Impact of County Sociodemographic Factors and State Policy on Geographic Access to Behavior Analysts Among Children with Autism Spectrum Disorder

Abstract

To examine the relationship between geographic access to Board Certified Behavior Analysts (BCBAs) among children with autism spectrum disorder (ASD) and county sociodemographic factors and state policy, we integrated publicly available 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 U.S. counties and county equivalents (e.g., parishes, independent cities) in 49 states and D.C. (N = 3040). Using GIS software, we assigned BCBAs to counties based on their residence, allocated children via school districts to counties, and generated per-capita children with ASD/BCBA ratios. We distributed counties into five categories based on these ratios: no BCBAs (reference), ≥ 31, 21–30, 11–20, > 0–10. We used a generalized logit model to conduct analyses. Highly affluent and urban counties had the highest access to BCBAs with odds ratio estimates for affluence ranging from 2.26 to 5.26. County-level poverty was positively associated with access, yet this relationship was moderated by urbanicity. Race-ethnicity and healthcare insurance coverage were negatively related to access. Other variables were not significant. Targeting non-urban and less affluent counties for provider recruitment and maintenance could most improve access to BCBAs. In addition to strategies specific to BCBAs for improving geographic access, traditional strategies used for other healthcare providers could be useful.

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?…”