Nearly all US states face shortage in therapists despite alarming rise in number of autistic kids
The supply of certified applied behavior analysis providers fell below the benchmark in 49 states, with only Massachusetts exceeding the required numbers, shows analysis.
The number of children diagnosed with autism has been increasing at an alarming rate, but almost every state in the US is grossly unprepared to handle this and meet the needs of these children.
The reason: The number of therapists or certified applied behavior analysis (ABA) providers is insufficient to treat children with autism in nearly every state, except Massachusetts, according to a new study.
The per capita supply of certified providers fell below the benchmark in 49 states, according to study authors Yidan Xue Zhang, and Janet R Cummings, from Rollins School of Public Health, Emory University, Atlanta.
An estimated one in 59 children had autism spectrum disorder in 2014, up from one in 125 a decade earlier in 2004, and one in 150 in 2000, says the Centers for Disease Control and Prevention (CDC). For 2014, the overall prevalence of autism was 16.8 per 1,000 children aged eight years, says CDC.
“With prevalence of autism ranging from 13.1 to 29.3 per 1,000 children aged eight years in different communities throughout the US, the need for behavioral, educational, residential, and occupational services remains high, as does the need for increased research on both genetic and non-genetic risk factors for autism,” says a CDC report.
The applied behavior analysis is the recommended treatment for children with autism and is supported by more than 30 years of research. It uses behavioral learning principles to help children with autism increase positive behaviors and social interactions and decrease problematic behaviors. The therapy is started in early childhood and it is provided between 20 and 40 hours per week.
For the current study, the researchers obtained state-level data on the total number of certified applied behavior analysis providers from the online database of the Behavior Analyst Certification Board in March 2018. The Board was established in 1998 to form professional standards to credential providers worldwide.
“The Board provides guidelines on the maximum caseload for certified behavior analysts under two scenarios. In the first scenario, an analyst can provide “focused treatment,” which targets discrete behavioral goals such as increasing instruction following or decreasing self-injury behavior. In the second scenario, an analyst can provide “comprehensive treatment” to improve multiple developmental domains and overall functioning,” says the research team.
The recommended maximum caseload for focused treatment is 15 children per analyst without the support of an assistant, or 24 children per analyst with an assistant (a 60% increase in caseload). The recommendation for comprehensive treatment is 12 children per analyst without an assistant, or 16 children per analyst with an assistant (a 33% increase in caseload), says the study.
According to the researchers, these numbers imply that a minimum of 6.4 and 8.1 behavior analysts are needed for 100 children with autism, who require either focused or comprehensive treatment, respectively.
The research team compared the per capita supply of certified ABA providers in each state with a benchmark established using the board's guidelines.
The team found that the supply of certified applied behavior analysis providers was insufficient to meet the needs of children with autism in nearly all states in the US. Their analysis shows substantial variation in the per capita supply of certified providers across states and regions.
“The supply of certified ABA providers fell short of the benchmark in 49 states and Washington, D.C., assuming all children with autism require only focused treatment. Massachusetts had the highest per capita supply of certified applied behavior analysis providers (8.8 providers per 100 children with autism), and it was the only state in which the supply exceeded the benchmark,” says the study published in Psychiatric Services.
The supply was highest in the Northeast, which included the top seven states in the US based on per capita certified providers. In the Midwest, however, no state had more than one-third of the minimum number of applied behavior analysis providers needed for the number of children with autism.
States with higher public education spending had significantly more certified providers per capita than states with lower spending. Similarly, states with a higher median household income had more certified providers per capita, says the study.
The researchers also conducted a “sensitivity analysis” in which they assumed that the caseload capacity for behavior analysts was double that of the Board guideline. Accordingly, they obtained new benchmarks of 3.2 and 4.1 analysts per 100 children with autism in either focused or comprehensive treatment, respectively.
“In the sensitivity analysis with the adjusted benchmark (assuming that ABA providers’ average case capacity is twice as much as the Board guidelines), the per capita supply of certified applied behavior analysis providers fell below the benchmark in 42 states and Washington, DC,” says the study.
The researchers recommend that given the increasing prevalence of autism among youths, new workforce policies may be needed to improve the supply of therapists in the US to meet the needs of this population.