30% of respondents reported receiving no ongoing training after starting a case with severe problem behavior. Ongoing training outside of case supervision is valuable for continued skill development for RBTs working high need cases. Although the cost to provide more training might be of concern to some businesses, modalities such as group trainings and self-instruction methods can be offered that can save time and money while providing ongoing training. Just as asking about RBT comfortability at the onset of the case is important, monitoring for signs of burnout on high intensity cases throughout service delivery should also be part of ongoing supervision of cases by BCBAs. Over two thirds reported never being asked about the effects of burnout while working cases with severe problem behavior. However, for those that were asked, over two thirds reported accommodations being made to help them manage the case and reduce burnout.

Implications for BCBAs in Applied Settings

Our survey results indicated that a number of RBTs reported receiving inadequate initial training or ongoing training for severe problem behavior cases. This may be a result of various factors such as lack of supervision training for BCBA’s or financial restraints from within organizations. However, it is an ethical obligation for BCBAs to uphold best practices for supervision and implementation of evidence-based strategies to deliver services to clients (4.08, BACB, 2020). To uphold these standards and give RBTs the training they need to provide best services to clients, supervisors need to be aware of their own limits when providing supervision on high-needs cases. For instance, if a BCBA feels as if they have too many cases on their caseload, it is still up to them to effectively manage the caseload. Managing the caseload effectively might involve speaking with organizational leadership about reducing cases or asking for additional support (i.e., from a BCaBA) or letting organizational supervisors know they need to reduce/modify their caseload. Supervisors should also develop feedback systems to allows them to better assess appropriate matches between staff and clients, monitor for burnout during service delivery, and survey RBTs under their supervision for their feedback preferences. This can be done with a simple social validity assessment and questionnaire that can be integrated into regular case supervision. Assessing RBT comfortability and strengths when assigning them to a client who exhibits significant problem behaviors also has the added advantage of preventing having to re-assign staff after a case starts.

One major finding of this survey was that few RBTs reported continued ongoing training after being placed with a client who exhibited significant problem behavior. As mentioned, supervisors may be limited with the number of hours approved and with time constraints related to travel and other case obligations. Video modeling and telehealth supervision might be appropriate to supplement one-on-one training for cases (see Cardinal et al., 2017, and Nohelty et al., 2022, for examples). Supervisors could also create an integrity checklist for BIPs as a self-monitoring form to help RBTs as a form of task clarification for the steps included in the intervention (Mouzakitis et al., 2015). Supervision logs and secure web-based communication applications could be used to record RBT concerns and provide written feedback when supervisors are not directly available. Increasing the amount of training and feedback for RBTs will at best improve case outcomes and at worse document and demonstrate the need for case modifications to best serve the client (i.e., requesting additional hours, center-based placement, BCaBA or other BCBA support).

In addition to improving treatment efficacy, additional training could help reduce the high percentages of RBTs that reported work related injuries in the current study. A total of 75% of RBTs reported a work related injury, 12% reporting having to visit the hospital, and over 8% reported they had to miss at least 1 week of work. These reported levels of workplace injuries are not uncommon in other human service fields. A 2015 report by the U.S. Bureau of Labor Statistics (2015) indicated that psychiatric aides and technicians experienced work related injuries 69 and 38 times higher than the national average, respectively. Perhaps more concerning, over 36% of respondents reported that their client sustained some type of injury. Only 40% of respondents reported receiving crisis management training prior to working with a client who exhibited significant problem behavior. Ensuring crisis management training is provided prior to the onset of treatment as well as increasing the amounts and types of support available to RBTs during treatment could have the combined effect of increasing treatment efficacy and safety for RBTs and clients alike.

Limitation and Future Directions for Research

Several limitations exist to the current study. A primary limitation of the current study is the sample size of 142 participants. Although the number of participants included may be similar to other published literature on professionals working with children (i.e., Boujut et al., 2017; Kazemi et al., 2015, Luiselli et al., 2017), the percentage of the number of currently certified RBTs (123,960 at the time of this writing) represented in this study was very low (0.11%; BACB, n.d.-b). This was likely because the survey was only distributed via social media platforms in ABA related groups on Facebook and Reddit, which limited the number of participants reached and not via other means such as a mass email service. The choice to distribute the current survey via social media channels was made primarily because a lack of research funding to cover the cost of using a mass email service. Future research should aim for an increased sample size to evaluate the reliability, validity, and generalizability of the data obtained in the current study. This could be done by distributing the survey to more social media channels, using a mass email service, or both. Likewise, collecting location data from respondents would also help to ensure that specific geographic areas are not over or underrepresented. Obtaining a larger and geographically representative sample of participants could allow for the use of statistical analyses to investigate the relationships between training and supervision variables with client safety and cost/benefit outcomes. More information on the types of cases (focused vs. comprehensive) worked by RBTs would provide contextual information to more thoroughly evaluate whether the supervision levels reported in this study appear adequate.

For these reasons, it is appropriate to frame the current study as a preliminary investigation into training needs of RBTs working with individuals who exhibit problematic behavior. Still, these results can be used as a first step in an effort to better identify the needs of RBTs to help guide BCBAs on what to monitor and consider when conceptualizing supervision and training for technicians working with clients who exhibit severe problem behavior. Future research could also assess the needs and/or barriers to BCBAs providing this training RBTs working with clients who exhibit severe problem behavior. For instance, knowing whether the barriers are related to insurance approved hours, organizational requirements for caseloads, or other factors would be helpful to understand what ways BCBAs can modify their practices to direct the RBTs working cases with individuals who exhibit challenging behaviors more effectively. Additional research into the needs and effective supervision modalities for RBTs working with client who exhibit less severe types of problematic behavior (e.g., noncompliance, verbal refusals) could also be helpful for providing more insight to the needs for more RBTs working in the field of ABA.

APPENDIX I

Data Availability

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

Declarations

Conflict of Interest Statement

On behalf of all authors, the corresponding author states that there is/are no conflict(s) of interest to disclose.