County-level variation in geographic access to Board Certified Behavior Analysts among children with Autism Spectrum Disorder in the United States

Abstract

This study examined variation in geographic access to Board Certified Behavior Analysts for children with autism spectrum disorder. Between March and May 2019, we integrated public data from the U.S. Department of Education’s Civil Rights Data Collection, Behavior Analyst Certification Board’s certificant registry, and U.S. Census. The study sample included all U.S. counties and county equivalents in 48 states and D.C. ( N = 3108). Using geographic information systems software, we assigned Board Certified Behavior Analysts to counties based on their residence, allocated children via school districts to counties, and generated per capita autism spectrum disorder/Board Certified Behavior Analyst ratios. We calculated the Getis-Ord G* statistics for each county and each ratio and compared counties in high-ratio clusters with counties in low-ratio clusters by socioeconomic variables. More than half of all counties had no Board Certified Behavior Analysts. Counties in the highest accessibility category had ⩽17.1 children with autism spectrum disorder per Board Certified Behavior Analyst ( n = 770), while counties in the lowest accessibility category had ⩾137.1 children with autism spectrum disorder per Board Certified Behavior Analyst ( n = 12). In all, 55 of the 129 counties with the highest autism spectrum disorder prevalence had no Board Certified Behavior Analysts. Higher accessibility counties were wealthier and had smaller uninsured populations. To improve geographic access, we must identify factors driving unequal distribution that can inform provider recruitment and retention efforts in underserved areas. Lay abstract This study looked at whether access to Board Certified Behavior Analysts for children with autism spectrum disorder is different between U.S. counties. The study included all U.S. counties and county equivalents in 48 states and D.C. ( N = 3108). Between March and May 2019, we combined data from the U.S. Department of Education’s Civil Rights Data Collection, Behavior Analyst Certification Board’s certificant registry, and U.S. Census. We assigned Board Certified Behavior Analysts to counties based on their address, matched children in school districts to counties, and determined how many children with autism spectrum disorder there were in a county compared with how many Board Certified Behavior Analysts there were in a county. The results show uneven numbers of Board Certified Behavior Analysts between U.S. counties. More than half of all counties had no Board Certified Behavior Analysts. National maps illustrate clusters of high and low accessibility to Board Certified Behavior Analysts. To improve access to Board Certified Behavior Analysts in underserved areas, we must identify what contributes to the differences in access.

Trends in Geographic Access to Board Certified Behavior Analysts Among Children with Autism Spectrum Disorder, 2018–2021

“…Unsurprisingly, counties that moved from zero to at least one BCBA between 2018 and 2021 had a mean population greater than those that remained with zero BCBAs (33,807 vs. 15,628), suggesting that non-metro counties with lower populations continue to experience lower access. This aligns with earlier findings that affluent and metropolitan counties enjoy the greatest geographic access to BCBAs (Yingling et al, 2021a , 2021b ). Although metropolitan areas are generally characterized by greater access, however, some populous counties of notable significance remain without a BCBA: Shawnee County (Topeka), Kansas (2020 Population = 178,909), Ector County (Odessa), Texas (165,171), and San Juan County (Farmington), New Mexico (121,661).…”

“…However, while this study shows some improvement in geographic access over time, in general it likely overestimates access. It also demonstrates how children with ASD living in rural counties who may already be at a disadvantage because they wait longer to receive a diagnosis (Daniels & Mandell, 2014 ) may be further marginalized due to a lack of access to BCBAs (Yingling et al, 2021a , 2021b ). This cumulative disadvantage (Lynch, 2008 ) has significant implications for child and family outcomes as well as the costs associated with lifelong services.…”

“…In a brief report, researchers documented that the per capita supply of BCBAs fell below caseload guidelines provided by the Behavior Analyst Certification Board (BACB) (Zhang & Cummings, 2020 ), and that as earlier work suggested (Deochand & Fuqua, 2016 ), Northeastern states continued to have the highest per capita supply of providers. At the county level, research indicates that more than half of all counties in the United States have no BCBAs, and that the differences in access to BCBAs among children with ASD cannot be entirely explained by the county-level variation of ASD prevalence, suggesting that demand for the treatment of ASD does not necessarily drive the supply of BCBAs (Yingling et al, 2021a , 2021b ). Furthermore, that affluent and metropolitan counties have the highest geographic access to BCBAs (Yingling et al, 2021a , 2021b ).…”

“…At the county level, research indicates that more than half of all counties in the United States have no BCBAs, and that the differences in access to BCBAs among children with ASD cannot be entirely explained by the county-level variation of ASD prevalence, suggesting that demand for the treatment of ASD does not necessarily drive the supply of BCBAs (Yingling et al, 2021a , 2021b ). Furthermore, that affluent and metropolitan counties have the highest geographic access to BCBAs (Yingling et al, 2021a , 2021b ).…”

“…However, given the swift increase in the number of certified practitioners, research on their accessibility quickly becomes outdated. Shortly after data for the most recent of these studies was collected (Yingling et al, 2021a , 2021b ; Yingling et al, 2021a , 2021b ), the number of BCBAs increased by more than fifty percent. Where growth is occurring is important to understand: is the uneven distribution documented worsening, improving, or staying the same?…”