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. 2025 Jul 8;19(3):1185–1197. doi: 10.1007/s40617-025-01076-7

Current Practices for the Assessment and Treatment of Severe Problem Behavior: A Colorado-Based Survey

Patrick W Romani 1,✉, Mathew C Luehring 1
PMCID: PMC13638825  PMID: 42840370

Abstract

Credentialed behavior analysts receive training to implement functional behavior assessment (FBA) to ultimately design function-based behavioral treatment for clients engaging in severe problem behavior. Severe problem behavior includes aggression (e.g., hitting, biting), property destruction (e.g., displacing furniture), and self-injury (e.g., self-biting) that has the potential to harm others or the client themselves. Although studies have surveyed current practices of credentialed behavior analysts when assessing problem behavior, a comprehensive survey of the entire assessment and treatment process is absent from the literature. To the extent that survey-based data lead to an understanding of current practices, it seems helpful to understand safety assessment practices, protective equipment usage, and use of single-case designs (SCD). The current study recruited 174 credentialed behavior analysts working with clients engaging in severe problem behavior. Participants responded to a Qualtrics survey to share the frequency with which they selected various FBA and behavioral treatment approaches to address severe problem behavior. We additionally asked participants to share ways they assess safety when working with this population of clients and how they evaluate treatment progress with SCD. Results replicated previous research showing credentialed behavior analysts most often use nonexperimental FBA to assess problem behavior. We will also present and discuss data regarding safety assessment, use of SCD, and treatment selection.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1007/s40617-025-01076-7.

Keywords: Functional behavior assessment, Functional communication training, Personal protective equipment, Staff training

Research documents the gradually increasing prevalence of intellectual and developmental disabilities (IDD; Zablotsky et al., 2019). Of this group of people, the occurrence of severe problem behavior is higher than in the general population (Soke et al., 2016). Severe problem behavior includes self-injury (e.g., head banging, hand biting), aggression (e.g., hitting others, pulling hair), and property destruction (e.g., displacing furniture, destroying materials) whose occurrence poses a high risk of the client injuring themselves or injuring other care providers (Colombo et al., 2020). These problem behaviors can be highly disruptive to home, school, and community functioning. As a result, individuals engaging in severe problem behavior are at increased risk of being denied access to services, over-use of medication, physical restraint, and out-of-home placement (Hyman et al., 1990; Matson et al., 2012; Newcomb & Hagopian, 2018).

Research supports using the principles of behavior analysis to design treatment arrangements to address the severe problem behavior exhibited by individuals with IDD (Roane et al., 2016). This practice is referred to as applied behavior analysis (ABA). Practitioners of ABA are credentialed through the Behavior Analyst Certification Board (BACB®) and identify as doctoral-level board-certified behavior analysts (BCBA-D®), board-certified behavior analysts (BCBA®), board-certified assistant behavior analysts (BCaBA), and registered behavior technicians. The BACB estimates that 82.1% of certificants serve individuals diagnosed with autism and related disorders (BACB, 2025). Although behavior-analytic practitioners engage in programming for reasons other than to reduce problem behavior (e.g., skill acquisition), this paper is only focusing on the treatment of severe problem behavior.

Behavior-analytic practitioners are encouraged to use a highly effective method of behavioral assessment and treatment for severe problem behavior (Lindgren et al., 2020). To that aim, Hagopian et al. (2013) and Kurtz et al. (2020) described this method in great detail, and Fisher et al. (2015) published a practitioner’s guide describing this process. Fisher et al.’s guide begins with using indirect (e.g., surveys, interviews) and descriptive (e.g., antecedent-behavior-consequence narrative) assessments to inform an experimental analysis (e.g., functional analysis of problem behavior). Indirect assessment involves procedures that assess the function of problem behavior without observing the actual response. Examples of indirect assessment include surveys (e.g., Functional Analysis Screening Tool; Iwata et al., 2013) and interviews (Functional Assessment Interview; Hanley, 2012). Descriptive assessments represent naturalistic observations of antecedents and consequences potentially related to problem behavior occurrence. Experimental analyses involve manipulating antecedents and consequences to identify reinforcing relations between a response and various sources of reinforcement (e.g., escape from task demands). Results from functional behavior assessments (FBAs) should be used to develop hypotheses regarding behavioral function and identify contextual variables that may be systematically tested within an experimental FBA (Tarbox et al., 2009).

After the indirect/descriptive assessments and before starting the experimental analysis, behavior analysts might consider conducting a risk assessment to identify safety considerations before beginning the experimental analysis (Betz & Fisher, 2011). Deochand et al. (2020) worked with 10 BCBA-Ds to develop a safety assessment algorithm for behavior analysts to determine the feasibility of conducting an experimental analysis. Responses to questions asking the supervising behavior analyst to consider

  1. Their clinical experience conducting experimental analyses,

  2. The environment in which the experimental analysis will be conducted,

  3. The intensity of the client’s problem behavior, and

  4. The type of support staff available to the analyst during the experimental analysis lead to a recommendation about the risk of conducting the experimental analysis (slight risk, moderate risk, substantial risk, and high risk).

After identifying a risk level, behavior analysts can use the information produced by the safety assessment to determine whether the risk can be mitigated through practices such as staff training (e.g., behavioral skills training; Parsons et al., 2013) or behavioral personal protective equipment (B-PPE; Daraiseh et al., 2018). Specific forms of B-PPE might include Kevlar arm sleeves to protect against bites and wearing bandanas to prevent hair pulls (Fisher et al., 2013). Considerations such as these are essential for analysts to consider prior to starting an experimental analysis due to the potential risks of evoking severe problem behavior.

If the behavior analyst concludes conducting the experimental analysis is safe, they can determine which procedure to use. Examples of experimental analyses of problem behavior include the traditional functional analysis (FA; Iwata et al., 1982/1994a, b), brief functional analysis (brief FA; Northup et al., 1991), and the interview-informed synthesized contingency analysis (IISCA; Hanley et al., 2014)1. While differing in terms of overall assessment length and design of individual sessions, these experimental analyses each arrange antecedent conditions meant to evoke problem behavior. Following problem behavior occurrence, the behavior analyst delivers a putative reinforcer and evaluates its effect on the future occurrence of problem behavior. Research often describes experimental analyses as the gold standard for identifying the function of problem behavior (Melanson & Fahmie, 2023). The results of experimental analyses frequently lead to effective behavioral treatment programs (Herzinger & Campbell, 2007). It should be noted that recent research suggests that effective behavioral treatments can be achieved without an experimental analysis of behavior (Call et al., 2024).

After an experimental analysis, the behavior analyst, the client, and the client’s caregivers determine the appropriate behavioral treatment program to reduce problem behavior and increase the use of alternative responses (e.g., functional communication). These treatment programs can vary but often involve a differential reinforcement (DR) contingency to reinforce an appropriate response according to a dense schedule of reinforcement (e.g., fixed-ratio 1) while problem behavior results in extinction (Tiger et al., 2008) or in the delivery of a lower quality, lower magnitude, or delayed reinforcer (Vollmer et al., 2020). Variations to this treatment arrangement might involve differentially reinforcing appropriate behavior with tokens (i.e., token economies) or differentially reinforcing the absence of problem behavior (i.e., differential reinforcement of other [DRO] behavior). Additionally, incorporating noncontingent reinforcement as an added component of differential reinforcement programs can be helpful (Marcus & Vollmer, 1996). After successful treatment implementation, behavior analysts thin the schedule of reinforcement to ensure treatment durability when exposed to more naturally occurring conditions (Kranak & Brown, 2024). After showing an effective treatment arrangement, the behavior analyst can evaluate the efficacy of the treatment within a single-case design (SCD; e.g., reversal design). Once the client meets the terminal goal of treatment, the behavior analyst then programs for generalization and maintenance of this treatment.

Although the practice guidelines described by Fisher et al. (2015) described current best practices, research has documented variation in the actual practice of behavior analysts (Colombo et al., 2020; Deroschers et al., 1997; Oliver et al., 2015; Roscoe et al., 2015; Saini & Cox, 2020). For example, Saini and Cox (2020) showed 55.7% of their sample of Canadian behavior analysts believed a functional analysis alone is sufficient for identifying the function of problem behavior. On the other hand, 39.8% of their sample had conducted between 1–10 functional analyses. These data replicated Oliver et al. (2015), who showed that 65% of respondents reported Never or Almost Never using functional analysis methods to assess problem behavior despite recognizing its value. Additionally, there may be variations in how BCBA-D and BCBA providers decide to treat severe problem behavior. Mitteer et al. (2024) showed that BCBA and BCBA-D providers both reported the highest preference for delay-and-denial tolerance training as treatment for severe problem behavior. However, BCBA-D respondents preferred differential reinforcement programs conducted within a multiple-schedule arrangement more than BCBA respondents.

This type of survey-based information is essential for understanding trends in how practitioners make assessment and treatment decisions (Mayo & Hoffman, 2024). This understanding can have numerous benefits, including informing future research and training opportunities (Morris et al., 2023). Surveys offer an anonymous and relatively low-effort method for gaining information from a large group of people. Given the attention devoted to FBA use, it seems important to expand the scope of future surveys of behavior analysts to incorporate considerations for assessing safety, evaluating treatment progress through SCD, and selecting treatment. This information is important because it allows researchers to address the research-to-practice gap that might affect the quality of care delivered to clients engaging in severe problem behavior (Slocum et al., 2014).

Prior survey-based research attempted to evaluate a representative sample of a country or region (Oliver et al., 2015; Roscoe et al., 2015). This practice certainly improves the generalizability of the results. However, surveying a specific area, like one state in the United States, can provide nuanced information that cannot always be accessed following a nationwide survey (Mayo & Hoffman, 2024; Stephens et al., 2023). The purpose of the current study was to replicate and extend previous research to understand how behavior analysts adhere to best practices when assessing and treating severe problem behavior. We extended previous work in two ways. First, we evaluated practices within the state of Colorado to support efforts to build and maintain a high-quality workforce working with clients engaging in severe problem behavior. Second, we evaluated the range of complex decisions behavior analysts make when deciding how to assess, treat, and evaluate effectiveness of treatment for individuals engaging in severe problem behavior.

Method

Participants

We sent an electronic survey via e-mail to 1250 practicing BCBA-Ds, BCBAs, and BCaBAs in the state of Colorado in the United States. We collaborated with Colorado Medicaid as part of their efforts to understand ways to support community providers serving their members. This project represented the first step toward designing a continuing education series for Colorado-based behavior analysts serving Colorado Medicaid members. Thus, because the focus was evaluating Colorado-specific behavior analysts, we did not attempt to recruit a more representative survey of behavior analysts in the United States. We recruited Colorado behavior analysts through the BACB Mass E-mail Service. The recruitment e-mail, which was sent out in the Fall of 2022, shared that the project's purpose was to understand common BCBA practices when working with clients engaging in severe problem behavior. We received 174 completed surveys (13.9%) over a 1-month period. We sent out two recruitment e-mails through the BACB registry over this time. As our response rate approximated that from other published papers, no other efforts were made to contact non-responders (Wu et al., 2022). We did not offer incentives for participating in this survey. No respondents indicated they did not work with clients engaging in problem behavior. Please see Table 1 for a complete description of participants.

Table 1.

Demographic information for all 174 respondents

Characteristic n %
Age
     18–34 71 40.8
     35–50 78 44.8
     51–69 25 14.4
Credential
     BCaBA 8 4.6
     BCBA 150 86.2
     BCBA-D 16 9.2
Race
     White 148 85.1
     Black/African American 2 1.1
     Asian 5 2.9
     American Indian or      Alaska Native 4 2.3
     Hispanic 11 6.3
     Other 4 2.3
Place of Employment
     Hospital 15 8.6
     School or other educational setting 129 74.1
     Home 65 37.4
     Clinic 69 39.7
     Community Setting/Residential Setting 21 12.1
Location
     Urban area 148 85.1
     Rural area 24 13.8
     Suburban 79 45.4
Years of Experience
     1–5 88 50.6
     6–10 56 32.2
     11–15 19 10.9
     16+ 11 6.3
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Materials

Prior to disseminating the survey, we presented a version of the survey to five behavior analysts working in school, clinic, and in-home settings. The purpose was to get feedback about whether the contents of the survey would lead to an informative evaluation of current behavior analyst practices in Colorado. After sending them the survey to review, we scheduled a meeting 1 week afterward to discuss their feedback. Their feedback included ways to make the survey content more culturally responsive, efficient not to overburden potential participants, and representative of the practices they commonly employ in their respective settings. This process led to the development of a 15-item survey (see Supplemental Materials).

We used Qualtrics (Provo, UT) (n.d.) as a platform to create and store data from participants completing the 15-item survey. Response options were presented in a single-option multiple-choice format or multiple-option multiple-choice format. We gathered demographic data by asking about participant’s certification level (e.g., BCBA-D, BCBA), gender, age, race, ethnicity, and location of employment. After this, respondents read the following definition of severe problem behavior described by Colombo et al. (2020), “severe problem behavior include self-injury (e.g., head banging, hand biting), aggression (e.g., hitting others, pulling hair), and property destruction (e.g., displacing furniture, destroying materials) whose occurrence poses a high risk of the client injuring themselves or injuring other care providers” and responded yes or no as to whether they treated this population of individuals. If they responded “yes,” they proceeded with the survey. If they responded “no,” they were thanked for their time and the survey ended. For participants confirming their exposure to individuals engaging in severe problem behavior, we asked participants to respond to a Likert-type scale of 0 (completely unlikely to use) to 10 (completely likely to use) about the likelihood of using various behavioral assessments (e.g., brief FA, FA). We used a multiple-response multiple-choice format to assess use of behavioral treatments (e.g., DR with extinction; DR without extinction), use of various SCD, safety assessment procedures (e.g., experience of staff conducting procedures), and behavioral personal protective equipment (e.g., helmet, Kevlar arm sleeves). Upon answering the last question of the survey, participants were thanked for their time. We arranged the survey to permit respondents to skip questions at any time.

Data Analysis

We analyzed these data in two ways. For items in which participants responded according to a Likert-type scale, we counted the number of respondents who made a particular choice. For example, when summarizing the reported usage of different FBA procedures, we calculated how many individuals with a particular credential level selected each option, divided that number by the total number of participants of the same credential level responding to the item, and multiplying by 100 to produce a percentage. For items for which participants could select multiple choices, we added the number of respondents from each credential level who made each choice and divided that number by the total number of respondents from each credential level who responded to that item. We then multiplied the resulting quotient by 100 to produce a percentage.

Results

A total of 174 certified behavior analysts completed the entire survey (please see Table 1). Of these, 85.8% of respondents reported being a BCBA, 9.4% reported being a BCBA-D, and 4.8% reported being a BCaBA. Most of this sample identified as White (87.6%) and being between the ages of 18–35 (42.0%) and 36–50 years (46.2%). Most respondents reported practicing as a BCBA-D, BCBA, or BCaBA for less than 5 years (52.1%). The majority (33.1%) of respondents reported being certified between 5 and 10 years, with fewer respondents reporting being certified for 11–15 years (11.2%) and over 16 years (6.5%). Most of our sample reported working in urban settings (87.6%) and at schools or other educational placements (76.3%). Respondents noted that the next most common places of employment were clinics (40.8%) and homes (38.5%).

As described by Fisher et al. (2015), we assessed the safety considerations credentialed behavior analysts took prior to working with clients engaging in severe problem behavior (Fig. 1). Responses to the available options were similar across credential types. Over 91.0% of respondents reported considering problem behavior intensity because of risk to staff and clients as well as the safety of the physical environment being used for therapy. Considering the experience of providers delivering care and having enough staff available for support while working with clients seemed to be an important consideration for all three types of credentials, too. Specifically, 76.5% (n = 12) of BCBA-D and 79.3% (n = 119) of BCBA respondents reported this as being something they regularly considered. In contrast, 87.5% (n = 7) of BCaBA respondents reported this as being important. When considering whether enough people are available to support clients, 87.5% (n = 14) of BCBA-D, 75.2% (n = 113) of BCBA, and 62.5% (n = 6) of BCaBA respondents reported this as being important. Several BCBA-D (31.3%; n = 5), BCBA (18.0%; n = 27), and BCaBA (37.5%; n = 3) respondents reported that there are situations in which they do not need to consider any of these safety considerations when working with clients engaging in severe problem behavior. In addition, we evaluated specific types of B-PPE used by all respondents (Fig. 2). The two most endorsed pieces of B-PPE were “pull my hair back” and “wear long-sleeve shirt.” Using Kevlar arm sleeves, face shields, and reinforced gloves were next most endorsed. Pieces of equipment like shin guards, lacrosse pads, helmets, and Kevlar jackets were less likely to be used when these respondents engage with clients engaging in severe problem behavior.

Fig. 1.

Fig. 1

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Percentage of respondents endorsing various safety considerations

Fig. 2.

Fig. 2

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Percentage of respondents endorsing the use of different B-PPE

Once respondents took safety considerations into account, they reported on the likelihood they would use experimental (traditional FA, brief FA, IISCA), descriptive (ABC Narrative), and indirect FBA (ABC Interview, Questionnaire/Survey; Table 2). All respondents across credential levels reported using descriptive and indirect FBAs more often than the experimental FBA. We defined “often” as when respondents rated an item between 8 and 10. As such, an average of 15.6% (n = 7) of BCBA-Ds often used the traditional FA, 4.7% (n = 2) reported often using the BFA, and 11.0% (n = 3) reported often using the IISCA. An average of 7.7% (n = 26) of BCBAs reported often using the traditional FA, 7.0% (n = 22) often used the BFA, and 13.7% (n = 45) reported often using the IISCA. With respect to BCaBAs, 4.3% (n = 1) reported often using the traditional FA, 4.7% (n = 1) reported often using the BFA, and 16.7% (n = 3) reported often using the IISCA.

Table 2.

Percentage of respondents using FBA procedures by credential level

graphic file with name 40617_2025_1076_Figa_HTML.gif
Rating 0 1 2 3 4 5 6 7 8 9 10
BCBA-D
     Traditional FA 7 20 0 20 0 0 7 0 7 27 13
     Brief FA 7 29 21 14 0 14 0 0 7 0 7
     IISCA 0 44 0 11 0 11 0 0 22 0 11
     ABC Narrative 7 7 0 0 0 7 7 13 7 7 47
     ABC Interview 0 14 7 0 0 0 0 7 7 14 57
     Questionnaire/Survey 0 8 8 8 8 8 0 0 0 8 54
BCBA
     Traditional FA 17 13 18 9 6 6 3 5 9 6 8
     Brief FA 6 13 17 7 5 19 10 3 10 5 6
     IISCA 7 4 10 5 9 12 9 5 13 10 18
     ABC Narrative .73 0 2 2 4 6 .73 7 10 8 60
     ABC Interview 2 .8 3 4 6 10 5 4 8 10 48
     Questionnaire/Survey 2 5 7 8 4 6 3 9 10 6 40
BCaBA
     Traditional FA 0 25 25 0 0 13 13 13 0 13 0
     Brief FA 0 14 14 14 14 29 0 0 14 0 0
     IISCA 0 17 17 0 17 0 0 0 0 17 33
     ABC Narrative 0 0 0 0 0 13 0 0 0 38 50
     ABC Interview 0 0 0 0 0 14 0 0 0 14 71
     Questionnaire/Survey 0 0 0 0 0 14 0 0 0 14 71
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After conducting the FBA, 37.5% (n = 6) of BCBA-D, 56.2% (n = 9) of BCBA, and 0% of BCaBA respondents reported that there were times in which they did not use SCD to evaluate the effectiveness of treatment when working with clients engaging in severe problem behavior (Fig. 3). Respondents seemed to most commonly use the AB arrangement (BCBA-D = 54.3%, n = 9; BCBA = 60.0%, n = 90; and BCaBA = 63.0%; n = 5). BCBA-D respondents reported using the multiple baseline (56.2%; n = 9) and reversal designs (56.2%; n = 9) most often after the AB design. BCBA respondents reported using changing criterion (57.4%; n = 86), multiple probe (56.7%; n = 85), multiple baseline (53.3%; n = 80), and alternating treatments/multielement designs (52.6%; n = 79). Finally, BCaBAs reported using multiple probe (62.5%; n = 5) and changing criterion (51.2%; n = 4) designs most often.

Fig. 3.

Fig. 3

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Percentage of respondents endorsing various SCDs

Next, we evaluated the treatment programs credentialed behavior analysts design based on the function of problem behavior (Fig. 4). Each credential level reported using DR without extinction (BCBA-D = 93.8%, n = 15; BCBA = 92.6%, n = 139; BCaBA = 87.5%, n = 7) more often than DR with extinction (BCBA-D = 87.5%, n = 14; BCBA = 73.3%, n = 110; BCaBA = 75.0%, n = 6). Respondents also reported commonly using NCR and differential reinforcement programs within token economy and multiple schedule arrangements. All credential levels reported using punishment-based approaches less than the reinforcement programs described above (BCBA-D = 62.5%, n = 10; BCBA = 29.3%, n = 44; BCaBA = 50.0%, n = 4). To evaluate how respondents determined appropriate treatment and what specific treatment they selected, we asked about the resources or experiences that guided these decisions (Fig. 5). BCBA-D respondents reported using the results of experimental analyses (93.8%; n = 15) and indirect and/or descriptive observations (87.5%; n = 14) to determine treatment. Their next most used decision-making methods were using peer-reviewed articles (75.0%; n = 12) and previous experience with similar clients (75.0%; n = 12). BCBA respondents reported using peer-reviewed articles (92.0%; n = 138), indirect and/or descriptive observations (89.3%; n = 134), and experimental analyses (88.0%; n = 132) most often to determine treatment approaches. Previous experience was reported in 79.5% (n = 119) of BCBA respondents. Finally, BCaBA respondents reported using textbooks (87.5%; n = 7) and indirect and/or descriptive observations (87.5%; n = 7) to determine treatment approaches. They reported using peer-reviewed articles, experimental analyses, and previous experience less often (each reported as 75.0% of respondents; n = 6).

Fig. 4.

Fig. 4

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Percentage of respondents endorsing behavioral treatment procedures

Fig. 5.

Fig. 5

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Percentage of respondents endorsing strategies to determine treatment direction

Discussion

The current study evaluated the extent to which credentialed behavior analysts working in the state of Colorado reported using best practices in the assessment and treatment of severe problem behavior (Fisher et al., 2015). Looking broadly at these data, we discerned areas of practice that match best-practice guidelines as well as opportunities to consider when training future practitioners. These identified areas of strength and opportunity matched previously published data in many ways and may be supportive of Colorado-based practitioners dedicated to supporting individuals engaging in severe problem behavior. Considering these data, we will structure the following discussion by expanding on each step of the evidence-based assessment/treatment procedure put forth by Fisher et al. (2015). Afterward, we will describe practice implications based on these data.

Regarding safety considerations, Deochand et al. (2020) emphasized evaluating the intensity of problem behavior, the environmental context for conducting experimental FBA, and the experience level of staff implementing these FBAs. It appears that prior to conducting experimental FBA, the surveyed practitioners commonly evaluated the intensity of problem behavior and the physical environment to mitigate risks of staff and patient injury. However, assessing the experience of behavior analysts conducting FBA and ensuring adequate staff availability for managing escalations were less consistently performed. These latter aspects are crucial, as experience in conducting experimental FBA can inform appropriate responses to challenging situations, and sufficient staff can help prevent adverse outcomes. While research on the overall impact of staffing ratios on safety yields mixed results, the need for a situation-dependent number of staff, supervised to avoid overcrowding, should be emphasized (Coleman & Paul, 2001; Romani et al., 2020). Nonetheless, it is concerning that approximately 28.3% of respondents reported working with clients exhibiting severe problem behavior without conducting a risk assessment. This practice highlights the potential for preventable adverse incidents. On the other hand, the way we described “severe problem behavior” in the survey may have led to confusion. We did not specify several critical client characteristics that may have changed choice responding. For example, a 4-year-old client engaging in aggression presents differently than a 17-year-old client’s aggression. Either way, using a risk assessment could mitigate negative experiences; for instance, the recommendation of B-PPE could protect staff, as demonstrated by prior studies (Fisher et al., 2013; Hill et al., 2015). However, only around 50% of respondents employ relatively low-effort interventions such as wearing Kevlar sleeves, with even fewer using B-PPE specifically targeting individual body parts.

Another deviation from best practice, replicated in our study, concerns the use of experimental FBA methods. As described by Kurtz et al. (2020), indirect/descriptive FBA leading to experimental FBA may be the best practice when evaluating severe problem behavior. However, consistent with previous findings, respondents reported using experimental FBA methods less frequently than descriptive and indirect methods, regardless of credential level (Colombo et al., 2020; Oliver et al., 2015; Roscoe et al., 2015; Saini & Cox, 2020). Descriptive methods, particularly antecedent-behavior-consequence narrative, were the most employed FBA approaches for evaluating severe problem behavior, followed closely by indirect methods such as interviews and questionnaires/surveys. We evaluated the usage of three experimental FBA methods—traditional functional analysis (Iwata et al., 1982/1994a, b), brief functional analysis (Northup et al., 1991), and IISCA (Hanley et al., 2014). Notably, respondents across all credential levels reported using these three experimental analyses in less than a third of cases involving assessment of problem behavior. BCBA-Ds most often used the traditional FA followed by the IISCA and BFA. In contrast, most BCBA and BCaBA respondents reported using the IISCA followed by approximately equal use of the traditional FA and BFA. While consistent with previous research, this may not always align with best practice, as poor convergent validity has been shown between descriptive and indirect measures compared to traditional functional analysis (Romani et al., 2023; Tarbox et al., 2009).

A novel aspect of our study was evaluating the usage of SCD among credentialed behavior analysts. Previous research indicates varying usage of SCDs, with the multiple baseline design being most prevalent (Byiers et al., 2012; Tanious & Onghena, 2021). All credential levels reported using the AB arrangement most frequently when evaluating treatment response for clients with severe problem behavior. Although not an experimental design, the AB arrangement affords the behavior analyst data for one comparison regarding rate of problem behavior before and after intervention. However, there is a notable research-to-practice gap, with 37.5% and 56.2% of BCBA-D and BCBA respondents, respectively, at least partially endorsing the response option for not using SCD when evaluating treatment. The absence of baseline data collection raises concerns about the objective measurement of treatment progress, especially given the severity of the behavior being addressed. There may be real barriers to implementing SCDs in applied settings, like schools and homes. For example, the risks of re-exposing problem behavior to reinforcement contingencies during a return to baseline may be too high. Although integrating SCD into practice can be challenging, it can be facilitated through supervision and access to resources guiding its implementation (e.g., Valentino, 2022).

In terms of behavioral treatment direction, it seems that respondents used peer-reviewed articles, textbooks, and results of experimental and indirect/descriptive FBA to determine treatment direction. Respondents to this survey generally leaned toward DR without extinction, using NCR, and incorporating discriminative stimuli into treatment. In some cases, it may not be safe or feasible for extinction-based approaches to be implemented (Athens & Vollmer, 2010). It could be the case that respondents felt the severity of problem behavior would adversely affect their ability to implement extinction during DR intervention. While these approaches can certainly be effective, more information is needed to determine the appropriateness of the non-extinction-based approaches being used. For example, it would be helpful to know how respondents determine dimensions of reinforcement to manipulate to encourage clients to engage in appropriate behavior. Additionally, schedule thinning with non-extinction-based treatment can be more challenging (Kranak & Brown, 2024). Punishment-based interventions represented the least endorsed component of treatment for this sample. The integration of punishment into a treatment plan can be complex for many providers. For example, providers in schools may encounter restrictions against using punishment-based procedures. It would be helpful for future research to tease apart whether practitioners cannot or choose not to use punishment-based procedures. Nonetheless, previous research comparing reinforcement only and reinforcement plus punishment-based interventions show punishment can be a helpful intervention, particularly when behavior analysts thin the schedule of reinforcement (Hagopian et al., 1998). Future research might investigate two areas. First, it would be helpful to know if practitioners cannot or choose not to use punishment-based interventions, and second, whether the low reported use of punishment in this study was related to a misunderstanding that response cost, in the form of removing a token from a token board following problem behavior, might be a punisher the same way that contingent restraint may be a punisher. This may need to be further clarified for future research.

Implications for Practice

Our study’s findings hold important implications for practice. Before discussing specific recommendations for behavior analysts to ensure adherence to best practice, it is first important to familiarize ourselves with the systemic landscape as it relates to the practice of behavior analysis. As described by Greer (2023), the landscape for organizations to deliver severe-behavior treatment services is challenging. These services often require a high technician-to-client ratio, specialized environments, and increased supervision from credentialed behavior analysts. Current Medicaid regulations and reimbursement rates in many states prohibit companies from meeting these standards (Graber & O’Brien, 2018). Thus, behavior analysts have a choice between treating this population under less-than ideal circumstances or not serving this population at all. This may help us understand some of the data obtained from this study. For example, although respondents to this survey reported less often considering the number of staff available to conduct experimental FBA, it could reasonably be the case that they do not have the preferred number of staff assigned to cases in the first place.

Similarly, a portion of respondents reported using no SCD or an AB arrangement to evaluate treatment progress. The balance of obtaining billable hours and conducting analytic treatment evaluations may be highly challenging for some providers. The variations from best practice noted in the literature may not solely be due to misunderstanding. Instead, these differences may be a result of the public policies that operate on behavior analysts’ responding when working with clients. This is clearly an area for future research. It will be important for supervising behavior analysts to be aware of these systemic barriers and coach their supervisees accordingly to make ethical decisions on behalf of their clients.

One way to address these systemic barriers to delivering these nuanced services is to systematically evaluate current state practices followed by public policy advocacy (Coop et al., 2023). State-specific surveys surely contribute to the field’s broader understanding regarding the assessment and treatment of clients engaging in severe problem behavior. However, these surveys also provide critical information to share with lawmakers as a way to advocate for reasonable conditions to provide services to this challenging group of clients. Coop and colleagues describe the importance of behavior analysts becoming familiar with public policies and how those policies affect their day-to-day work. These authors provide concrete strategies for how behavior analysts can become involved in advocacy efforts. In fact, these authors led efforts to improve Medicaid reimbursement rates for behavior-analytic providers in Colorado. Colorado-based behavior analysts recently successfully advocated for increased Medicaid rates for many of the Adaptive Behavior CPT® codes. This represents one of many large steps forward that may be impactful in the future.

To the extent that some of the reported differences in adherence to best practices are related to a skill or knowledge deficit, there is rich literature describing ways for behavior analysts to continue building their skillsets as lifelong learners (e.g., Valentino, 2022). For example, organizations should prioritize safety discussions and consider adopting elements of behavior-based safety (BBS) to enhance workplace safety (Geller, 2001). BBS involves performance analysis to understand environmental barriers to a safe working environment and ways to deliver behavior-based feedback to shape safe behavior in the future. This approach has proven beneficial for a variety of settings, including industrial and construction settings (Depasquale & Geller, 1999; Li et al., 2015). Additionally, understanding the prevalence of injuries among credentialed behavior analysts is crucial. These data should be shared to help the field develop benchmarks to ensure safety and quality when working with clients engaging in severe problem behavior (Romani et al., 2020; Ruby et al., 2023). Ultimately, providers should ensure sufficient supervision and ongoing education for behavior analysts to safely and effectively work with clients engaging in severe problem behavior.

Insurance providers and other federal guidelines mandate the FBA process prior to delivering treatment services to clients engaging in severe problem behavior (Gresham et al., 2001). As was shown in the current study, and has been shown in previous studies (Oliver et al., 2015; Colombo et al., 2020), providers appear to select descriptive and indirect FBA procedures to develop hypotheses as to behavioral function. When considering clients engaging in severe problem behavior, these approaches may be more socially acceptable to consumers. For example, describing an experimental analysis in which the BCBA will arrange antecedents to occasion problem behavior and reinforce problem behavior occurrence may be difficult for some to understand. On the other hand, observations or asking questions to understand correlations between antecedents/consequences to problem behavior may be perceived as less risky and more socially acceptable. Experience may be another contributing factor to the decision to not use experimental FBA. Half of this study sample reported being a credentialed behavior analyst for 5 years or less. Depending on the work setting, their case load may not contain a high number of clients engaging in severe problem behavior. Employers should ensure that the credentialed behavior analysts working for them have sufficient supervision and continuing education opportunities to (a) appropriately implement experimental FBA and (b) problem-solve potential barriers to implementing these assessments.

The current study is not without limitations. First, behavior-analytic providers from only one state in the United States were surveyed. This limits the generalizability of these data. Similarly, respondents could forego answering any question on the survey. This was mostly an issue with the FBA evaluation of the study. Future research might consider only allowing respondents to progress with the survey once responding to all previous items. Second, the majority of our sample represented BCBA providers. It would have been helpful to conduct more meaningful comparisons between BCBA and BCBA-D and BCaBA providers. This could be an area for future research. These limitations represent common difficulties when conducting survey-based research (Van Selm & Jankowski, 2006). We found purposefully engaging behavior analyst leaders in the community helped create awareness and excitement regarding the survey. These leaders encouraged their immediate colleagues to complete the survey and sent it to their professional networks. We also found that sharing the funding source helped increase awareness of the study. Colorado Medicaid invested resources to learn ways to support community providers and emphasizing their partnership potentially helped with recruitment. Third, the way we structured questions did not permit a complete understanding of provider decisions to use different treatment or SCD procedures. We only know that they sometimes decide to use different treatment or SCD procedures. This certainly limits conclusions we can make based on these data. Future research should change the way questions are presented to provide this type of information. Similarly, a fourth limitation is our decision to only assess use of the traditional FA, brief FA, and the IISCA in lieu of other forms of functional analysis (e.g., latency-based FAs). When developing the questions for this survey, we assessed credentialed behavior analyst input. Their input placed a focus on the traditional FA, brief FA, and IISCA. Future research should address this limitation and survey respondents about a wider variety of functional behavior assessment and treatment procedures. Fourth, we did not collect qualitative information regarding provider rationale for their assessment and treatment decisions. These data could have helped inform targeted training opportunities. Clinical leaders should consider purposefully holding conversations about barriers to implementing best practices with this challenging population of clients. Future research could also investigate this further, similar to how Mitteer et al. (2024) conducted their qualitative analysis.

In conclusion, the current study provided a comprehensive analysis of how 174 credentialed behavior analysts work with clients engaging in severe problem behavior. We used Fisher et al. (2015)’s practice guide as a way to structure our survey and discussion of results. Using the information collected, we offered several concrete practice recommendations that clinical leaders in various settings might consider when onboarding new credentialed behavior analysts or supporting already employed behavior analysts. As the field of ABA grows and evolves, it will be important for future survey-based studies to be conducted to provide a global overview of current practices to help guide future practitioners to provide high-quality services.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 30 KB) (30KB, docx)

Acknowledgments

Author Note

The authors would like to thank the participants for their time responding to this survey.

Author Contribution

PWR conceptualized the project, engaged in data collection and data analysis, and wrote the manuscript. MCL supported data collection and analysis and edited the manuscript.

Funding

Thea authors declare they have no financial interests.

Data Availability

Data supporting the findings from this paper are available from the corresponding author upon reasonable request.

Declarations

Competing Interests

The authors declare they have no competing interests or conflicts of interest.

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

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

Clinical Trial Number

Not applicable.

Footnotes

1

We recognize the IISCA is distinct from the Practical Functional Assessment (PFA). Our intention was to specifically evaluate use of the IISCA and not the other components of the PFA.

Publisher's Note

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

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Associated Data

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Supplementary Materials

Supplementary file1 (DOCX 30 KB) (30KB, docx)

Data Availability Statement

Data supporting the findings from this paper are available from the corresponding author upon reasonable request.

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