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. 2024 Nov 5;18(4):1064–1075. doi: 10.1007/s40617-024-00996-0

County Variation in the Supervision of Registered Behavior Technicians for the Provision of ABA Services in the United States

Marissa E Yingling 1,✉, Matthew H Ruther 2, Erick M Dubuque 3
PMCID: PMC12779808  PMID: 41523821

Abstract

The implementation of behavior analysis for the provision of autism services frequently entails the close supervision and direction of behavior technicians implementing programs designed and overseen by qualified applied behavior analysis (ABA) providers. To date, there has been no investigation into the geographic distribution of the supervision of ABA services, which has important implications for the implementation of a quality tiered service-delivery model. In this study, we examined county-level distribution of the supervision of ABA services by BCBAs in the U.S. as well as the number of Registered Behavior Technicians (RBTs) with an active credential overseen by BCBAs. The sample included all U.S. counties in 50 states and D.C. (N = 3138). Of all qualified supervisors, one-half were not supervising any RBTs. Most actively supervising BCBAs oversaw 10 or fewer RBTs. Just over half of counties did not have either at least one RBT with an active credential or at least one qualified supervisor; 24.2% did not have a qualified supervisor or an RBT with an active credential. These and other results are discussed in the context of the provision of a tiered service-delivery model of ABA services to children with autism.

Keywords: Registered behavior technicians, Board certified behavior analysts, Supervision applied behavior analysis, Geographic access

The implementation of behavior analysis for the provision of autism services frequently entails the close supervision and direction of behavior technicians implementing programs designed and overseen by qualified applied behavior analysis (ABA) providers. Known as a tiered service-delivery model, this customary approach is critical for ensuring cost-effectiveness of ABA services, establishing adequate provider networks, and facilitating access to high quality services for individuals in underserved communities. Because not all Board Certified Behavior Analysts (BCBAs) supervise Registered Behavior Technicians (RBTs), existing research on the geographic accessibility of these providers may overestimate accessibility to qualified supervisors credentialed by the Behavior Analyst Certification Board (2024a). Practically speaking, those working to improve accessibility could benefit from a more complete picture as they prioritize strategies for workforce development that facilitate equitable access to services. Analyses could inform county, state, and regional efforts, including partnerships with governments via grants, legislation, or other means.

In 2014, the BACB began offering the RBT credential (BACB, 2013) for paraprofessionals practicing under the close and ongoing direction of qualified supervisors. Qualified RBT Supervisors or RBT Requirements Coordinators may supervise RBTs, who primarily work with children with autism and provide in-home or clinic-based services (BACB, 2022a). Qualified RBT Supervisors must hold a BCBA professional credential or be licensed in another behavioral health profession with ABA in its legislative scope. RBT Requirements Coordinators hold the BCBA credential and usually supervise multiple RBTs (Kazemi et al., 2019; LeBlanc et al., 2020; Tarbox & Tarbox, 2017). A Board Certified Assistant Behavior Analyst (BCaBA) may supervise or direct RBTs under a Qualified RBT Supervisor or RBT Requirements Coordinator.

Before supervising RBTs, the BACB requires that its BCaBAs, BCBAs, and Board Certified Behavior Analyst-Doctorals (BCBA-Ds) meet certain eligibility qualifications, including successful completion of an 8-h training based on the BACB’s Supervision Training Curriculum (BACB, 2024a). To maintain eligibility to supervise, these certificants are required to obtain three supervision continuing education units, or CEUs, during every 2-year recertification cycle (BACB, 2024a). Qualified supervisors overseeing ongoing services are responsible for providing monthly supervision that constitutes a minimum of 5% of the hours their RBTs spend delivering ABA services (BACB, 2024b). This 5% can also be split across supervisors. An RBT working with a client who receives 40 h of services per week, for example, must be supervised for a minimum of two hours per week. It is worthwhile to note that supervision of RBTs differs from supervision of the clients that are part of a BCBA’s caseload.

In the past two decades demand for the supervision of ABA services as a core component of autism service provision has increased substantially. In response, the number of certified providers—supervisors and RBTs—has steadily and often unprecedentedly risen (Behavior Analyst Certification Board, n.d.-a). The importance of the supervisory relationship between these providers and how it can positively impact services has been acknowledged (e.g., Kazemi et al., 2019; LeBlanc et al., 2020; Tarbox & Tarbox, 2017). In terms of service accessibility for children with autism, significant growth in the number of certified providers is favorable. There is no question that health insurance reform has resulted in more children with autism receiving ABA services than in years past (National Conference of State Legislatures, 2023). However, empirical and anecdotal evidence suggest that children and families continue to have difficulty accessing qualified providers indicating that challenges to sufficient and equitable access endure (Bekker, 2018; Bump, 2017; Johnson, 2018; Lofton, 2016; Mello et al., 2016; Ovaska-Few, 2018; Yingling & Bell, 2019; Yingling et al., 2017, 2019).

Although the field of behavior analysis is placing greater emphasis on researching the supervisory relationship (e.g., LeBlanc & Luiselli, 2016) and developing guidelines for supervision (Behavior Analyst Certification Board, 2024a), little is known about the accessibility of qualified supervisors in the U.S. or the supervisory relationship in terms of the number of RBTs supervisors oversee in practice. To date, the closest account is a survey in which respondents reported the percentage of direct service hours for which they provided oversight to RBTs (N = 317). Among respondents, 41% of supervisors reported that they did not supervise RBTs, 17% reported that they supervised 5% of direct services, and the remainder (37%) reported providing supervision for between 10 and 20% of direct services (Hajiaghamohseni et al., 2021). Although these results offer preliminary data on the percentage of direct services supervisors oversee, they do not shed any light on accessibility to supervisors or the number of RBTs that qualified supervisors oversee.

In recent years, our understanding of the geographic accessibility of ABA service providers for individuals with autism has improved. Building on early work which demonstrated significant variation in the per capita distribution of BCBAs (Deochand & Fuqua, 2016), McBain et al. (2020) documented that states with health care insurance mandates for the diagnosis of autism and service provision were associated with an approximately 16% increase in BCBAs between 2003 and 2017. A common theme is that Northeastern states enjoy the greatest geographic accessibility (Deochand & Fuqua, 2016; Yingling et al., 2021a, 2021b). A series of studies at the county level have demonstrated that more than half of all counties in the U.S. have no BCBAs, that the differences in access to BCBAs among children with autism cannot be entirely explained by the county-level variation of autism prevalence, that affluent and metropolitan counties have the highest geographic access to BCBAs, and that although geographic accessibility has improved in the past several years, uneven county-level access persists (Yingling et al., 2021a, 2021b, 2022a, 2022b).

Despite enhancement of our understanding of provider accessibility in recent years, the authors are unaware of investigations into the supervisory relationship. Not all BCBAs in recent literature may be qualified to supervise RBTs and those that are qualified may not be doing so. Current findings may therefore overestimate accessibility to supervisors and to RBTs, which are necessary for the provision of a quality tiered service-delivery model. The purpose of this study, therefore, is to examine the county-level distribution of supervision of ABA services by BCBAs in the U.S. as well as the number of RBTs overseen by BCBAs. Although RBTs and BCBAs may work with populations other than autism, they are specifically included within the service models used for individuals with autism (Council of Autism Service Providers, 2020). Moreover, the majority of BCBAs (75.39%) and RBTs (84.85%) report working with individuals with autism (BACB, n.d.). This suggests that matters related to supervision are likely to disproportionately impact the provision of ABA services within this population. Thus, findings are presented in the context of services for individuals with autism.

Method

Data and Sample

We used a list of 222,106 providers shared by the BACB that only included publicly available information found in the BACB Certificant Registry (BACB Certificant Registry, n.d.). This list included 171,441 RBTs and 50,665 BCBAs certified by the BACB in the U.S. on or before December 31, 2021. For the purposes of this study, the BCBA-D designation is included with the BCBA certifications, and the BCaBA certification is excluded because these mid-level providers represent less than 10% of the BACB certificants in the U.S. (with the exception of higher rates of over 40% in Florida) and must be supervised by a BCBA or BCBA-D (Behavior Analyst Certification Board, n.d.-a). The provider list included the location ZIP code of each provider, as well as their certification and supervisor status. All records with a certification status of “Inactive” or “Revoked” were removed from the sample (4481 RBTs and 228 BCBAs). This study received approval from the University of Louisville Institutional Review Board.

Variables

Qualified supervisors were those BCBAs with a date of qualification for supervision and those without a date of qualification were designated as unqualified supervisors. Active supervisors were those BCBAs who reported supervising one or more RBTs. Non-active supervisors reported supervising no RBTs. Supervisor caseload was the number of RBTs assigned to BCBAs.

To examine the geographic accessibility of BCBAs qualified to supervise RBTs, we categorized supervisor presence as (1) at least one qualified BCBA in a county and at least one RBT, (2) no qualified BCBAs in a county and at least one RBT, (3) at least one qualified BCBA in a county and no RBTs, and (4) no qualified BCBAs in a county and no RBTs.

Providers were assigned to their county of practice based on their location ZIP code. Approximately 70% of ZIP codes lie within a single county. In those cases where a ZIP code crossed a county boundary, providers within that ZIP code were assigned to each county based on the percent of overlap of business addresses between the ZIP code and the county using the HUD ZIP-County Crosswalk (Wilson, 2024). The number of RBTs and BCBAs certified between January 1, 2015, and December 31, 2021 (the RBT credential first became available in late 2014) was then aggregated within each county (N = 3138), as were the number of BCBAs qualified to supervise and supervising, and the total number of RBTs they were assigned to supervise. Small numbers of providers had ZIP codes that did not exist within the U.S. Census Bureau’s ZIP code database. The absence of these ZIP codes is most likely due to the procedure through which ZIP codes (which are technically routes) are converted into polygons. Of the 166,960 RBT providers, 1292 (0.8%) had ZIP codes that could not be accurately assigned to a county and were excluded from further analysis. Of the 50,437 active BCBA providers, 115 (0.3%) had ZIP codes that could not be accurately assigned to a county and were excluded from further analysis. In addition, 888 (1.8%) of the BCBAs who were indicated as actively supervising were not indicated as being qualified to supervise. It is not clear whether this could be an error in the administrative data. Regardless, the number is small enough that it does not substantially affect results. Whether included or excluded, these BCBAs could result in evaluation of geographic access that is slightly better or worse. With this understanding, because they existed in the data as actively supervising, the authors decided to include them. Nearly all of these BCBAs had zero supervisees and were retained as such. The study sample included all U.S. counties and county equivalents (e.g., boroughs, parishes, independent cities) in all 50 states and the District of Columbia (N = 3138).

Results

As demonstrated in Table 1, by January 1, 2022, among the 83.5% of BCBAs who were qualified to supervise RBTs (N = 41,925), the number of RBTs supervised ranged from 0 to greater than 100. A total of 11.7% were supervising 1 RBT, 20.4% were supervising between 2 and 5 RBTs, and 10.6% were supervising between 6 and 10 RBTs. The remaining 7.4% (n = 3074) were supervising between 11 and 20 RBTs (5.6%), 21 and 50 RBTs (1.6%), and in rare cases, greater than 51 RBTs (0.2%). Approximately 50% of BCBAs qualified to supervise (n = 20,950) in the U.S. were not supervising any RBTs. Of those BCBAs who were qualified to supervise and were supervising at least one RBT, the mean number of RBTs supervised was 6.

Table 1.

Descriptive statistics for supervision of Registered Behavior Technicians by qualified BCBAs in 2021 (N = 41,925)

Variable n % Mean Median SD
Number of RBTs assigned to qualified BCBAs 3.0 1.0 1.0
 > 100 22 0.1
51–100 56 0.1
21–50 662 1.6
11–20 2,334 5.6
6–10 4,432 10.6
2–5 8,558 20.4
1 4,911 11.7
0 20,950 50.0
Number of RBTs assigned to qualified and supervising BCBAsa 6.0 10.0 4.0
 > 100 14 0.1
51–100 43 0.3
21–50 435 3.4
11–20 1447 11.4
6–10 2577 20.2
2–5 5196 40.8
1 3030 23.8
0
No Qualified BCBAs, No RBTs 760 24.2
At least 1 Qualified BCBA, No RBTs 132 4.2
At least 1 Qualified BCBA, At least 1 RBT 1,541 49.1
No Qualified BCBAs, At least 1 RBT 705 22.5
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aExcludes qualified BCBAs not supervising. The 888 BCBAs who supervised but were not qualified are not included here. Per personal communication with the BACB on August 9, 2022, some RBT Coordinators have large numbers of RBTs assigned to them because they are the primary contact for their organization not because they are supervising all of them. The BACB reviews these data regularly and has implemented volume-based triggers for audits for RBT supervisors that lead the BACB to reach out to certificants to verify information

Figure 1 illustrates the co-presence (or absence) of RBTs with an active credential and qualified supervisors across the U.S. This map demonstrates that approximately half of all counties have at least one RBT with an active credential and one BCBA that is a qualified supervisor. Approximately one in four counties have one provider type (usually an RBT) but not the other. However, 24.2% of counties—indicated in pink—have neither a BCBA nor an RBT in residence. These “no-provider” counties follow a swath from the upper Mountain and Plains states down through Texas. There are also notable concentrations in parts of the Southeast and in the Appalachian region in West Virginia and Kentucky.

Fig. 1.

Fig. 1

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U.S. Counties by presence of Board Certified Behavior Analysts qualified to supervise Registered Behavior Technicians, 2021

Table 2 highlights differences in the county means of basic demographic and socioeconomic variables based on the presence of BCBAs and RBTs. Bivariate t-tests based on a significance level of 0.05 illustrate that counties that have at least one BCBA and one RBT are far more likely to be urban than are those with no providers (p < 0.001), and they have much larger populations on average (p < 0.001). Counties with providers of each type also have higher median household incomes (p < 0.001), lower poverty rates (p < 0.001), and larger black populations (p < 0.001) than do counties with no providers. There is no statistically significant difference between counties in the mean percentage of the county that is Hispanic or Latino (p < 0.097).

Table 2.

Comparison of county socioeconomic and demographic factors for different levels of BCBA and RBT presence (N = 3138)

Group Description Stat Population* Urban* Income* Poverty* Black* Hispanic
Min 74 0.0% $20,330 2.6% 0.0% 0.0%
1 No qualified BCBAs, no RBTs Mean 10,154 6.5% $45,289 16.8% 6.6% 10.3%
Max 107,902 100.0% $91,518 52.0% 86.4% 94.1%
Min 2885 0.0% $19,264 2.4% 0.0% 0.0%
2 At least 1 Qualified BCBA, at least 1 RBT Mean 190,834 60.7% $54,280 14.9% 9.5% 9.5%
Max 10,105,722 100.0% $129,588 41.0% 81.5% 99.2%
Min 602 0.0% $22,413 2.8% 0.0% 0.0%
3 No qualified BCBAs, at least 1 RBT Mean 22,696 21.6% $44,613 17.6% 10.9% 7.9%
Max 134,187 100.0% $85,000 45.9% 86.9% 95.3%
Min 1139 0.0% $23,558 5.7% 0.0% 0.1%
4 At least 1 qualified BCBA, no RBTs Mean 22,774 21.4% $48,804 15.0% 4.3% 5.5%
Max 81,224 100.0% $84,911 39.5% 50.1% 59.4%
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* = Statistically significant difference (p < 0.05) between group 1 and group 2 based on bivariate t test

Figure 2a illustrates the percent of BCBAs qualified to supervise across the U.S. while Fig. 2b shows the percent of qualified BCBAs who are supervising. The percent of BCBAs qualified to supervise is relatively high—more than 50%—in most counties. Among the 827 counties with five or more active BCBAs, the mean percent qualified to supervise is approximately 84%. Counties with low qualification rates, which are darker red in Fig. 2a, tend to have few BCBAs overall. However, among BCBAs qualified to supervise, active supervision rates tend to be lower. Among the 764 counties with five or more qualified BCBAs, the mean percent supervising is approximately 59%. There were 140 counties with five or more qualified BCBAs that have fewer than 50% supervising. This included Miami-Dade, Florida (1352 qualified, 478 supervising), New Haven, CT (217 qualified, 108 supervising), and Nashville-Davidson, TN (187 qualified, 91 supervising).

Fig. 2.

Fig. 2

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a–b (a) Percent of Board Certified Behavior Analysts qualified to supervise by U.S. county, 2021 and (b) supervision caseload of Board Certified Behavior Analysts actively supervising by U.S. county, 2021

Figures 3 and 4 display the mean number of RBTs supervised by county and the ratio of RBTs to qualified BCBAs, respectively. These maps demonstrate similar results: average BCBA supervisory loads are higher in states, such as Indiana and Florida, with larger relative numbers of RBTs. In fact, of the 764 counties with five or more qualified BCBAs, the ten counties with the highest mean supervisor loads are all in Indiana. Although RBT to qualified BCBA ratios are also highest in Indiana, several major metropolitan areas— Atlanta, Georgia and the Texas metropolitan areas of Dallas-Fort Worth, Houston, and El Paso—exhibit similarly high numbers.

Fig. 3.

Fig. 3

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Mean number of Registered Behavior Technicians supervised by U.S. county, 2021

Fig. 4.

Fig. 4

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Ratio of Registered Behavior Technicians to Board Certified Behavior Analysts who are qualified to supervise by U.S. County, 2021

Discussion

This study provides a comprehensive overview of the geographic distribution of BCBAs qualified to supervise RBTs with an active credential in the U.S. County variation is apparent, and several insights are noteworthy. First, among the 83.5% of BCBAs who were qualified to supervise RBTs (N = 41,925), approximately one-half of BCBAs were not supervising any RBTs. Findings also illustrate the location of qualified supervisors and the co-presence of RBTs with an active credential and qualified supervisors across counties. Although there are numerous confounding factors that cannot be accounted for in the current study, this data does serve as a proxy for counties in which intensive services for individuals with autism are provided. In other words, a county without any BCBAs qualified to supervise is unlikely to have early intensive services. Just over half of all counties did not have either at least one RBT with an active credential or at least one qualified supervisor. Notably, 24.2% (n = 760) of counties did not have a qualified supervisor or an RBT. This number is slightly higher than the 23.1% (n = 726) of counties that earlier work indicates did not have a BCBA or an RBT (Yingling et al., 2022a), suggesting less accessibility to a tiered service-delivery model when accounting for whether a BCBA is qualified to supervise. Future research on the accessibility of ABA services will need to account for this.

As demonstrated in Figs. 3 and 4, the average number of RBTs overseen by BCBAs are higher in states, such as Indiana and Florida, with larger relative numbers of RBTs. Of the 764 counties with five or more qualified BCBAs, the ten counties with the highest mean number of RBTs overseen by BCBAs were all in Indiana. Larger organizations that serve highly populated metropolitan areas may utilize RBT Requirements Coordinators that result in an increase of RBTs assigned to qualified supervisors in the BACB data. Additionally, Florida Medicaid appears to require the RBT credential, and there is evidence that Indiana managed care organizations also require it. Also, importantly, when the qualifying exam for BCBAs moved online at the beginning of the COVID-19 pandemic, there were reports of fraud in Florida regarding the RBT credential (Behavior Analyst Certification Board, 2022a). The number of RBTs who participated in this activity and therefore impacted the data is unknown.

One explanation for study results is that the RBT credential requires significant investment in time and resources for organizations to support, and therefore this return on investment may only be considered beneficial when a funder requires it. When funders do not require the RBT credential, agencies may still use the tiered service-delivery model, but they may not seek the RBT credential for their staff given the time and resources required. A second potential explanation pertains to supervision credentials. Currently, the BACB only requires BCBAs to complete 8-h of training based on their supervision training curriculum (BACB, 2024a) to qualify to supervise RBTs, BCaBAs, and trainees accumulating fieldwork hours toward a BACB exam. Additionally, BCBAs only need to accumulate three supervision continuing education units each recertification cycle to remain eligible to supervise (BACB, 2022b). It is reasonable to assume that some BCBAs continue to meet these standards but do not necessarily plan to provide supervision in the immediate future.

Moreover, some of these BCBAs may work in areas other than autism that do not implement a tiered service-delivery model in which BCBAs supervise RBTs. Indeed, the latest data from the BACB suggests that although 71.91% of BCBAs provide services to individuals with autism, others are working in areas such as education (12.19%), with individuals with intellectual and developmental disabilities (4.97%), or in higher education (1.16%). However, other areas of professional emphasis and related explanations may not account for all qualified supervisors who were not supervising RBTs at the time of the study. BCBAs could also be unemployed or on leave. Still, the demand for professionals with a BCBA credential should not be understated. For example, a recent job demand analysis indicated that there were more job postings in the U.S. for BCBAs in 2023 (N = 65,366) than there were U.S. providers holding that credential in December that same year (N = 60,341) (BACB, 2024c, n.d.). Alternatively, they could be working but providing comprehensive ABA services outside of a tiered model or primarily engaging in consultative work, which does not require RBTs. It is also possible that BCaBAs, who are supervised by BCBAs, are providing supervision to RBTs. Notable for future research, however, is that the number of annual BCaBA certificants appears to be declining (BACB, n.d.-a).

BCBAs may also be new to the field and not yet overseeing RBTs as they search for work and build their caseloads. It is common for providers to work as RBTs while they earn the BCBA credential. It could take time for these certificants to transition into a position in which they are overseeing other RBTs. The data supports these possibilities. We compared dates of BCBA certification and dates of qualified supervision between those qualified supervisors who were actively supervising and those who were not. Qualified BCBAs who were supervising (n = 23,149) had, on average, been certified as BCBAs for 1.75 years longer than qualified BCBAs who did not supervise (n = 18,776). Qualified BCBAs who were supervising had, on average, been eligible to supervise for 1.5 years longer than qualified BCBAs who did not supervise. It is also not clear what impact a new requirement implemented by the BACB on January 1, 2022, which requires BCBAs certified in their first year to participate in monthly consultations with a qualified consulting supervisor, may have on newly credentialed BCBAs serving as supervisors (BACB, 2023).

Of all qualified supervisors, a minority supervised between 11 and 20 RBTs (5.6%), 21 and 50 RBTs (1.6%), and in rare cases, greater than 51 RBTs (0.2%). To better understand these results, we emailed the BACB to ask what could account for such high numbers. They suggested that they are likely explained by the role of a Requirements Coordinator. Those BCBAs who serve as Requirements Coordinators for their organizations are the primary contacts for their organizations. They therefore have much larger numbers of RBTs that are assigned to them, even though they are not providing all of the supervision. Importantly, the BACB conveys that it regularly employs an audit when a high volume of cases justifies verifying information (M. R. Nosik, personal communication, August 9, 2022).

Nineteen of the 65 counties with an RBT to qualified BCBA ratio greater than 15 are in the state of Indiana—this includes both urban and rural counties in the state. Several other metropolitan areas exhibit similarly high numbers. Although prior work indicates that geographic accessibility to providers is greater in metropolitan areas compared to nonmetropolitan areas, it is possible that these numbers reflect areas for improvement in geographic accessibility in these counties. Relatedly, Table 2 highlights that more than 90% of counties with neither a BCBA nor an RBT are rural. Given that many of these counties are too small to support typical services, additional methods of reaching these populations must be investigated.

Future Research

There are several opportunities for future research related to the geographic accessibility of quality ABA services in a tiered service-delivery model. First, there is a need to determine whether counties with low numbers of supervising BCBAs or RBTs can be explained by insurance requirements. Specifically, if insurance companies do not require an RBT credential, this could disincentivize BCBAs from obtaining or maintaining their supervisor credential. This research could identify areas in which the profession can improve the credentials of practitioners available to provide supervision. It could also inform future data collection and subsequent analyses to track geographic accessibility more accurately.

Another opportunity for investigation concerns remote supervision. Where telehealth is a viable option for providers to offer quality supervision (Council of Autism Service Providers, 2021), digital equity is an important factor to consider, including the challenge of connecting rural populations to services. The COVID-19 pandemic thrust healthcare providers and patients into using telehealth on an unprecedented scale. However, it also exposed significant inequities in access to telehealth (Phuong et al., 2023). Many households do not have a computer or smart phone in their homes. Those that do have one do not necessarily have the internet (National Center for Education Statistics, 2018). In rural counties and in rural counties with persistent poverty, only 72% and 63% of residents, respectively, have moderate or high-speed broadband internet available (Dobis et al., 2021). Rural counties in the lower Great Plains and western Mountain states and persistently poor rural counties in the Deep South and Southwest experience low access to internet. Thus, although virtual supervision may be feasible in one county or state, it may not be feasible in another. In these cases, barriers to in-person supervision will need to be addressed. For instance, the driving time required for supervisors to provide in-person supervision likely varies by state (Dobis et al., 2021) and may require providers to generate creative solutions. Further, state licensing boards regulating ABA providers (BACB, n.d.-b) may have administrative regulations requiring out-of-state supervisors to be licensed in the state where services are received (e.g., Telehealth and Telepractice, 2022). Although this is a justifiable requirement to ensure appropriate oversight of the profession, it does create an additional administrative cost for providers delivering telehealth services across state lines. Although a strength of this study is the national-level picture it documents, conducting state and regional analyses will be useful for identifying nuance and particular opportunities to improve access.

A potential first step to conducting research that explores the feasibility of a tiered service-delivery model in rural areas within states or regions is to leverage or improve existing data collection initiatives. How are organizations currently reaching rural populations? What are the most effective methods? Additional areas of inquiry include, for instance, the proportion of clients who do not have internet access to receive supervision in their homes, the proportion of prospective clients turned away because quality in-person supervision cannot be offered, the proportion of clients that receive supervision through telehealth, the driving distance for clients from their homes to clinics to receive in-person supervision, and the difference in quality of supervision received between in-person and telehealth services. Estimating the extent to which these matters prevent quality access to services could ultimately be useful when determining the resources required to resolve them and in advocacy efforts to secure those resources. By answering these questions and others, organizations could maximize data utility and inform local services. If existing data is of sufficient quality, combining retrospective as well as prospective approaches could expedite research and subsequent solutions.

Another potential area for research is the examination of whether the number of monthly hours of RBT supervision impacts client outcomes, a relationship indicated by extant evidence (Dixon et al., 2016). If this relationship is identified in additional research, how it impacts client outcomes will be important to evaluate. One potential factor to consider is the extent to which supervisors have sufficient time to allocate to the provision of quality supervision (Turner et al., 2016). Time constraints of a supervisor can lead to less supervision than a supervisee needs and be detrimental to the supervisor–supervisee relationship, which may negatively influence services (Valentino, 2021). This research has practical implications for funding. For instance, in 2019, the American Medical Association unveiled a new set of Current Procedural Terminology (CPT) codes for adaptive behavior services (American Medical Association, 2018). These codes include uniform service descriptors that are used by providers when submitting claims to funders for reimbursement. They do not allow providers to seek reimbursement for providing supervision (or direction as it is described in these codes) when a patient is not present. This means providers need to treat any non-face-to-face supervision time as a bundled service when negotiating rates with funders. These financial contingencies make it very likely that almost all supervision (or direction) takes place only when a client is present. This arrangement may limit the types of supervisory activities that can take place. For example, the direction provided must be related to the client present. Likewise, there is evidence of funders adopting policies that contradict industry guidelines (ABA Coding Coalition, 2022) and even the American Medical Association (2021) by putting limitations on concurrent billing for adaptive behavior services (Department of Defense, 2021). This is extremely problematic as many BCBAs are concurrently providing program modification and direction (supervision) under the 97155 CPT code while the RBTs under their supervision is offering services under the 97153 code. However, sometimes the feedback that needs to be provided to a Behavior Technician may be relevant outside of a specific case (e.g., appropriate dress) or may be ill-suited to deliver in front of a patient (e.g., practicing soft-skills when interacting with caregivers).

Limitations

There are limitations to consider alongside study findings. We did not examine the willingness of approved supervisors to supervise RBTs. The BACB’s Certificant Registry displays the date when a BCaBA, BCBA, or BCBA-D met the eligibility requirements to supervise and whether a supervisor is willing to supervise trainees pursuing a BACB credential or BCaBAs providing ongoing services (BACB, n.d.). Importantly, just because a supervisor does not indicate a willingness to supervise does not mean they are not already providing supervisory oversight. It may mean that the supervisor has reached their maximum capacity of supervisees, or they are unable or unwilling to supervise RBTs, trainees or BCaBAs outside of their organization and do not wish to advertise their availability as a supervisor on the BACB’s Certificant Registry.

The BACB does have a mechanism that permits non-BACB certified professionals to oversee RBTs if they are competent in ABA and licensed in another behavioral health profession that has ABA in its legislative scope of practice (BACB, 2020). Although the number of non-BACB RBT supervisors is unknown, there does not appear to be any evidence to suggest a large number of non-BACB certificants are taking on this role.

Furthermore, it is noteworthy that since data collection for this study concluded on December 31, 2021, the BACB has credentialed many more BCBAs and RBTs. In published research that utilizes valuable administrative data to assess the provision of health services for individuals with autism, there is a time lag between data collection and publication ranging from 5 to 10 years (e.g., Franklin et al., 2022; Jariwala-Parikh et al., 2019; Lindly et al., 2019; Ruble et al., 2005; Thomas et al., 2011). Despite this reality, research that utilizes such data remains valuable because of its potential to inform services on a large scale, of the enduring challenges to service provision that it often identifies, and of its contribution to tracking trends over time. In the case of supervision for ABA services, although the number of providers continues to increase, recent data suggests that results of the current study are likely to be just as relevant at the time of publication. That is, aggregated certificant data published on the BACB website demonstrates a continued increase in the number of RBTs per BCBA between 2021 and 2023 (2021, 2.07 RBTs/BCBA; 2022, 2.17 RBTs/BCBA; 2023, 2.41 RBTs/BCBA). The cross-sectional examination of the supervision of RBTs by BCBAs provided by this study is an important reference point to assess progression or regression of accessibility in future analyses, and it is relevant now.

Conclusion

Without a sufficient supply of BCBAs who are qualified to supervise RBTs, ABA services using a tiered service-delivery model will be less accessible to populations in need of them. Although the current study offers a foundation on which to build inquiry into the accessibility of supervision, future work is required to identify specific opportunities to expand access. To advance knowledge regarding the supervisory relationship between BCBAs and RBTs, data must be available, aggregated, and analyzed at local as well as national levels.

Author Contributions

MY conceived of the study, led its design and coordination, drafted the introduction and discussion, and finalized the manuscript; MR contributed to design and conceptualization, conducted analyses, drafted the methods and results, and provided feedback on manuscript drafts. ED contributed to study design, provided expertise especially in the discussion, and offered feedback on manuscript drafts. All authors read and approved the final manuscript.

Funding

This study received no funding.

Data Availability

Data will be made available upon reasonable request.

Declarations

Ethics Approval

This research did not include human subjects.

Informed Consent

Informed consent was not required.

Conflicts of Interest

The authors have no relevant financial or non-financial interests to disclose.

Footnotes

This study was completed at the University of Louisville.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Data Availability Statement

Data will be made available upon reasonable request.

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