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Neurodivergent-affirming care within applied behavior analysis

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Neurodivergent-affirming care within applied behavior analysis

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Content Neurodivergent-Affirming Care Within Applied Behavior Analysis
Kristina S. Judie
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
August 2024

© Copyright by Kristina S. Judie 2024
All Rights Reserved

The Committee for Kristina S. Judie certifies the approval of this Dissertation
Erika Page
Don Trahan
Marsha Boveja Riggio, Committee Chair
Rossier School of Education
University of Southern California
2024

iv
Abstract
Applied behavior analysis (ABA) is a leading recommended intervention for autistic individuals,
and reports indicate that trauma has occurred as a result of ABA interventions. Board-certified
behavior analysts (BCBAs) oversee ABA interventions and follow guidance from the Behavior
Analyst Certification Board (BACB) on service implementation. Most (75.39%) BCBAs indicate
a professional emphasis on autism. However, data indicate organizations and educational
institutions do not provide the necessary training on autism, ableism, and the trauma history of
ABA for BCBAs to implement the intervention in a neurodiversity- or neurodivergent-affirming
way. This study used critical disability theory and gap analysis to identify the knowledge,
motivation, and organizational influences on BCBAs’ ability to implement neurodivergentaffirming care. A review of literature relevant to autism, ABA, and interventions moving toward
neurodivergent-affirming care indicates the necessity to reform practices and the availability of
strategies to assist with reform. The BCBAs, organizations, and educational institutions were
identified as the primary stakeholders for this study. Data analysis consisted of interviews and
document analysis of organizations providing ABA services to autistic clients and educational
institutions with accreditation to provide ABA coursework. Findings suggest additional
knowledge on autism from a social model lens and training on trauma and ableism would
facilitate BCBAs’ ability to implement neurodivergent-affirming care. An increase in knowledge
would increase BCBAs’ motivation, and educational institutions and organizations play a
significant role in the acquisition of this knowledge. Recommendations pertain to the BACB,
educational institutions, and an implementation and evaluation plan utilizing Kirkpatrick and
Kirkpatrick’s model for BCBAs working independently toward neurodivergent-affirming care
and organizations working toward this goal for their BCBAs.

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Keywords: autism, board-certified behavior analyst, neurodiversity, neurodivergent,
applied behavior analysis, ableism, trauma, neurodiversity-affirming care, neurodivergentaffirming care, knowledge, motivation, organization.

vi
Acknowledgments
I would like to express my deepest gratitude to my husband and best friend, Benjamin
Judie, whose unwavering support and encouragement have been instrumental throughout this
journey. Your belief in me, even during the most challenging times, has been a constant source
of strength and motivation. Your love and confidence in my abilities have helped me persevere,
even while you were away, and I could not imagine having done this without you. Thank you for
being my person. Next, I would like to express my gratitude for my autistic son, Mason. Mason
has given me a purpose and is my constant inspiration. He taught me to see the world in a new
and meaningful way and introduced me to the world of autism. I am thankful for that and for him
every single day. This journey started for him, and I am forever grateful for the joy and
motivation he has brought into my life. I would also like to thank my friends and family, the ones
who have not received the attention they deserve over the years of this program but supported me
nonetheless. Thank you for your love, your time, and your patience.
Next, I would like to thank those at USC who encouraged me to keep going. Beginning
with my fellow OCL Cohort 22 members, all of you have touched my life in some way, and I
will forever be grateful for the experiences we have had and for the connections we have built.
Sommer Jabbar, Zack Yarde, and Melissa Mayard, from the beginning, you have been a constant
source of encouragement and support throughout this journey. I needed it more than you know.
Thank you, Dr. Sneha Kohli Mathur. You helped me see that this was possible and that although
it would be difficult, it was necessary, and it mattered. Thank you. Dr. Ayesha Madni. You
helped me throughout courses, but you also helped me outside of courses. You challenged me to
do my best, supported me along the way, and read through this dissertation to give me your
valuable insight. Your support and encouragement and your ability to instruct and inspire as a
professor will never be forgotten. To my committee members, Dr. Erika Page and Dr. Don

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Trahan, and to my chair, Dr. Marsha Boveja Riggio, thank you for your support and encouraging
words, for challenging my thought processes and writing abilities, and for ensuring that the work
I produced was meaningful.
Next, I would like to thank those outside of USC who encouraged me or inspired me to
keep going. Beginning with the research participants, without whom this work would not be
possible. Thank you for your time and insight; I hope I have done justice to your stories. Now, to
the wonderful group of humans I have had the pleasure of working with over the years. Thank
you for your support, encouragement, and for your inspiration. You all challenge me to be better,
and your love and care for our clients show me that positive change is possible in our field.
Thank you for loving the autistic community like I do, and thank you for showing our kids every
day that they matter, that their voices matter, and that they deserve to be heard and celebrated. I
would also like to thank the clients I have had the privilege of working with over the years for
showing me the beauty of autism every day. Being introduced to the world of autism by my son
was one of the greatest gifts I have received. It allowed me to learn more about autism and to see
the true beauty and authenticity of him and my clients by joining their world. It is a world that I
love being a part of and a world I want more people to see, love, and embrace.

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Table of Contents
Abstract.......................................................................................................................................... iv
Acknowledgments.......................................................................................................................... vi
List of Tables ................................................................................................................................. xi
List of Figures............................................................................................................................... xii
Chapter One: Introduction to the Study ...........................................................................................1
Purpose of the Study ............................................................................................................7
Research Questions..............................................................................................................8
Significance of the Study .....................................................................................................8
Abbreviations and Definitions...........................................................................................11
Assumptions and Positionality...........................................................................................13
Conclusion .........................................................................................................................14
Organization of the Dissertation ........................................................................................15
Chapter Two: Literature Review ...................................................................................................17
Search Description .............................................................................................................17
Theoretical and Conceptual Framework............................................................................17
Critical Disability Theory ..................................................................................................19
Clark and Estes’s Gap Analysis.........................................................................................20
Literature Review...............................................................................................................26
Applied Behavior Analysis................................................................................................29
Conclusion .........................................................................................................................40
Chapter Three: Methodology.........................................................................................................41
Qualitative Research Design..............................................................................................41
Participants.........................................................................................................................43
Data Collection ..................................................................................................................46
Procedures..........................................................................................................................52

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Ethical Considerations .......................................................................................................52
Data Analysis.....................................................................................................................56
Conclusion .........................................................................................................................62
Chapter Four: Findings ..................................................................................................................64
Interview Participants ........................................................................................................64
Document Analysis............................................................................................................65
Research Question 1: What Are BCBAs KMO Experiences With NeurodivergentAffirming Practices? ..........................................................................................................66
Research Question 2: What Are Behavior Analysts’ KMO Challenges Around
Neurodivergent-Affirming Practices?................................................................................79
Research Question 3: How Can Behavior Analysts’ KMO Competencies Around
Neurodivergent-Affirming Practices Be Improved?..........................................................90
Summary ............................................................................................................................95
Chapter Five: Recommendations...................................................................................................97
Potential Impacts of Not Reforming ..................................................................................97
Discussion of Findings.....................................................................................................103
Recommendations for Practice ........................................................................................104
Limitations and Delimitations..........................................................................................141
Recommendations for Future Research ...........................................................................143
Conclusion .......................................................................................................................143
References....................................................................................................................................145
Appendix A: Institutional Review Board at the University of Southern California Approval....159
Appendix B: Research Invitation and Participant Information Sheet..........................................161
Appendix C: Qualtrics Demographic Survey Informed Consent and Questions ........................162
Demographic Survey Questions ......................................................................................162
End of Survey Note..........................................................................................................163
Appendix D: Informed Consent Disclosure.................................................................................164

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Appendix E: Interview Questions................................................................................................166

xi
List of Tables
Table 1: Example of Areas Effectively Addressed Using Applied Behavior Analysis With
Autistic Clients 34
Table 2: Data Sources 48
Table 3: Interview Protocol Question Alignment 50
Table 4: Data Retrieved From the Demographic Survey 64
Table 5: Participant Responses on the Training They Received on Autism 68
Table 6: Document Analysis Results From Five Educational Institutions 73
Table 7: Document Analysis Results for Five Organizations Providing ABA Services to
Autistic Clients 76
Table 8: Sample Income for an Organization Serving Autistic Clients 101
Table 9: Cost Analysis of Neurodivergent-Affirming Care Training Outside of the
Organization 111
Table 10: Outcomes, Metrics, and Methods for External and Internal Outcomes 112
Table 11: Critical Behaviors, Metrics, Methods, and Timing for Evaluation of Behavior
Analysts 114
Table 12: Required Drivers to Support Critical Behaviors of Behavior Analysts 117
Table 13: Evaluation of the Components of Learning for the Program 124
Table 14: Components to Measure Reactions to the Program 126
Table 15: Outcomes, Metrics, and Methods 131
Table 16: Critical Behaviors, Metrics, Methods, and Timing for Self-Evaluation 133
Table 17: Required Drivers to Support Critical Behaviors of BCBAs 135
Table 18: Evaluation of the Components of Learning for the Program 139
Appendix E: Interview Questions 166

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List of Figures
Figure 1: Theoretical and Conceptual Framework ....................................................................... 18

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Chapter One: Introduction to the Study
The primary recommended intervention for autistic people, Applied behavior analysis
(ABA), has produced phenomenal results (Leaf et al., 2011) and, according to the autistic
community, has caused them significant harm (Shyman, 2016). Research suggests that ABA,
which is rooted in the medical model of autism, inherently incorporates ableist practices and
prioritizes recovery, or the reduction of autistic characteristics, as the desired outcome. This
approach significantly increases the risk of trauma for clients (Shyman, 2016). Within ABA,
interventions are moving toward neurodivergent-affirming practices; however, data are
nonexistent on the quantity of board-certified behavior analysts (BCBAs) modifying their
practices to meet autistic clients’ needs and prevent trauma. Also lacking is research on what
influences BCBAs’ abilities and decisions to modify practices. Identifying influences for the lack
of reform within ABA will aid in determining how to meet clients’ needs and implement
practices while respecting their autonomy. This occurred by framing the study through critical
disability theory to affirm necessity and using Clark and Estes’s (2008) gap analysis to analyze
the knowledge, motivation, and organizational (KMO) factors influencing BCBAs,
organizations, and educational institutions’ ability to reform.
Context and Background of the Problem
A scientific approach used to study and shape human behavior, ABA aims to modify
teaching strategies to improve socially significant behaviors (Cooper et al., 2007). Lovaas (1987)
began implementing ABA with autistic clients and reported that early intensive ABA resulted in
recovery from autism in 47% of patients. Since then, ABA has prompted scrutiny regarding its
efficacy and ethical nature, and it has been reported to have caused severe harm to the autistic
community (Wilkenfeld & McCarthy, 2020). As a relatively newer field, various intervention
methods continue to evolve alongside the ethical guidelines established by the Board Analyst

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Certification Board (BACB) that BCBAs are required to follow (BACB, 2020). Although
modifications have been made to service implementation, a significant portion of the control is
given to the BCBA and the organization when choosing appropriate behaviors to address that are
deemed socially significant (BACB, 2017). This control results in targeting self-stimulatory
behaviors for reduction and identifying social skill deficits to intervene on, which further harms
the autistic community (Kapp et al., 2019; Miller et al., 2021; Wilkenfeld & McCarthy, 2020).
Given the responsibilities of BCBAs and the influence of educational institutions and
organizations on their practice, this study focused on the background of the problem in relation
to BCBAs, organizational influences, and educational institutions.
Board-Certified Behavior Analysts
The first area to consider regarding why there is a lack of reform in ABA pertains to
BCBAs. In 1988, the BACB was established to protect individuals receiving behavior analytics
services (BACB, n.d.-a). The BACB has developed an evolving set of ethical guidelines and
requirements that require evidence-based practices and outline appropriate intervention methods
and requirements to shape behaviors (BACB, 2020). When identifying behaviors determined as
socially significant or appropriate to align with the BACB requirements, a behavior analyst
shapes the behavior of an autistic person into what they determine is socially appropriate
(BACB, 2020). The expectation for successful outcomes is at the forefront of behavior-analytic
training and research; the definition of successful outcomes is fading from services and often
fitting in with neurotypical peers (Lovaas, 1987). As a result, ABA has been reported to produce
post-traumatic stress symptoms due to attempts to teach individuals to mask their autistic
characteristics to conform to societal norms (Kupferstein, 2018). Additionally, significant
concerns have arisen regarding the efficacy and ethical nature of ABA services, given the severe
harm reportedly caused to the autistic community (Wilkenfeld & McCarthy, 2020). Various

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methods have been introduced in ABA to better support the autistic community’s needs;
however, there is no documentation indicating that BCBAs have broadly shifted their practices,
and reports of trauma continue to emerge (Wilkenfeld & McCarthy, 2020). I aimed to determine
whether BCBAs lack the necessary knowledge to become neurodivergent-affirming, lack the
motivation to do so, or lack organizational support to reform their practices.
To become a BCBA, individuals must become certified by the BACB. Individuals
pursuing board certification receive a task list of knowledge and skills required, and the required
course content aligns with these skills. To obtain certification, an individual is assessed on these
skills after completing coursework and fieldwork. This knowledge must be maintained, and
continuing education must be completed to apply for recertification every 2 years (BACB, 2022).
Because of this, educational institutions and organizational resources influence the ability of a
BCBA or an individual pursuing certification to become neurodivergent-affirming.
Educational Institutions
The second area to consider regarding the lack of reform within ABA lies with
educational institutions. As outlined in the BCBA handbook provided by the BACB (2022),
individuals must complete a master’s degree (or higher) through a behavior analysis program
accredited and recognized by the Association for Behavior Analysis International (ABAI) or
through verifying course sequences determined by ABAI, in addition to holding a graduate
degree. The accreditation standards include expectations in nine areas: mission, curriculum,
outcomes assessment, administration, resources, faculty, student services, public disclosure, and
degree programs (ABAI, 2023). Degree program expectations include content in principles of
behavior, research methods, conceptual analysis, ABA, fundamental behavior analysis, and
ethics, with the addition of specialized electives for doctoral courses. The content areas most
relevant to the course content are conceptual analysis and ethics. The purpose of conceptual

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analysis course content is to teach students to acquire knowledge related to the history of
behaviorism, an understanding of behavior regarding theoretical approaches, and interpretations
of behavior related to the principles and concepts of behavior analysis (ABAI, 2023). There is no
content on the need to learn about the history of trauma caused by ABA or about neurodivergentaffirming practices. The content areas required by ABAI (2023) in an ethics course include an
understanding of legal constraints and ethical guidelines regarding practice and research. No
content covers neurodivergent-affirming care or procedure requirements indicative of a method
in a neurodivergent-affirming care direction.
Depending on course content, students working toward their certification may not receive
the tools to provide neurodivergent-affirming services. There is no requirement that courses
include training on neurodiversity and ableism. However, course content in this area could better
equip students with the knowledge and motivation to implement neurodivergent-affirming
services and help them identify indicators of supportive organizational practices.
Organizational Influences
Organizational influences are the third area to consider when examining the lack of
reform within ABA. One major component of gaining certification includes supervised fieldwork
that can occur during or after educational programs. Fieldwork hours range from 1,500 to 2,000
and require 5% to 10% of those hours supervised by a BCBA who meets the criteria outlined by
the BACB (2022). Outside of employee certification, organizations providing ABA services are
not required to have specific accreditation. This situation resulted in the establishment of the
Behavioral Health Center of Excellence (BHCOE). Organizations are not required to attain
BHCOE accreditation, but according to BHCOE, the accreditation improves the facility’s quality
and performance, employee retention, and parents’ satisfaction. The BHCOE (2022) has set
standards for organization training programs for individuals pursuing certification; however,

5
outside of the standards set by the BHCOE, fieldwork hours from the BACB (2022) focus on the
supervisor, not the organization. Overlapping organizational recommendations and BHCOE
standards regarding supervision relevant to this study include ethics, integrity, professionalism,
diversity, equity, inclusion, service delivery, and supervisor qualifications and competence
(BHCOE, 2022). Within these standards, several components reflect the importance of providing
ethical ABA in the best interest of the client receiving care, but no further expectation
emphasizes what ethical ABA is or indicates information regarding neurodivergent-affirming
care.
Depending on the organization and a BCBA’s training, supervised fieldwork does not
require neurodivergent-affirming training, regardless of BHCOE accreditation. This is supported
by guidelines outlined in the BACB (2022) handbook and BHCOE (2022) accreditation. Outside
of BACB parameters for recommended and required criteria for accruing hours, the organization
chooses the fieldwork content where the individual accrues their hours. Once an individual
graduates from school and passes their certification exam, the organization that employs them
determines their training and protocol implementation. Organizations’ policies regarding
employees’ training expectations and abilities differ. In some situations, the organization can
provide required training or free training sessions. If a BCBA seeks additional training outside of
what is provided or required, the cost would be their responsibility. Some organizations provide
a stipend for continuing education, allowing the BCBA to determine what continuing education
units to take within BACB-set parameters. An organization might provide one or all of these
options. If an organization maintains BHCOE (2022) accreditation, BCBAs have access to
additional training content. However, whether this training leads to reforming services is up to
the BCBA, influenced by the organization’s restrictions. Additionally, organizational

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expectations for program implementation and goal selection influence a BCBA’s ability to
implement neurodivergent-affirming services.
Statement of the Problem
The potential harm of not reforming ABA to become neurodivergent-affirming is
significant. The ABA is effective in helping autistic individuals increase their independence, but
it is important to do so without causing harm. This necessity should be at the forefront of
practitioners’ minds. The KMO influences on BCBAs, educational institutions, and
organizations themselves are directly affected by the aforementioned problems.
Board-Certified Behavior Analysts
The efforts of the BCBA are the most significant and influenced by their educational
institutions and organizations. A BCBA’s lack of knowledge regarding neurodivergent-affirming
care can harm clients due to selecting targeted behaviors to decrease, such as self-stimulatory
behaviors needed to regulate an autistic person’s body (Kapp et al., 2019), and behaviors to
increase, such as those considered socially appropriate (Miller et al., 2021). Targets such as these
can be indicative of ableist practices and goal selection because of the desired outcome to
conform an autistic person to social norms (Hall, 2019). If a BCBA lacks the motivation to
implement neurodivergent-affirming practices and educate themselves on the necessity to reform
practices, they are unlikely to seek such education. This lack of initiative will prevent them from
developing the self-efficacy to reform their practices.
Educational Institutions
Educational institutions are responsible for educating individuals seeking certification in
behavior analysis. These individuals must meet specific criteria on course content to acquire
accreditation and meet the criteria outlined by the BACB (2022). Required course content does
not specify criteria for including neurodivergent-affirming care, history of trauma, or ableism

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(ABAI, 2023). Educational institutions do not provide course content in these areas, which
decreases the likelihood that future behavior analysts will know how to implement
neurodivergent-affirming care. As the field shifts toward becoming neurodivergent-affirming,
educational institutions without these updated courses may no longer be as highly recommended
because of outdated and harmful practices.
Organizations
Organizational expectations for providing ABA services are limited without accreditation
criteria, which significantly harms BCBAs and the autistic community. Organizations’ lack of
knowledge of the need to reform practices decreases the likelihood that BCBAs will implement
neurodivergent-affirming care and that organizations will train future behavior analysts to do so.
Additionally, a lack of motivation within the organization lowers BCBAs’ self-efficacy, support
for implementing neurodivergent-affirming services, and the BCBAs’ motivation to ensure no
harm occurs to their clients. In turn, this could result in harm toward the clients, increase
turnover at the organization for BCBAs moving toward reforming their practices, and put current
and future families’ attendance at risk.
Purpose of the Study
This study aimed to better understand the lived experiences of BCBAs as they related to
their experiences, challenges, and competencies. These included their experiences regarding
reform within ABA to move toward neurodivergent-affirming care and the KMO factors
influencing them. Additionally, I was interested in identifying the KMO influences of
universities on individuals working toward certification, specifically in relation to training on
neurodivergent-affirming care and ableism. Lastly, I worked toward identifying influences on
BCBAs related to organizational support for implementing neurodivergent-affirming services.

8
Research Questions
Three research questions guided this study:
1. What are behavior analysts’ knowledge, motivation, and organizational experiences
around neurodivergent-affirming practices?
2. What are behavior analysts’ knowledge, motivation, and organizational challenges
around neurodivergent-affirming practices?
3. How can behavior analysts’ knowledge, motivation, and organizational competencies
around neurodivergent-affirming practices be improved?
Significance of the Study
This study was essential to understanding the lived experiences of BCBAs and the role
that they, their organizations, and their educational institutions have in moving ABA toward
neurodivergent-affirming care. Current research gaps include the process of reforming services,
information relating to the lack of reformed services, and data documenting the barriers leading
to or influencing a lack of reform for behavior analysts. More research is needed to fill these
gaps to identify the barriers to reform and possible influences preventing reform to improve the
quality of services for the autistic community without causing harm. Conducting this study
allowed me to begin to fill some of these gaps and develop a framework to better support
BCBAs in acquiring the knowledge needed to implement neurodivergent-affirming care and
increase their motivation and self-efficacy. Additionally, I developed a framework for
organizations to implement, aimed at supporting BCBAs and individuals in training to become
behavior analysts in acquiring the necessary knowledge to move toward neurodivergentaffirming care.

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Board-Certified Behavior Analysts
The significance of this study as it relates to BCBAs is the necessity to increase their
knowledge and motivation to improve the quality of services to support the autistic community
and prevent harm. Ethical guidelines assist with reducing harm and increasing assent (BACB,
2020), yet the areas targeted and procedures used are implemented at the BCBA’s discretion o
and what they deem as socially appropriate (BACB, 2020). Protocols and methods have been
designed to improve ABA services, such as trauma-informed care (Rajaraman, Austin, et al.,
2022) and assent-based services (Breaux & Smith, 2023); however, there is no requirement to
use them if interventions are evidence-based and align with behavior-analytic practices (BACB,
2017).
Educational Institutions
Educational institutions play a significant role in reforming ABA to become more
neurodivergent-affirming because they are a primary and mandatory starting point for all
individuals working toward certification (BACB, 2022). Research has documented the need for
reform in other fields, including the need for occupational therapists to provide neurodivergentaffirming services (Dallman et al., 2022) and the steps required to do so. Additionally, at the time
of this study, Mathur et al. (2024) published research on strategies to work toward
neurodiversity-affirming care within ABA. Known barriers to reforming these services include
ABA’s foundation and core components (Lovaas, 1987), as well as following a medical model of
the diagnosis (Shyman, 2016). To move in this direction, educational institutions must provide
future practitioners knowledge with knowledge of these practices, assist with increasing their
motivation, and provide them with the tools to reform an organization and identify organizations
that provide neurodivergent-affirming care.

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Organizations
Another significant aspect of moving toward neurodivergent-affirming care is the
organization’s role in the process. To become a BCBA, an individual must attend an ABAIaccredited program and accrue fieldwork hours (BACB, 2022). These hours are often accrued
within an organization. The content of these hours consists of activities an individual would
engage in as a BCBA, such as conducting assessments, selecting goals to target, writing
protocols for how to target those goals, and training technicians to implement the goals targeted
(BACB, 2022). One or more BCBAs at an organization oversee these tasks. Depending on the
organization’s layout, these determinations must be based on criteria, and whether these goals
are ableist or not relies on the training of the individuals overseeing the new trainee. Increasing
the knowledge and motivation of a BCBA and individual working toward certification allows for
developing the skills to become neurodivergent-affirming. For a BCBA to have the skills to train
individuals working toward certification, organizations must provide or otherwise enable a
trainee to receive the continuing education required to maintain certification (BACB, 2022).
Without these skills, organizations are at risk of causing harm to clients based on targeted
behaviors (Kapp et al., 2019), which could result in fewer families seeking services, increasing
the risk of turnover and decreasing the organization’s profitability. The BCBAs, educational
institutions, and organizations are key in effectively reforming services to support the autistic
community’s needs without causing harm.

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Abbreviations and Definitions
Applied behavior analysis (ABA): A scientific method used to shape human behavior
(Cooper et al., 2007).
Assent: Per the BACB, 2020,
Vocal or nonvocal verbal behavior that can be taken to indicate a willingness to
participate in research or behavioral services by individuals who cannot provide informed
consent (e.g., because of age or intellectual impairments). Assent may be required by a research
review committee or a service organization. In such instances, those entities will provide
parameters for assessing assent. (p. 7)
Autism or autism spectrum disorder: Autism, or autism spectrum disorder (ASD), is a
neurodevelopmental difference. This is due to the significant differences in brain functioning,
architecture, and maturation development (Bölte et al., 2021).
Behavior Analyst Certification Board (BACB): A governing board created to protect
individuals receiving ABA services. Certification must be acquired from the BACB to become a
BCBA. The BACB provides requirements for individuals to meet to acquire and maintain
certification. Additionally, they have a task list of competencies that are assessed and ethical
guidelines to which they are bound.
Board-certified behavior analyst (BCBA): An individual who has been certified by the
BACB to provide ABA services.
Continuing education unit (CEU): Education that takes place after certification to ensure
behavior-analytic knowledge is expanded and BCBAs remain up to date on research (BACB,
2022).

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Educational institution: An ABAI-accredited institution or an institution with a verified
course sequence that provides coursework utilized to meet the criteria set by the BACB to allow
an individual to become eligible to sit for the BCBA examination (BACB, 2022).
Knowledge: An individual’s ability to achieve the goal if they wanted to and had the
resources necessary (Clark & Estes, 2008).
Motivation: An internal physiological process influenced by choosing to work toward a
goal, being persistent in achieving the goal, and the amount of mental effort willing to be
invested to achieve the goal (Clark & Estes, 2008).
Neurodivergent: Neurodivergent is a brain that operates in a way that is not the norm. It
is a term used to replace terms such as abnormal (Resnick, 2022).
Neurodiversity pertains to the normal cognitive variation expected among humans and
that shows in the way people process information and behave. It encompasses neurotypical and
neurodivergent (Resnick, 2022).
Neurodivergent/neurodiversity-affirming care: an approach to care that recognizes that
neurodivergence is not an illness that needs to be fixed and that it can be disabling. Marschall
(2022) stated that a neurodiversity-affirming therapist understands that each person is an expert
on themselves and emphasizes listening to what the neurodivergent community determines is the
most appropriate for themselves versus providers telling them what it should be from a
neurotypical perspective. These terms will be used interchangeably throughout the dissertation to
align with current research.
Organization: A business implementing ABA services.
Organizational barriers: Inadequate resources provided by an organization needed to
achieve a goal (Clark & Estes, 2008).

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Assumptions and Positionality
Outlining the assumptions in a study allows researchers to disclose potential limiting
factors to the study and to show an in-depth understanding of the topic. Providing this
information strengthens a study by discussing these factors and allowing researchers to
recommend improvements in these areas and determine other methods to ensure the study’s
validity. Additionally, discussing a researcher’s positionality proves a study’s reliability,
specifically confirmability, allowing the researcher to take additional steps to address
assumptions and biases because of her positionality (Merriam & Tisdell, 2015).
Assumptions
Assumptions in a study are factors the researcher assumes to be true or plausible
(PhDStudent.com, 2023). Assumptions within this study differ depending on the data collection
method chosen by the researcher. The primary assumption is truthfulness because I interviewed
participants and conducted document analysis on material from organizations providing ABA
services and educational institutions with accredited ABA programs. Regarding interviewees, the
assumption is that participants are truthful with the responses provided. When conducting
document analyses, the assumption is that the information honestly represents the organization or
educational institution and reflects internal practices.
Positionality
Issues of positionality and power that are important considerations for this study include
that I am a BCBA and clinical manager overseeing other BCBAs and the mother of an autistic
individual who receives ABA services and has ADHD, which falls under the neurodivergent
umbrella. Additionally, I feel that the services need to be reformed based on feedback from the
autistic community and the trauma the services have caused. Being involved in different roles
within this study can create blind spots and biases. Being a BCBA within a larger organization

14
who has worked for multiple organizations, both for-profit and nonprofit, I have seen different
methods of implementation, highlighting both the need for change and the benefits of change as
her roles have changed. Having an autistic child, I developed a deeper understanding of the
development of an autistic individual, the necessity for additional support and therapy services,
and the direct harm that can occur because of inadequate and ableist practices. Lastly, being a
part of the neurodivergent community, I have a better understanding of the need for change, the
benefit of embracing diversity, and the impact of ableism on individuals who are not
neurotypical on a much lower scale than that which autistic individuals face. Because I am not
autistic, I cannot speak on the lived experiences of autistic people. Thus, through this study, I
sought to amplify autistic voices.
I implemented different strategies throughout the study to mitigate potential assumptions
and biases and ensure reliability and validity. These included additional components in the
recruitment process to allow for a broader range of perspectives, simultaneous data collection
and analysis to ensure confirmability, and an objective analysis (Creswell & Poth, 2018).
Information regarding these methods will be outlined with more specifics in Chapter Three.
Additionally, I consulted with Professor Dr. Ayesha Madni when developing research questions
to eliminate biases and leading questions. I consulted with my dissertation team to ensure biases
were avoided when developing additional research and interview questions. I avoided leading
questions during the interviews, including sharing personal impressions with participants to
prevent modified responses. I reported multiple perspectives in addition to contrary perspectives
to ensure that information and data were presented as received (Creswell & Creswell, 2018).
Conclusion
Applied behavior analysis is a scientific approach used primarily with autistic clients that
aims to address socially significant behaviors (Cooper et al., 2007). However, these services

15
have caused significant harm to the autistic community (Shyman, 2016). I identified alternative
methods that appear to move toward neurodivergent-affirming care; however, there is no
documentation on whether this has occurred. I used a qualitative approach to understand the
lived experiences of BCBAs regarding their experiences, challenges, and competencies related to
the need for ABA reform to move toward neurodivergent-affirming care. I also sought to
understand the KMO factors influencing these decisions and the role of the BCBAs, educational
institutions, and organizations in moving toward this care. I included terms necessary to
understand this study, outlined the assumption that interviewees would be honest and truthful in
their responses, and that documentation provided by organizations and educational institutions
reflects internal behaviors and practices. Because of my positionality, I implemented different
strategies to remain as objective as possible and develop a theory based on varied perspectives
provided by participants.
Organization of the Dissertation
This dissertation will be outlined in five chapters. In this chapter, I introduced the focus
problem for this study and information relevant to understanding the significance. I also provided
the terms important in this study and the study’s assumptions. Concluding this section, I
disclosed my positionality, indicating potential biases and strategies to mitigate them. Chapter
Two presents the study’s theoretical and conceptual frameworks: critical disability theory (CDT)
and Clark and Estes’s (2008) gap analysis, known as KMO. The chapter also presents additional
information on motivational factors guiding this study. I then include a literature review to
ensure a thorough understanding of different variables within the study. This literature review
begins with autism, followed by an in-depth dive into ABA. Within the ABA literature review, I
will discuss trauma, benefits, and the direction of ABA that can align with moving toward
neurodivergent-affirming care. Chapter Three will consist of the research methodologies used for

16
this study, including critical information regarding participants, data collection methods, and data
analysis strategies. Chapter Four will review the research findings, and Chapter Five will
conclude this dissertation with information on future recommendations and conclusions from the
study.

17
Chapter Two: Literature Review
This chapter will begin with a review of CDT as a framework for the study detailing the
necessity for reforming ABA services and Clark and Estes’s (2008) gap analysis, breaking down
categories for KMO influences on BCBAs moving toward neurodivergent-affirming care. This
will be followed by a comprehensive review of current literature related to autism,
neurodiversity, and neurodivergent-affirming care, and both the benefits of ABA and the trauma
reportedly caused. The chapter will conclude with different ABA strategies currently accessible
to BCBAs that could move toward neurodivergent-affirming care.
Search Description
The sources I used to complete this chapter were the University of Southern California’s
online library, Google, and Google Scholar. Within the virtual libraries, I searched the following
terms across all sources: trauma-informed care ABA; assent-based practices; ABA trauma;
autistic perspective; neurodiversity-affirming care; neurodiversity-affirming care in OT/ST/PT;
and knowledge, motivation, and organizational ABA. In addition to this method, I used the
references listed in each article with information relevant to this research. Doing so allowed me
to expand the research based on titles not included in the search above.
Theoretical and Conceptual Framework
The theoretical and conceptual frameworks that framed this study are CDT and Clark and
Estes’s (2008) gap analysis. As indicated in the concept map in Figure 1, to understand the
research problem of determining influences and barriers on BCBAs implementing
neurodivergent-affirming care, I first looked through the critical disability lens to highlight the
necessity to reform services and modify practices. To further understand influences, I reviewed
different aspects of knowledge and motivation and identified organizational factors. Meeting this

18
study’s purpose required determining how knowledge affects BCBAs’ practices, whether
motivation plays a role, and whether organizational factors hold significant influence.
Figure 1
Theoretical and Conceptual Framework
Note. This figure demonstrates the theoretical and conceptual frameworks I used to guide her
study. Critical disability theory was used to indicate the necessity of modifying practices, and
Clark and Estes’s (2008) gap analysis provided the lens to analyze the influences on BCBAs’
modifying practices.

19
Critical Disability Theory
Critical disability theory aims to analyze ableism and the social construct of disabilities,
highlighting how ableism affects people identified as having a disability (Hall, 2019). Critical
disability theory focuses on listening to the lived experiences of the population and the
oppression that occurs when an individual is considered disabled (Hall, 2019). Identifying and
analyzing ableism, as emphasized in CDT within ABA, would allow behavior analysts to better
support the autistic community by listening to their lived experiences to ensure they receive
equitable treatment and are accepted and embraced for their differences (Hall, 2019). In past
years, autistic people have historically been excluded from providing guidance and insight into
their community’s interventions, treatments, and needs in both research and action (Benevides et
al., 2020). Excluding autistic voices on this scale harms the community, and this can be seen
throughout recommended treatments, including ABA (Shyman, 2016). Examples of this are
targeting behaviors such as self-stimulatory behaviors for reduction (Kapp et al., 2019) and
addressing perceived social deficits (Miller et al., 2021) to shape behaviors in an ableist manner
to mimic socially accepted actions or meet a corporeal standard as emphasized in CDT (Hall,
2019).
Analyzing ABA through the critical disability lens would allow an emphasis on including
autistic voices in the treatment of their community and the need for further analysis of ableism’s
role in the selection of targeted behaviors and strategies used in ABA. Viewing the problem
through the critical disability lens highlights autistic voices and the necessity of reforming the
field. To do so on a more palatable scale, combining another theoretical framework can assist
with addressing possible influences of the lack of inclusion and reform and determining how to
move forward.

20
Clark and Estes’s Gap Analysis
The gap analysis, as presented by Clark and Estes (2008), is a method that can assist in
determining if the gap between where an organization or industry is and where it wants to be is a
result of the lack of knowledge, motivation, or organizational resources. The purpose of gap
analysis (Clark & Estes, 2008) is to determine a performance problem and use improvement
strategies to address it. For this study, I examined a lack of reform as the problem and collected
data to determine what influences that lack to develop improvement strategies for BCBAs,
organizations, and educational institutions. There is a need to determine the cause of the gap
between the goal of implementing neurodivergent-affirming care and the current status of many
BCBAs not doing so. Clark and Estes identified three critical factors to identify the cause of the
gap: knowledge and skills, motivation to achieve the targeted goal compared to other goals, and
organizational support.
Key Stakeholders’ KMO Influences
Determining possible influences leading to the lack of reform within ABA could allow
for additional insight into potential influences and barriers impacting reform within the field.
Through the use of KMO as an additional theoretical framework, I can better understand if the
gap in reform by providing neurodivergent-affirming services is due to the lack of knowledge
provided by institutions or organizations to BCBAs, if there is a lack of motivation for change
and what is influencing that motivation, or if organizations and institutions providing ABA
services and training future behavior analysts are not adequately preparing the behavior analysts
and leaders for reform (Clark & Estes, 2008).
Knowledge
According to Bloom’s original taxonomy, six cognitive domain categories consist of
subcategories that outline what an individual should learn from instruction: knowledge,

21
comprehension, application, analysis, synthesis, and evaluation (Bloom, 1969). In the revised
taxonomy, a two-dimensional construct was designed: the knowledge and the cognitive process
dimensions (Krathwohl, 2002).
Knowledge Dimension
The knowledge domain includes four dimensions: factual, conceptual, procedural, and
metacognitive (Krathwohl, 2002). Factual knowledge includes the essential elements of
knowledge, such as terms and details. Conceptual knowledge begins when an individual can
build interrelations between the concepts learned to allow overlapping functions. This is
followed by procedural knowledge, where a person can implement the information learned. The
knowledge of cognition, metacognitive knowledge, is the ability to be self-aware of what is
known within a domain (Krathwohl, 2002).
Cognitive Process Dimension
The cognitive process dimension of the revision of Bloom’s taxonomy has six categories
with varied complexity and overlaps: remembering, understanding, application, analysis,
evaluation, and creation (Krathwohl, 2002). This dimension begins with the ability to recall
relevant knowledge. This is followed by understanding and being able to interpret, summarize,
compare, and explain the content. Application is the ability to execute the procedures given or
implement instructions provided. The fourth category is breaking down the material and
analyzing it before evaluating and critiquing it. The last category of the cognitive dimension
process is having the ability to create, plan, and produce content in a given area (Krathwohl,
2002).
Determining Knowledge Gap
Determining if there is a gap in knowledge influencing BCBAs’ ability to reform requires
ensuring they understand the necessity for reform and how to enact that reform. Additionally, it

22
must be determined that BCBAs have had success implementing neurodivergent-affirming
strategies in the past. This can be done through active listening, interviews, focus groups, or
surveys (Clark & Estes, 2008).
Motivation
Motivational barriers influencing BCBAs’ ability to implement neurodivergent-affirming
care are more complex. According to Pintrich and Schunk (1996), motivation is an internal
psychological process that gets an individual to begin a goal and continue working toward the
goal until completion. Motivation energizes, directs, and sustains progress toward a goal (Schunk
et al., 2008). Motivation has three critical influences on the lives of an individual: determining if
an individual would like to work toward a goal, continuing to work toward the goal selected, and
the level of mental effort required to achieve the goal (Clark & Estes, 2008). Different
motivational theories can assist with determining what influences an individual’s motivation to
begin, persist, and achieve a goal. For this topic, three motivational theories are highlighted:
expectancy-value theory, attribution theory, and self-efficacy theory.
Expectancy-Value Theory
Expectancy-value theory has evolved since its inception in 1964 by Atkinson (Eccles &
Wigfield, 2002). The modern expectancy-value theory overlaps with Atkinson’s expectancyvalue theory by directly linking expectancy-related and task-value beliefs to an individual’s
choice of goal, persistence in continuing to work toward the goal, and performance. Feather
(1988) expanded Atkinson’s expectancy-value model by integrating work from Rokeach (1979),
stating that values contribute to an individual’s motivation to do what they believe should occur
by influencing the appeal of working toward the goal (Eccles & Wigfield, 2002). The modern
expectancy-value theory differs from Atkinson’s expectancy-value theory in several ways. The
modern expectancy-value theory, more recently named the situated expectancy-value theory, has

23
both positive and negative characteristics influenced by an individual’s choice (Wigfield &
Eccles, 2020). Expectancies and values influence task-specific motivation by an individual’s
perception of their competence related to the task, the difficulty of tasks, and the individual’s
own goals and beliefs of themselves and their actions. An individual’s memories, previous
successes, and beliefs about others’ expectations actively influence these perceptions. According
to Eccles and Wigfield (2002), an individual’s expectation to succeed is directly related to if they
believe they will succeed.
Eccles et al. (1983) categorized value beliefs into attainment value, intrinsic value, utility
value, and cost. Attainment value links to an individual’s belief regarding the importance of
succeeding with the designated task and how relevant the task is to align with significant
components of an individual’s self-schema (Battle, 1966; Eccles et al., 1983; Feather, 1988;
Markus & Wurf, 1987; Rokeach, 1979). Intrinsic value, similar to constructs of intrinsic
motivation (Deci & Ryan, 1985; Harter, 1981), is the enjoyment an individual will gain from
completing the task or the interest they have in the content or subject the task is related to (Eccles
& Wigfield, 2002). Intrinsic value can also be situational. Hidi and Renninger (2006) proposed
that events can lead to situational interests and intrinsic values that can develop based on
personal interests and become internalized (Wigfield & Eccles, 2020).
The utility value of a task relates to how the completion of the task can connect to the
individual’s personal or career goals. If the individual is not necessarily interested in the task
itself but in how it can contribute to future success toward goals, it is defined as utility value.
However, when utility value connects to personal goals and an individual’s identity, it can
connect with attainment value, resulting in subtle distinctions between intrinsic value, attainment
value, and utility value, depending on the importance of the goal and how it relates to an
individual’s self-schema (Wigfield & Eccles, 2020). Lastly, cost is an important consideration

24
when determining the value of a task. Cost considers aspects of the task that are negative. This
can include anxiety, fear, and the effort it would take to succeed. Cost could relate to the loss of
an opportunity or success that could come from making a different choice (Eccles & Wigfield,
2002).
Self-Efficacy Theory
Bandura (1997) proposed self-efficacy as a social cognitive model. As Bandura defined,
self-efficacy is a multidimensional construct of a person’s confidence in their ability to
accomplish a task. This construct can vary across dimensions, and an individual can have high
self-efficacy in some areas and low self-efficacy in others. Much like the expectancy-value
theory, the self-efficacy theory emphasizes expectancies. The two expectancy beliefs Bandura
distinguished were outcome expectations, where an individual believes that specific behaviors
will influence the outcome, and efficacy expectations, where an individual believes they can
complete the tasks associated with the expected outcome. Bandura (2000) noted that selfefficacy influences the goal an individual will work toward and the effort expenditure and
persistence to achieve it, directly influencing multiple aspects of human behavior.
Attribution Theory
People often look for attributions when attempting to determine the cause of someone’s
behavior or their own behavior. Attribution theory, introduced by Heider (1958), analyzes the
reasons for those attributions and what occurs as a result of the attributions (Sockbeson, 2023).
Attribution theorists differ in their beliefs by emphasizing success as the determining factor
influencing future action. Attribution theory considers internal and external causes. According to
Weiner (1985), the most important attributions for achievement include ability, effort required,
difficulty of the task, and luck. These were classified into locus of control, stability, and
controllability. Locus of control focuses on whether the behavior that has occurred is a result of

25
internal or external factors of the person, while stability looks at whether the cause of the
exhibited behavior could change in the future. Lastly, controllability focuses on whether the
individual or people around them could have influenced what caused the behavior to occur
(Sockbeson, 2023).
Applied Behavior Analysis
Because of the field of focus, ABA, I felt it was necessary to include a simplified and
brief overview of motivation from the perspective of a behavior analyst. In ABA, a three-term
contingency describes the interdependent relationship between what occurs immediately before a
behavior (the antecedent), the behavior itself, and what occurs immediately after (the
consequence). When discussing operant behaviors, which are not reflexive, the likelihood of a
behavior reoccurring is directly influenced by the immediate consequences following the
behavior. If the behavior is reinforced, the probability of its future occurrence increases, whereas
if the behavior is punished, the probability of its future occurrence decreases (Mayer et al.,
2014). Other aspects that influence an individual’s motivation are motivating operations and
setting events. Motivating operations alter the value of a stimulus, and setting events are events
or circumstances that occur prior to the behavior and influence its likelihood (Cooper et al.,
2007). With these things in mind, an individual’s motivation is influenced by the value of
engaging in that behavior based on their current state (motivating operations), considerations
currently happening in their life (setting events), and their learning history of what has occurred
when they have engaged in that behavior in the past and if it has accessed reinforcement or
punishment.
Determining Motivation Gap
Determining a motivation gap influencing a BCBA’s ability to reform occurred through
active listening during interviews. When identifying motivational barriers, Clark and Estes

26
(2008) recommended looking at commitment, underconfidence, and overconfidence.
Additionally, I aligned interview responses with the motivational theories discussed to determine
if they influence the BCBAs’ ability to modify their practices.
Organizational Influences
Organizations play a significant role in working toward neurodivergent-affirming care.
Organizational barriers are related to the need for more resources or adequate protocols, which
impact the ability to meet a goal (Clark & Estes, 2008). In ABA, they often go further than this.
They play a critical role in the training and development of individuals pursuing certification
because candidates have to accrue 1500-2000 hours to apply for certification, and are often
accrued at the organization.
Literature Review
The literature review will begin with research on autism, also referred to as ASD. It will
cover both the medical model, which is more prevalent in ABA, and the social media, or
neurodiversity paradigm, preferred by the autistic community. The next portion will discuss the
negative impact of ABA, followed by its benefits, to highlight the trauma that has occurred and
how it can be used to provide significant benefits to the autistic community. The literature review
will conclude with information on neurodivergent-affirming practices and ABA methodologies
that have been documented moving toward neurodivergent-affirming care to highlight the
evidence-based research showing that reforming the field is possible with modified strategies and
practices.
Autism
Autism, or ASD, is a neurodevelopmental diagnosis provided due to the significant
differences in brain functioning, architecture, and maturation (Bölte et al., 2021). In 2020,
approximately one in 36 children received the diagnosis across all races and socioeconomic

27
groups, but it is almost four times more common in children declared male at birth than children
declared female at birth (Maenner et al., 2021). Approximately 17% of children between three
and seventeen were diagnosed with a co-occurring developmental disability in a study conducted
between 2009 and 2017 (Maenner et al., 2021). The diagnosis of autism can be described in two
ways: the medical model and the neurodiversity paradigm.
Medical Model
According to the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-V), for an individual to receive an autism diagnosis, they must have deficits or
impairments in social communication and interactions, and they must have restricted or
repetitive behaviors or interests (American Psychiatric Association, 2013; Lai et al., 2014).
These symptoms must have been present (or be present) in early childhood development and
must have a significant impact on their level of functioning (American Psychiatric Association,
2013; Lai et al., 2014). Three severity levels are provided regarding the levels of support the
individual needs (American Psychiatric Association, 2013). The DSM-V (American Psychiatric
Association, 2013) levels are as follows: Level one requires support, level two requires
substantial support, and level three requires very substantial support.
Negative Impact
The medical model of autism focuses on comparative normalization, characteristics as
symptoms, and aspirations to eliminate or reduce identified symptoms (American Psychiatric
Association, 2013; Baker, 2011; Hall, 2019; Kapp et al., 2019). The model emphasizes deficits,
lacking advantageous characteristics of the diagnosis, leading to recommendations to treat and
cure the disorder (American Psychiatric Association, 2013; Kapp et al., 2019). This is often
through treatments teaching individuals to mask the characteristics that align with the diagnosis
to meet societal expectations of what is considered the norm (Miller et al., 2021), creating ableist

28
approaches and perspectives (Hall, 2019). Seeking normality, or an approximation of it, connects
autism and abnormality, connecting abnormality with the person with the diagnosis, producing
an ableist notion of treatment and rehabilitation (Shyman, 2016). Additionally, viewing autism
through the medical model positions autism as something to be eliminated or minimized
(Shyman, 2016) and as an undesired variation from what is considered normal functioning,
impacting the approach of therapeutic interventions emphasizing deficits, not strengths
(Pellicano & den Houting, 2022). Another negative impact of using the medical model alone
includes the exclusion of the lived experiences of autistic people, suggesting that a deficit in the
theory of mind impairs their mental ability to reflect on their experiences accurately (Pellicano &
den Houting, 2022), excluding first-person accounts in research (Benevides et al., 2020).
Neurodiversity Paradigm
In the 1990s, autism advocates worked toward shifting the perspective of autism, with
neurodiversity becoming a term coined by Judy Singer and Harvey Blume (Pellicano & den
Houting, 2022). Neurodiversity is a term that includes a range of naturally occurring diversity in
neurodevelopment, including neurotypical, which falls within what is considered typical, and
neurodivergent, which is outside of what is considered typical (Pellicano & den Houting, 2022).
The neurodiversity paradigm conceptualizes autism as neurodiversity, a natural variability of
human brain differences, versus an abnormality. The neurodiversity paradigm challenges
inclusion following a social model of disability (Bölte et al., 2021), considering the
environmental factors that influence the ability of an individual and focusing on the
characteristics of autism being different strengths, recommending a strength-based approach to
therapeutic services (Bölte et al., 2021; Pellicano & den Houting, 2022). The neurodiversity
paradigm emphasizes normal variation in neurodevelopment, eliminating the assumption that
one type of neurodevelopment is better or worse than the other and that all people deserve equal

29
levels of respect and dignity regardless of neurotype and continues to be a recommended
approach from autistic advocates (Pellicano & den Houting, 2022).
Applied Behavior Analysis
Applied behavior analysis is the science of behavior and is primarily used as an
intervention for autistic individuals built based on the behaviorism philosophy by B.F. Skinner
(Moore, 2011). This intervention has been questioned on the efficacy and ethical nature of the
services and has reportedly caused severe harm to the autistic community (Wilkenfeld &
McCarthy, 2020). As a newer field, several intervention methods have continued to evolve in
addition to the ethical guidelines that must be followed by BCBAs (BACB, 2020). Although
there have been modifications, a significant portion of the control is given to the BCBAs and the
organization when choosing appropriate behaviors to address deemed socially significant
(BACB, 2017).
Applied behavior analysis is a scientific approach to studying and shaping human
behavior by manipulating environmental variables that influence the targeted behaviors (Cooper
et al., 2007). It was built off the foundation of behavior analysis that began with the philosophy
of the science of behavior, behaviorism, established by John B. Watson, emphasizing the focus
on studying observable behavior and how environmental stimuli evoke responses. In 1938, the
next aspect of behavior analysis, experimental analysis of behavior, began when B. F. Skinner
published The Behavior of Organisms on his research regarding respondent behaviors that are
reflexive and involuntary brought about by what occurs immediately prior and operant behaviors
that are behaviors that occur based on what has immediately occurred after the behavior in the
past (Cooper et al., 2007).
Skinner (1938) then shifted the focus onto what occurs immediately after a behavior and
how that influences its occurrence in the future, termed operant conditioning. Thus, ABA, the

30
final component of behavior analysis, moved toward modifying teaching strategies to improve
socially significant behaviors (Cooper et al., 2007). In 1961, Charles Fester published the first
paper analyzing autism using these methodologies, followed by Ivar Lovaas, who considered
autistic children a blank slate: ‘[Y]ou start pretty much from scratch when you work with an
autistic child… they are not people in the psychological sense’ (Chance, 1974, p. 76). Lovaas
used physical aversives, including electric shock, which was supported by many until 1988,
when the use of ABA and autism transformed, followed by claims that early intensive ABA
resulted in recovery from autism for 47% of patients (Lovaas, 1987).

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Trauma
When conducting a Google search of “applied behavior analysis,” the first post was from
a well-known organization, Autism Speaks, which the autistic community broadly does not
support (Autistic Self Advocacy Network, 2023). This was followed by pages of research
supporting ABA, organizations providing services, and educational institutions providing
education to become certified in ABA. Halfway down the page, one link discusses the
controversy around ABA from the Child Mind Institute (2023). If a parent were to search
“Should I put my child in ABA,” the fourth link was labeled “Why No Autistic Child Should Be
in ABA Therapy” (Des Roches Rosa, 2020). This page discusses trauma that can and has
occurred as a result of services since its inception and cautions parents against medical
recommendations to place their children in the services because of the likelihood of trauma and
the emphasis on compliance, magnifying vulnerabilities to abuse and other harmful outcomes
(Des Roches Rosa, 2020).
Common strategies recommended for autistic individuals within ABA focus on the
perspective of a medical model by attempting to address, reduce, or eliminate the symptoms of
the disability (Shyman, 2016). Operating in this role presents a patient to be ‘cured’ and a
therapist to ‘treat’ the patient (Shyman, 2016). This is done with minimal research on autistic
adults’ views of what is necessary for their health and independence and little involvement from
the autistic community in research that impacts their care (Benevides et al., 2020). This
exclusion probably results in recommendations for treatments using the medical model (Shyman,
2016) to teach them to hide their autistic characteristics to fit societal expectations (Hall, 2019).
Bradeley et al. (2021) surveyed to better understand the consequences of teaching autistic people
to hide their autistic characteristics, often referred to as masking or camouflaging. The survey
indicated a decrease in self-acceptance, leading to exhaustion and increased suicidal ideation

32
(Bradeley et al., 2021). Additionally, data indicated it led to an increase in anxiety, possibly
contributing to the increased rate of suicide attempts or completion among the autistic
community (Kölves et al., 2021).
Self-stimulatory behaviors, also known as stereotypy or stimming, are repetitive motor
(e.g., hand flapping, spinning) or vocal (e.g., humming, grunting) behaviors that are common
characteristics of autistic individuals (Kapp et al., 2019). Autistic adults have provided feedback
on the necessity of stereotypy, stating that it helps regulate their bodies in response to internal
and external factors and that negative reactions of others and feedback to stop engaging in these
behaviors are harmful (Kapp et al., 2019.). These behaviors are often targeted for reduction or
elimination by BCBAs. Another common area for focus is social communication. Social
communication and social engagement differences are highlighted as core indicators of autism
and are often highlighted in treatment recommendations to make autistic people
indistinguishable from peers (Wilkenfeld & McCarthy, 2020). Addressing these differences from
a neurotypical perspective often results in hiding parts of themselves, or masking their autistic
characteristics, decreasing self-acceptance and leading to exhaustion and increased suicidal
ideation (Bradeley et al., 2021).
Benefits
A logical response to the trauma that ABA caused could be that ABA is not an
appropriate service for autistic members and should not be utilized. As a mother and a BCBA, I
do not fault people for having this response; these were among the feelings that had surfaced for
me as well when conducting her research into the trauma that had occurred. I include a benefits
section in this literature review, not to discount the trauma or to justify traumatizing individuals
during skill development and behavior reduction, but to show the benefits of the services and the

33
necessity to reform versus abolish services. This will be followed by methods detailing how to
improve the services to better support the autistic community without causing trauma.
Since the inception of ABA, significant benefits have been documented in the efficacy of
the intervention itself. An early introduction into the benefits of early and intensive intervention
was documented in 1987, with 47% of autistic participants who received services reportedly
having “normal intellectual and educational functioning,” with only 2% of a control group
meeting the same criteria (Lovaas, 1987, p. 7). It is important to note that in this particular
research, physical aversives were used, and this occurred prior to the development of the BACB
and the mandate of ethical guidelines in 1988. Within and outside of early and intensive behavior
interventions, multiple different areas have been targeted and proven effective using ABA for
autistic individuals. Multiple areas discussed that have been addressed utilizing ABA and their
respective articles of examples (Table 1).

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Table 1
Example of Areas Effectively Addressed Using Applied Behavior Analysis With Autistic Clients
Example focus areas Articles showing effectiveness
Language development Durand & Moskowitz, 2015; Falligant et al.,
2020; Kalgotra & Warwal, 2019; Marion et
al., 2012; Martin et al., 2013; Williams et
al., 2000; Sundberg et al., 2001; Sumter et
al., 2020;
Self-advocacy Arndt et al., 2006; Sievert et al., 1988
Safety skills Bergstrom et al., 2012; Carlile et al., 2018;
Gunby & Rapp, 2014; Johnson et al, 2005;
Jostad et al., 2008; Rizzi & Dibari, 2019;
Taber et al., 2002; Taylor et al, 2004;
Vanselow & Hanley, 2014
Social skills Francisco & Hanley, 2012; Leaf, et al., 2011;
LeBlanc et al., 2003; Nikopoulos & Keenan
2004; Shrandt et al., 2009; Thiemann &
Goldstein, 2001
Feeding interventions Geller, Eason et al., 1980; Yu et al., 2018
Adaptive living skills Cicero, 2019; Cividini-Motta et al., 2020;
Gerow et al., 2021; Graves et al., 2005;
Matson et al., 2012; Pierce & Schreibman,
1994; Trask-Tyler et al., 1994
Self-management Briesch & Chafouleas, 2009; J. E. Carr et al.,
2014
Vocational skills Schroder et al., 2023
Maladaptive behavior reduction (i.e.,
aggression, self-injury, property
destruction, elopement)
Call et al., 2011; E. G. Carr & Carlson, 1993;
Phillips et al., 2017; Rajaraman, Hanley et
al., 2022
Note. Maladaptive behaviors reviewed do not include targeting self-stimulatory behaviors for
reduction unless they are causing harm to the individual or others and are categorized as selfinjury or aggression.

35
Communication across ages and lifespans is a primary area of focus for most clients
receiving ABA services. Addressing communication often occurs through functional
communication training, and clients are taught how to better communicate to get their needs met
safely (Sumter et al., 2020). Functional communication training teaches replacement behaviors
for unsafe behaviors such as aggression, self-injury, property destruction, and elopement
(Durand & Moskowitz, 2015). Functional communication training is used across modalities
depending on the learner’s needs and can include vocal verbal language or augmentative and
alternative communication. Focusing on communication is a priority and can be used for all
aspects of communication, including requesting basic wants and needs, listener skills, asking and
responding to questions, labeling, reciprocal conversations, self-advocacy, proper grammatical
structure, and other forms of personal and social communication (Falligant et al., 2020; Kalgotra
& Warwal, 2019; Marion et al., 2012; Martin et al., 2013; Sundberg et al., 2001; Williams et al.,
2000).
While ABA methodologies have been used with younger clients on school readiness
skills, producing significant outcomes in areas related to language, social, and cognitive
development, they have also been shown effective in teaching other skills. ABA has been used to
teach a substantial variety of activities of daily living (Table 1), including toilet training,
handwashing, bathing, dressing, preparing meals, self-management, and masturbation. Skills are
selected to increase independence in the home, school, and community setting and improve an
individual’s quality of life. Increasing safety skills for autistic individuals has proven effective
using ABA strategies as well (Rizzi & Dibari, 2019; Vanselow & Hanley, 2014). Example safety
skills addressed using ABA (Table 1) include abduction safety (Gunby & Rapp, 2014; Johnson
et al., 2005), gun safety (Jostad et al., 2008), and seeking assistance when lost (Bergstrom et al.,
2012; Carlile et al., 2018; Taber et al., 2002; Taylor & Fisher, 2004).

36
Another significant area to highlight is the effectiveness of feeding therapy using ABA
strategies to target food selectivity, reducing rapid eating that puts individuals at risk for choking
(Anglesea et al., 2013), and increasing consumption of healthy foods (Hodges, 2017; Koegel et
al., 2012). Additionally, ABA has been used to effectively increase social skills, social
communication, safety in social situations, and increase confidence in social engagement
(Francisco & Hanley, 2012; Leaf et al., 2011; Thiemann & Goldstein, 2001). More commonly
known, ABA is utilized to address to decrease maladaptive and dangerous behaviors that
interfere with learning, safety, and independence, which often includes increasing tolerance to
delays, denials, and non-preferred activities like medical and dental procedures (Call et al., 2011;
E. G. Carr & Carlson, 1993; Phillips et al., 2017; Rajaraman, Hanley, et al., 2022). This is a
small example of the use of ABA to increase socially significant behavior, Heward et al. (2022),
created a list of 350 domains addressed utilizing ABA across specialties.
Neurodivergent-Affirming Practices
Limited research exists on therapeutic entities implementing neurodivergent, or
neurodiverse, affirming practices. In the last 2 years, research has begun to emerge in practices
working with neurodivergent clients to include the necessity to reform practices in occupational
therapy (Dallman et al., 2022), neurodiverse-affirming approaches in speech-language pathology
(Santhanam, 2023), and most recently, within ABA (Mathur et al., 2024).
Current Directions Within ABA
Methodologies for ABA are not inherently good or bad. The BCBA’s application of
methods and skills plays a significant role in service outcomes, including utilizing approaches
that have reportedly caused harm. While implementing neurodivergent-affirming services in
ABA is a newer concept, several strategies have been identified that could align with
neurodivergent-affirming practices with intentional and compassionate implementation.

37
Recently, Mathur et al. (2024) highlighted that a significant portion of ABA literature has
emphasized enhancing autistic clients’ quality of life, while a smaller number of resources
without this as the primary purpose has had a more significant influence on behavior analysts’
practices. Several ABA researchers have focused on effectively implementing ABA services
while ensuring harm does not occur to the people receiving services. Some of the methodologies
identified include trauma-informed care (Rajaraman, Austin, et al., 2022), assent-based practices
(Breaux & Smith, 2023), ethical ABA (Contreras et al., 2022), skill-based treatment (Rajaraman,
Austin, et al., 2022) compassionate care (Denegri et al., 2023). More recently, an article
highlighted that a specific methodology alone is not necessary but that the necessity lies in
utilizing a social paradigm lens when assessing behaviors to target and designing strategies to
support autistic clients (Mathur et al., 2024).
Trauma-Informed Care
Trauma-informed care is a practice implemented across therapeutic entities and began
surfacing in ABA in recent years. Rajaraman, Austin et al. (2022) presented strategies to begin
utilizing a trauma-informed approach in ABA services. Four core commitments were identified
across the research and analyzed in accordance with ABA: acknowledge trauma and any
potential impact it may have (Harris & Fallot, 2001), ensure safety and trust between the client
and provider, remain respectful (Guarino et al., 2009), promote client choice and autonomy
(DeCandia et al., 2014), and emphasize skill development to empower clients (Hopper et al.,
2010; Moses et al., 2003). These core components are analyzed and aligned with ABA practices,
emphasized within our ethical guidelines, with recommendations on what this would look like in
practice. Client assent would be prioritized, behavior analysts would avoid implementing
programming instructions that could occasion a trauma response, and behavior analysts closely

38
monitor client responses and modify quickly if a negative emotional response occurs
(Rajaraman, Hanley, et al., 2022).
Assent-Based Practices
Because of the ability level of many individuals receiving ABA services, assent was
recently added to the ethics code for behavior analysts (BACB, 2020). When an individual is
unable to provide consent because of age or ability, assent measures the vocal or nonvocal
behavior of the individual as indicative of whether they are willing to participate in services
(BACB, 2020). As a newer included concept, published research is limited; however, it is an
extension of consent, not in place of consent. Assent, like consent, can be withdrawn at any time
during an intervention; it differs in the sense that the client provides it versus their family
members or legal guardians. This perspective allows the individual impacted by the interventions
to choose whether they are comfortable and willing to participate, ensuring client dignity and
teaching them that their assent matters, and when withdrawn, that choice will be respected
(Breaux & Smith, 2023).
Assent-based services, or interventions, are person-centered approaches that individually
define assent and assent withdrawal based on each individual’s abilities. This is consistently
evaluated and modified as necessary throughout service implementation and requires a detailed
functional definition of the function and topography of assent and assent withdrawal, as well as
consideration across all conditions of the intervention (Breaux & Smith, 2023). Implementing
assent-based practices alone is not sufficient; compassion must be considered. Abdel-Jalil et al.
(2023) recommended integrating compassion and assent to ensure ethical practices. This is
because of the necessity to assess genuine versus apparent assent (Linnehan et al., 2023) because
of the ability to coerce assent through control of stimuli in the environment (Abdel-Jalil et al.,
2023). To effectively assess assent and ensure it is genuine, compassion needs to be considered,

39
and the client needs to have the ability to access the consequence in multiple ways and the
freedom to do so.
Social Model Approach
When assessing autistic clients, determining targets to focus on, and developing
programs, another recommended approach is utilizing the social model lens versus the
commonly used medical model lens. The medical model of disability focuses on deficits and
treatment, creating bias and stigma toward autistic people (Angulo-Jiménez & DeThorne, 2019).
In contrast, the social model, or neurodiversity paradigm, emphasizes inclusion and embracing
neurodiversity by celebrating and normalizing cognitive variation and reframing deficits as
differences (Rosqvist et al., 2020). Mathur et al. (2024) discussed common criticisms of ABA
corresponding with practices deemed as suboptimal, in addition to alternative practices that
center neurodiversity. These recommendations include centering clients and their values,
monitoring assent and affect in response to programs, utilizing a trauma-informed approach, and
consulting autistic individuals for research and practices (Mathur et al., 2024). For ABA
practitioners to shift their practices and use the social model, the authors recommended that
practitioners acknowledge the pain that has occurred and commit to improvements:
We must believe them when they tell us that their experiences were traumatic. We must
center their voices, understand their concerns, and include them in the solutions we offer.
We can do so by viewing autism through a social model lens rather than a medical model
lens. Rather than thinking of ourselves as the sole experts, we can reconceptualize our
treatment approach as a collaborative process between experts in behavior (us) and
experts in autism (our clients). (Mathur et al., 2024, p. 12)

40
Conclusion
Research indicates the necessity to reform based on the lived experiences of the autistic
community and the trauma that has occurred. Although ABA has developed several strategies
that move toward neurodivergent-affirming care, with a recent article highlighting the necessity
and steps to take to move in that direction, there needs to be an indication of the barriers or
influences impacting reform within the field. Conducting BCBA interviews and document
retrieval and analysis helped provide insight into these barriers and the steps to take to address
them.

41
Chapter Three: Methodology
The purpose of this study was to better understand the lived experiences of BCBAs
regarding their experiences, challenges, and competencies related to the current necessity for
reform within ABA to move toward neurodivergent-affirming care and the KMO factors
influencing this decision. This information was acquired through interviewing BCBAs and
analyzing documentation provided by educational institutions and organizations to determine
educational and training opportunities and limitations. Acquiring this knowledge allowed for a
better understanding of barriers for participants and allowed me to develop recommendations for
BCBAs to acquire the knowledge needed to implement neurodivergent-affirming care, increase
their motivation, and increase their self-efficacy. Additionally, I developed a framework of
recommendations for educational institutions on course content to inform future behavior
analysts of ableism, the history of ABA and the trauma that has occurred, and neurodivergentaffirming care. I also developed a framework for organizations to support individuals working
toward becoming behavior analysts and current BCBAs in implementing neurodivergentaffirming care.
Qualitative Research Design
I used a qualitative design for this study. The qualitative approach aligns with the purpose
of the study because it allows for more exploration into barriers or influences into BCBAs
modifying their practices toward more neurodivergent-affirming care. With limited research into
these topics, additional data were needed before moving toward a quantitative or mixed-methods
approach. Qualitative research allowed me to have open-ended discussions with BCBAs to better
determine the barriers based on their lived experiences regarding training within their
universities, organizations, and training they sought to complete independently using an
interpretive/constructivist approach (Merriam & Tisdell, 2015). Additionally, an inductive

42
approach allowed me to gather data and build hypotheses on these barriers to provide
recommendations for future studies and develop a list of recommendations for BCBAs,
educational institutions, and organizations (Merriam & Tisdell, 2015). Data sources were semistructured interviews and documents.
Case Study Research
Case study research is the type of qualitative research used for this study. This theory is
defined as an approach that allows an investigator to conduct an exploration of real-life bounded
systems using multiple sources of information, producing a report of themes to allow for an
understanding of influences and barriers (Creswell & Poth, 2018). Defining characteristics of
case study research that can be incorporated into a study include identifying a bounded case
identification with parameters outlined in consecutive sections. In this instrumental case analysis,
I worked to understand the barriers to neurodivergent-affirming care and analyze data as they
were collected. I used memoization processes systematically to better understand or explain a
process they have identified for their research. To have an in-depth understanding of the cases
selected, I integrated many forms of data through three data collection points: demographic
surveys, semi-structured interviews, and document analysis of organizations and educational
institutions (Creswell & Poth, 2018).
Case study research aligns with this study because I sought to understand the lived
experiences of different BCBAs, the training they have received, and whether it is provided by
their organization, educational institutions, or sought out by themselves, and how it relates to
neurodivergent-affirming care. I conducted a collective case study to show different perspectives
to assist with theory development. I analyzed data while acquiring them through the three forms
of data to develop an assertion on the influences and barriers to applying neurodivergentaffirming care within ABA. I then used this assertion to understand what steps to take to move

43
toward neurodivergent-affirming care in ABA and produce a list of recommendations to BCBAs,
organizations, and educational institutions.
Research Questions
Three research questions guided this study:
1. What are behavior analysts’ knowledge, motivation, and organizational
experiences around neurodivergent-affirming practices?
2. What are behavior analysts’ knowledge, motivation, and organizational
challenges around neurodivergent-affirming practices?
3. How can behavior analysts’ knowledge, motivation, and organizational
competencies around neurodivergent-affirming practices be improved?
Research Setting
The research setting consisted of virtual interviews conducted online via Zoom. The
interviews were recorded, and I used Otter.ai to ensure an accurate transcription. This method
did not provide the same level of anonymity as in-person interviews but allowed for a broader
range of participants, and additional safeguards were put in place to protect the participants’
anonymity.
Participants
To attain accurate data in alignment with the research questions, selecting interviewees is
a critical process. I chose participants according to the criteria described in the following
sections. I used a screening survey to prevent frequent overlap of participants with identical
demographic criteria, including length and positions in the field.

44
Target and Accessible Population
The target population was BCBAs in the United States. The accessible population is
BCBAs in the United States who met specific criteria. The sample was eight BCBAs in the
United States who met specific criteria.
Sample
Interviews occurred with eight participants before I reached a point of saturation. This
allowed me to collect enough data to reach saturation and receive varied perspectives and
responses to answer the research questions selected for the study (Merriam & Tisdell, 2015).
Participants in this study were BCBAs working with autistic clients. As of July 2024, the BACB
reported 62,856 BCBAs, 75.39% of them with a primary professional emphasis on ASD (BACB,
n.d.-b). The following sections present the criteria for the sample.
Criterion 1
Individuals had to have passed the board certification exam and actively maintained
certification as current BCBAs. This criterion ensured that participants were subject to the same
ethical guidelines with consistent training criteria.
Criterion 2
Individuals had to be currently working with the autistic community and have for at least
1 year. This work could be direct or indirect, so they could be organizational leaders overseeing
people who are working directly with autistic clients but have the subspecialty of working with
autistic individuals. This criterion ensured that the participants had experience working with the
autistic community.

45
Criterion 3
The BCBAs had to be currently employed by an organization of at least 50 people across
or have been within the 30 days prior to their interview. This criterion allowed more in-depth
information on the organizational resources that can be provided to a BCBA or the lack of
resources provided through an organization.
Sampling Method
Purposeful sampling is an integral part of qualitative research, and sampling methods can
differ across the qualitative approach identified to best support the goal of the study. When
determining appropriate participants in a case study research approach, theory development
contribution must be at the forefront of a researcher’s mind (Creswell & Poth, 2018). Maximum
variation sampling is a common approach used in qualitative research (Creswell & Poth, 2018).
In maximum variation sampling, a researcher determines key criteria prior to selecting
participants, allowing for more varied perspectives once data collection begins because the
greater the variation, the more useful the patterns become as a theory begins to develop (Merriam
& Tisdell, 2015). Another common method of sampling includes snowball, or chain, sampling.
Snowball sampling occurs when participants refer a researcher to potential participants to expand
on the research (Merriam & Tisdell, 2015).
In this study, I used maximum variation sampling by determining key criteria for
participant eligibility. Additionally, I used snowball sampling to access additional interviewees
to expand on the research. This method was a part of the process but not the primary method in
an attempt to avoid groupthink.

46
Recruitment
I first sought approval from the institutional review board (IRB) at the University of
Southern California (Appendix A). After this, I distributed interview participant requests via a
research invitation letter (Appendix B) across platforms, including social media (i.e., Facebook,
Instagram) and professional pages (i.e., LinkedIn). Doing so allowed for a broader range of
participants to avoid biases. The request included a link to the demographic survey on Qualtrics
(Appendix C), which served as a screening survey to allow me to vary the interviewees and
ensure variability in demographic criteria. The demographic survey included an informed
consent form (Appendix D). Upon receipt of the survey results, I followed up with each
participant, informing them of the determination to move forward and sending them the consent
letter. Once I received their letter, I scheduled the interview.
Data Collection
Selecting instruments useful to the study is a necessary process to acquire the data needed
to develop a theory in research. While new forms of data collection within qualitative research
continue to emerge, data collection primarily results from interviews, observations, and artifact
or document analysis (Merriam & Tisdell, 2015). Qualitative data are pieces of information
found useful to the study, often consisting of words versus numbers. Qualitative data collection
frequently occurs through interviewing participants with information relevant to the study.
Interviewing, while an effective form of data collection, does not have to be used in isolation,
depending on the needs of the study, and can often be used in conjunction with other methods
such as observation and document analysis (Merriam & Tisdell, 2015).
There were three data sources for this study: a demographic survey, interviews, and
documents. Data collection within qualitative research consists of more than the collection of

47
data and how to collect that data; multiple processes are involved to ensure the quality of the
data. Creswell and Poth (2018) considered the data collection process to consist of multiple
interrelated activities visualized as a data collection circle. In the circle’s center, Creswell and
Poth (2018) placed ethical considerations to ensure that a researcher examines all aspects of data
collection through an ethical lens. One of the interrelated activities includes locating a suitable
site and building rapport with participants. Purposeful sampling is another component and varies
depending on the theory of inquiry chosen. Other components include collecting data, recording
information as data collection occurs, and properly storing data in compliance with
confidentiality regulations. The remaining activity outlined by Creswell and Poth (2018) is to
prepare for potential issues in the field and minimize those issues’ impact on the ability to collect
data. I followed these recommendations and simultaneously collected and analyzed data through
interviews and document analysis.
Data collection methods were utilized to answer the research questions outlined in Table
2. Interviews as a form of data collection in this study provided me with the data necessary to
develop a better understanding based on participant responses to interview questions included in
Appendix F. Questions in this interview were designed to cover KMO factors influencing the
ability of a BCBA to implement neurodivergent-affirming care in addition to the BCBAs
experiences, challenges, and competencies in doing so. To increase the variety of interviewees, I
used the demographic survey on Qualtrics (Appendix C).

48
Table 2
Data Sources
Research questions Demographic
survey
Interviews Document
analysis
What are behavior analysts’ knowledge,
motivation, and organizational
experiences around neurodivergentaffirming practices?
X X X
What are behavior analysts’ knowledge,
motivation, and organizational
challenges around neurodivergentaffirming practices?
X X
How can behavior analysts’ knowledge,
motivation, and organizational
competencies around neurodivergentaffirming practices be improved?
X X
Document analysis coincided with the interviews. Document analysis occurred on
documentation from five educational institutions with ABAI accreditation that provide required
coursework in ABA and five organizations that provide ABA services to autistic clients. The
documents used for analysis were the course content presented in the program to determine if
additional information is provided on the history of ABA, the trauma that has occurred, and any
information on ableism and neurodivergent-affirming care. This allowed me to determine if
educational institutions provided training in these areas to individuals working toward
certification. I also conducted a document analysis of five organizations that provide ABA
services to autistic clients. The analysis included information provided publicly on each
organization’s website to determine if it included ableist content, whether they required training
for BCBAs, if BCBAs could choose their training, and if BCBAs received a stipend to do so.
This allowed me to determine if the organizations provide resources related to neurodivergent-

49
affirming care, allowing BCBAs to seek that education themselves, or if they limit their BCBAs’
ability to seek that training without continuing education funding.
Demographic Survey
A demographic survey is used to collect information regarding the basic characteristics of
the participants that will be studied to ensure data collection aligns with the information
necessary to meet the study’s criteria. This study’s demographic criteria include participants who
must hold board certification in behavior analysis and work with the autistic community. To vary
the protocol responses, I used a screening survey to learn of potential participants’ length in the
field and professional experiences to prevent more than three interviewees with mirrored
demographic criteria. There were no criteria outside those parameters to allow the research to
include varied perspectives to better understand the lived experiences of multiple BCBAs
regarding neurodivergent-affirming care and training.
Interview Protocol
I followed a semi-structured interview protocol (Appendix E). This method allowed for
control over the questions and content of the interview to gain the most information and provided
enough structure to remain on topic. Semi-structured interviews allowed for the flexibility
needed throughout the interview and allowed me to modify the order or content of questions to
better meet the study’s needs and the participants’ feedback (Merriam & Tisdell, 2015). The
interview consisted of 15 questions with multiple probes dependent on each participant’s
response. The questions began with brief information about the participant’s time and experience
within ABA and working with the autistic population and their self-efficacy in their work.
Questions gradually moved to more direct questions related to their training, behavior, opinions,
and values, shifting into their knowledge regarding the opposition to ABA and how their

50
practices have or have not been influenced by this knowledge. The remaining questions asked
were regarding the BCBA’s feelings on influences to reforming the field, the necessity to do so,
and the organizational barriers that could impact this process.
Each interview question provided information on different components of the outlined
research questions related to the experiences, challenges, and competencies of BCBAs working
toward neurodivergent-affirming care or influences if they are not (Table 3). Additionally, the
questions were designed to provide insight into the knowledge and motivation of the BCBAs
related to neurodivergent-affirming care and if there are organizational supports in place to
support reform.
Table 3
Interview Protocol Question Alignment
Research questions Interview protocol alignment
What are behavior analysts’ knowledge,
motivation, and organizational experiences
around neurodivergent-affirming practices?
Questions 1–9
What are behavior analysts’ knowledge,
motivation, and organizational challenges
around neurodivergent-affirming practices?
Questions 8–14
How can behavior analysts’ knowledge,
motivation, and organizational competencies
around neurodivergent-affirming practices
be approved?
Questions 4–7 and 9,

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Document Analysis
Documents can be a helpful data source in qualitative research and often exist prior to the
conception of a study. Data collection in this form is solely guided by the researcher, relying on
their skills to interpret the data meaningfully for the research. Document collection and analysis
is a systematic process that evolves as it occurs and requires determining the authenticity and
usefulness of each item (Merriam & Tisdell, 2015). I followed a 10-step process for the
document analysis in alignment with recommendations beginning with clearly defined research
questions and identifying what documents can assist with producing data relevant to answer the
questions. The next step was to select the data and prepare it. I completed this part to become
more familiar with her data. The steps included developing appropriate codes and documenting
the ones that were consistent and relevant to the research questions as well as utilizing a constant
comparative method to determine the effectiveness of the chosen codes. Modification to the
codes occurred in the next step prior to determining the final coding, analyzing, and comparing
documentation prior to interpreting and presenting findings.
I sought documentation from five universities with ABAI-accredited ABA programs in
this study. I analyzed current course content for the chosen universities to determine the role
universities play in providing knowledge related to ableism, the history of ABA and reported
trauma caused, and neurodivergent-affirming care. Additionally, I conducted a document
analysis on five ABA organizations that provide services to autistic clients and employ BCBAs. I
sought insight into the organization’s mission and vision to determine if there were indicators of
ableist practices based on research on harmful terms and practices. Additionally, I attempted to
determine if the organization requires mandatory training for their BCBAs, if BCBAs have the

52
opportunity to choose their training with a company stipend for continuing education, or if
BCBAs are limited to a select range of training unless they are using personal funds to seek out
additional resources. This information allowed me to gain insight into potential barriers or
influences to implementing neurodivergent-affirming care within the organization.
Procedures
I used a demographic survey to assist with selecting varied participants to provide a
varied range of experiences and inform potential participants to complete the screening to
determine if they were a good fit for the study. Once I received those documents and determined
an individual to be a good fit for the study, I scheduled interviews with eight participants who
met the criteria outlined and had varied experiences as indicated in the demographic survey.
Logistical procedures for collecting interview data included time estimates, location, procedures
for data collection, and transcription procedures. The estimated time to complete the interview
with the current set of questions ranged from 30 to 60 minutes. A range was provided due to the
participants’ varied lengths of time in the field and the impact that additional time and training
had on the length of responses to interview questions. Interviews concluded by asking the
participants if they would like to add information regarding the interview content and if they
would be comfortable with follow-up meetings to confirm that I interpreted the responses as
intended.
Ethical Considerations
Ethics in qualitative research depend significantly on the ethics of the study’s author
(Merriam & Tisdell, 2015). To have a credible study with trustworthy data, there is a direct tie to
a researcher’s credibility and ability to carry out the study with integrity. It is important to follow
ethical guidelines, protect participants, and implement strategies for each phase of the study.

53
Factors to consider are participants’ right to privacy, informed consent, the potential impact on
the participant in the data collection process, the interpretation of data, and the dissemination of
findings at the conclusion of the study (Merriam & Tisdell, 2015). The IRB is guided by policies
related to respect for participants, concern for their welfare, and justice (Creswell & Poth, 2018).
To properly respect participants in a study, considerations include preparing for and disclosing
their right to privacy and their ability to withdraw from the study at any time without
repercussions. Participants must be treated fairly at all times, and the researcher must ensure data
acquired are not putting participants at risk (Creswell & Poth, 2018). IRB approval is required
before beginning the data collection portion of the study.
To have an ethical study, action must be taken before conducting the study, at the onset
of data collection, throughout the data collection and analysis, and during the dissemination of
the results. Creswell and Poth (2018) outlined ethical concerns and steps to address the potential
concerns that were used as a guide for the research. Before beginning the data collection process,
I submitted documentation to the IRB for approval that contained the following strategies that
were put in place at the onset of the data collection portion of the study and the consecutive
phases of the study. First, I reviewed the ethics code for behavior analysts to include Section 6,
focusing on responsibility in research, to ensure all guidelines were followed (BACB, 2020). I
prepared for ethics at the start of the study by disclosing the purpose of the study prior to
conducting interviews, ensuring informed consent was reviewed and approved, and ensuring that
all participation was voluntary. I provided an informed consent form with this information, forms
requesting consent to record the interview, and acknowledgment of data storage and disclosure.
All questions were designed with the intent to avoid leading questions and were approved by my
dissertation committee and another professor for confirmation. When analyzing data, I reported
multiple perspectives with contrary findings and used pseudonyms to protect anonymity. All data

54
were coded, and member checks occurred throughout the analysis. All data were reported
honestly with appropriate language, and participants will receive copies.
Confidentiality Parameters
Maintaining the confidentiality of participants is a mandatory and vital component of
qualitative research. Before participating in the interview, participants received information on
the purpose of the study and confidentiality parameters prior to completing a screening survey.
Once the screening survey was complete, I responded to the individual. If they were selected to
participate, I provided them with an informed consent form in addition to a document confirming
their participation and permission to record the interview. Participants consented to be involved
in the research and read and signed an informed consent document before being interviewed. To
protect their confidentiality, I took multiple measures. Because meetings occurred virtually, once
I received consent to record the interview, I downloaded the recordings directly to my computer
and data-encrypted OneDrive. I used participant numbers when coding and analyzing data.
Additionally, I reviewed the information and checked back in with the participants to confirm the
information was interpreted as intended, performing member checks throughout the study
(Merriam & Tisdell, 2015).
Data Management
I utilized data storage recommendations suggested by Creswell and Poth (2018),
including storing interview recordings and transcripts on my password-protected laptop with a
backup copy located in a locked file cabinet on a password-protected thumb drive to access
control and secured through OneDrive. Additionally, I had data encryption by MacAfee installed
on my laptop and iMac to protect access to data and further protect sensitive research data. I
ensured additional recommended cybersecurity practices by using strong passwords that differed

55
across platforms, locking the workstation when not in use, and ensuring the encryption stayed
with the data. I used participant numbers in all coding and documentation, and all records with
the codes were stored in a separate location. When collecting the data, I allowed the participant
to choose a site that protected their privacy, and I encrypted sensitive email communication by
OneDrive and only accessed on devices with recommended cybersecurity practices.
Dissemination of Findings
The intended purpose of this study was to gather information regarding the lived
experiences of BCBAs and their KMO supports in place that influence becoming
neurodivergent-affirming to aid in developing a more thorough understanding of the lived
experiences of multiple BCBAs. Once this information was acquired and analyzed, I built a list
of recommendations for BCBAs to acquire the knowledge needed to implement neurodivergentaffirming care, in addition to a list of recommendations for educational institutions on
coursework to help with knowledge acquisition of future behavior analysts. Lastly, I developed a
list of recommendations for organizations to implement to ensure that support and training are in
place to move toward neurodivergent-affirming care for BCBAs in the organization. This study
occurred as a dissertation process, in addition to an initial step into the process of identifying
barriers to reform and potential strategies to put in place to assist with becoming neurodivergentaffirming. As I progressed in this study, I hoped to begin or recommend a quantitative study
including an experimental design component based on this study’s findings to move toward
having the opportunity to present this research in conferences and publish her findings in the
Journal of Applied Behavior Analysis to allow these findings to support both the need for reform
and the steps to move toward becoming neurodivergent-affirming. This completed dissertation
will be shared with the study participants.

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Data Analysis
Data analysis within research differs depending on the type of research method(s) used.
In qualitative research, data analysis coincides with data collection and generally includes data
preparation and organization, coding and identifying patterns in the data, and then determining
the best method to display the results (Creswell & Poth, 2018). In addition to the differences
between analysis in qualitative versus quantitative research, recommendations also differ
depending on the approach to inquiry used (Creswell & Poth, 2018). In this study, I used case
study research and analyzed data in alignment with this theory. Data analysis consists of multiple
simultaneous steps to have a well-developed analysis and, in this study, involved a within-case
analysis followed by a cross-case analysis (Creswell & Poth, 2018). I used three phases of
coding to develop categories, interconnect the categories developed, and move toward pattern
development and recommendation (Strauss & Corbin, 1990). Data acquired through the
demographic survey, interview protocols, and document analysis were analyzed using a constant
comparative method, comparing each interview transcript and document to one another
throughout the analysis.
The demographic survey data were collected from Qualtrics and exported to Excel for
analysis using descriptive analysis. The interview data were analyzed using ATLAS.ti once
exported to Word using thematic analysis. I analyzed documentation from selected educational
institutions and organizations through descriptive and thematic analysis. The study used
descriptive and thematic analysis to analyze data to answer the research questions:
1. What are behavior analysts’ knowledge, motivation, and organizational experiences
around neurodivergent-affirming practices?
2. What are behavior analysts’ knowledge, motivation, and organizational challenges
around neurodivergent-affirming practices?

57
3. How can behavior analysts’ knowledge, motivation, and organizational competencies
around neurodivergent-affirming practices be improved?
Descriptive Analysis
Descriptive analysis is used in research to describe basic features necessary to inform the
study and helps to better understand the data (Salkind & Frey, 2020). Descriptive analysis was
used for responses provided in the demographic survey. Chapter Four presents the participants’
responses to highlight the variety of experience levels and lengths in the field. This variation
allowed me to better understand the influence it could have on the study’s validity and the
successfulness of the maximum variance sampling method utilized.
I also used descriptive analysis with documentation analysis on selected organizations
related to the following characteristics: number of BCBAs on staff in the organization, indicators
of ableist language, training structure of the organization and whether free CEUs were available
or if stipends were provided, and if there were indicators of neurodivergent-affirming practices.
These data were characterized using measures of central tendency. When analyzing
documentation on selected organizations, the following characteristics were considered: number
of students annually in the ABA program, course content related to neurodivergent-affirming
care, courses related to autism and the social or medical model, and history of trauma in ABA
and ableism. The data were characterized for this area using the measures of frequency and
measures of central tendency.
Thematic Analysis
Thematic content analysis is a method of data analysis that occurs when a researcher
begins to organize the data into themes or categories (Merriam & Tisdell, 2015). I used thematic
analysis in this study following the six phases outlined by Braun and Clarke (2006): familiarizing
herself with the data, generating initial codes, searching for themes within the codes, reviewing

58
themes and generating a thematic map, defining and naming, and producing a report. I used
ATLAS.ti to assist with the process. This occurred for the interview protocol and the document
analysis of the identified universities and organizations.
After the first interview, thematic analysis occurred. This began with reviewing the
interview transcripts to become familiar with the responses, making notations in a notebook
relating to thoughts, observations, or questions that could be relevant to the study, and
developing codes based on data that stood out (Merriam & Tisdell, 2015). This early in the
analysis, open coding occurred; however, I selected a priori codes based on Clark and Estes’s
(2008) framework: KMO factors. Once I concluded the analysis of the first interview, I reviewed
codes and determined if anything could be grouped, a process referred to as axial coding
(Creswell & Poth, 2018). After the following interview, I began analyzing the transcript with the
previous analysis in mind, engaging in open coding, and developing a list from this analysis. I
then implemented a constant comparative method of analysis by comparing the two interview
transcripts and codes developed together to move toward axial coding, creating a visual model
for analysis to identify any merging patterns or themes. This continued throughout all transcript
analyses working toward selective coding, where I developed a core category leading to the
development of a theory (Creswell & Poth, 2018).
I analyzed documents from selected ABAI-accredited ABA programs and organizations
providing ABA services to autistic clients. The analysis followed a ten-step process for the
documentation analysis in alignment with recommendations. I had clearly defined research
questions and had determined that analyzing organizations and educational institutions would
provide the data needed to develop additional perspectives based on the research questions. Once
data were selected and prepared, I began by analyzing a single portion of the website, making
notations in an Excel document, and engaging in open coding. Coding was utilized that was

59
relevant to the research questions and modified as necessary to meet the needs of the study.
Concurrent document analysis occurred, resulting in constant comparative analysis as themes
and categories were developed between interview transcripts and documents acquired through
university programs and organizations. Axial coding occurred to develop categories before
selective coding occurred. I analyzed and interpreted findings throughout the data collection
process until saturation occurred.
Reliability
Reliability in research primarily refers to the ability to replicate the research findings and
can be limiting when applied to social sciences (Merriam & Tisdell, 2015). Because of the
inability to isolate human behavior using qualitative research, reliability within qualitative
research focuses on the ability to confirm consistency between the data and the study’s results
(Merriam & Tisdell, 2015).
Dependability
To ensure dependability, Merriam and Tisdell (2015) recommended four strategies for
qualitative researchers: triangulation, peer examination, the positionality of the researcher, and
audit trail. Triangulation was used to increase dependability through the use of multiple data
collection methods within this study, collecting data through interviews and document analysis
from multiple sources. Peer examination occurred through the dissertation committee consisting
of three professors at the University of Southern California and Dr. Ayesha Madni, an inquiry
professor, to confirm plausibility based on the data provided. To increase dependability, I also
maintained an audit trail throughout the data collection and analysis to include a research journal
with reflections, ideas, and interpretations (Merriam & Tisdell, 2015).

60
Confirmability
The study’s confirmability can be established by auditing the study process and the data
consistently throughout without being influenced by researcher biases (Moon et al., 2016). This
allows for establishing the value of the data (Creswell & Poth, 2018). To ensure confirmability
and alignment with the study’s methods, I consistently analyzed data as they were collected. This
coincided with data collection methods throughout the study. Additionally, as Miles and
Huberman (1994) recommended, I was sure to include information regarding her positionality
and potential biases to address in the study and ensure data are collected, analyzed, and
disseminated objectively (Moon et al., 2016).
Validity
Validity within research is considered the ability of the findings to match what really
occurred during the research and the ability to generalize those findings. Because of the nature of
qualitative research, validity can be a challenging aspect to achieve depending on the
interpretation of the meaning. In qualitative research, a researcher collects data on reality from an
individual perspective, which can make validity difficult if considered from a quantitative
perspective; however, because of the ability to work closely with participants, some view
validity as a strength of qualitative research. Multiple methods can be used to strengthen a
study’s validity by expanding methods to prove both credibility and transferability (Merriam &
Tisdell, 2015).
Credibility
An essential factor in ensuring a study’s internal validity is a researcher’s ability to
ensure the study is credible. As Merriam and Tisdell (2015) recommended, I paid careful
attention to the study’s approach and development to adhere to ethical considerations when

61
collecting and analyzing data. I followed Lichtman’s (2011) recommendations for the
development of good qualitative research, including being transparent about my positionality and
role in the research and being clear about the study’s development (Merriam & Tisdell, 2015).
In addition, triangulation can increase internal validity with four proposed types: multiple
methods, investigators, data sources, or theories (Merriam & Tisdell, 2015). I used triangulation
regarding multiple data sources to include interviews and documentation provided by leading
educational institutions and organizations, in addition to interviewing individuals with varied
backgrounds and experiences within the field. I conducted member checks, also known as
respondent validation, with participants to ensure data were interpreted in alignment with their
intended responses. Lastly, saturation and redundancy were the indicators for the number of
participants selected for interview and analysis (Merriam & Tisdell, 2015), and data were
analyzed to identify if alternative explanations could be supported as patterns were developed
(Patton, 2015).
Transferability
External validity, or transferability, is the degree to which the results of a study can be
applicable to situations outside of the study (Merriam & Tisdell, 2015). Much like reliability, the
ability to generalize the results of a study using qualitative research is not as straightforward as it
is in a quantitative study. Shifting the view of generalizability can assist with ensuring that a
qualitative study has validity. One recommendation by Patton (2015) is to promote extrapolation
over-generalization to allow for varied similar but non-identical conditions to apply findings.
Concrete universals, a notion termed by Erickson (1986), discuss the ability to use the
knowledge acquired in a study to transfer to other similar situations (Merriam & Tisdell, 2015).
In this study, I worked to extrapolate findings relevant to other BCBAs’ experiences based on the

62
outlined criteria specified by the BACB on skills necessary to acquire and maintain certification.
Concrete universals were used from this study to further findings and move into a quantitative
analysis after the conclusion of the study to test findings. Additionally, maximum variation
sampling varied the participant range (Merriam & Tisdell, 2015).
Conclusion
In conclusion, I conducted a qualitative study using the case study research method of
inquiry to develop a better understanding of the experiences and challenges of BCBAs’ ability to
move toward neurodivergent-affirming care. I conducted semi-structured interviews to acquire
data related to the KMO influences on reforming ABA and their experiences, competencies, and
challenges to doing so. Document analyses of selected universities’ course content and
organizations’ training structure and content to further analyze this data acquisition occurred. I
used various sampling methods, including maximum variation sampling and snowball sampling,
to guide me to the most relevant and varied data. Data analysis coincided with data collection
and consisted of descriptive and thematic analysis to ensure I thoroughly understood the data. A
constant comparative method occurred as data were collected to allow me to develop patterns in
coding in the research and produce recommendations grounded in the data.
I considered reliability and validity throughout the study, and recommended strategies
were used to include triangulation, member checks, and active engagement in the collection and
analysis of data, in addition to peer review, a documented audit trail, and maximum variation
(Merriam & Tisdell, 2015). Findings allowed me to develop a list of recommendations for
BCBAs to acquire the knowledge and motivation to move toward neurodivergent-affirming care.
Additionally, a framework was developed for the course and training content provided in
organizations and recommendations on course content within educational institutions to improve

63
the quality of services provided to the autistic community and increase BCBAs’ self-efficacy to
implement these strategies.

64
Chapter Four: Findings
The purpose of this study was to understand the lived experiences of BCBAs better as they
related to their experiences, challenges, and competencies regarding reform within ABA to move
toward neurodivergent-affirming care. This information relates to their knowledge, motivation,
and the organizational factors influencing them. I was also interested in identifying the influences
of organizations and educational institutions on the knowledge and motivation of BCBAs, as well
as the organizational support in place for BCBAs to reform their practices. I used three research
questions to guide this study:
1. What are BCBAs’ knowledge, motivation, and organizational experiences around
neurodivergent-affirming care?
2. What are BCBAs’ knowledge, motivation, and organizational challenges around
neurodivergent-affirming care?
3. How can BCBAs’ knowledge, motivation, and organizational competencies around
neurodivergent-affirming practices be improved?
Interview Participants
I interviewed eight BCBAs during this study. All met the study criteria: maintaining an
active BCBA certification, being eligible to supervise individuals pursuing certification, having
experience working with autistic clients, and working within an organization of at least 50
employees currently or within 30 days prior to their interview. Table 4 indicates responses to the
three additional questions. Of the participants selected, 50% worked with autistic clients for 7–10
years, and 50% worked with autistic clients for over 10 years. There were seven BCBAs
interviewed and one BCBA-D, and certification dates ranged from 2007 to 2019.
Table 4
Data Retrieved From the Demographic Survey

65
Participant Eligibility pathway Certification
year
Years of experience
with autistic clients
Participant 1 Other: different because it was prior
to the BACB guidelines
2009 10+ years
Participant 2 Graduate degree and behavioranalytic coursework
2007 10+ years
Participant 3 Graduate degree and behavioranalytic coursework
2019 7–10 years
Participant 4 Graduate degree and behavioranalytic coursework
2018 7–10 years
Participant 5 ABAI-accredited or ABAIrecognized graduate program
2018 7–10 years
Participant 6 ABAI-accredited or ABAIrecognized graduate program
2009 10+ years
Participant 7 Doctoral degree and postdoctoral
experience in aba
2017 7–10 years
Participant 8 Graduate degree and behavioranalytic coursework
2019 10+ years
Document Analysis
Document analysis coincided with the interviews. I analyzed documents from five
educational institutions with ABAI accreditation that provide required coursework in ABA and
five organizations that provide ABA services to autistic clients. Educational institutions were
selected based on varied factors, including variations in the number of individuals listed to pass
their BCBA examination on their first attempt. These numbers were used to provide a better
understanding of the number of participants attending. The organizations included those with and
without BHCOE accreditation, variations in the number of employees listed, and all indicating
they had programs for individuals acquiring hours toward certification. Data were collected via
online web pages for each educational institution and company site, in addition to LinkedIn and
Indeed.
When analyzing documents for educational institutions, I looked at the course content
presented in the program to seek course content related to the history of ABA, the trauma that

66
has occurred, autism, and any additional information on ableism and neurodivergent-affirming
care. Document analysis at organizations focused on indicators of neurodivergent-affirming care,
possible ableist language, and the organizational training structure.
Research Question 1: What Are BCBAs KMO Experiences With NeurodivergentAffirming Practices?
My intention to better understand the lived experiences of BCBAs and their KMO
experiences around neurodivergent-affirming practices produced findings in three categories,
with subcategories in each. Categorization began with BCBAs’ knowledge and motivation,
followed by experiences within educational institutions according to the document analysis and
interviews, ending with the organizational factors that influence BCBAs’ knowledge.
Board-Certified Behavior Analysts
Board-certified behavior analysts are the primary focus of this study due to the significant
impact each BCBA has on the goals selected and the approach taken. Data for this section will
consist of eight interview transcripts and documentation analysis on five organizations and five
educational institutions. Analyzing this documentation allowed for a more in-depth
understanding of the influence of organizations and educational institutions on BCBAs’
experiences.
Knowledge
Ethical guidelines established by the BACB bind BCBAs upon certification. Upholding
these ethical guidelines across professional contexts in all activities from the onset of client
engagement and assessment to the end of the professional relationship falls under the
responsibility of each BCBA. The first section of the ethical handbook encompasses the
professional responsibilities that correlate to knowledge. Section 1, code 1.05, highlights the
necessity for BCBAs to practice within their scope of competence:

67
Behavior analysts practice only within their identified scope of competence. They engage
in professional activities in new areas (e.g., populations, procedures) only after accessing
and documenting appropriate study, training, supervised experience, consultation, and/or
co-treatment from professionals competent in the new area. Otherwise, they refer or
transition services to an appropriate professional. (BACB, 2020, p. 9)
This code is followed by 1.06, which requires BCBAs to maintain competence:
“Behavior analysts actively engage in professional development activities to maintain and further
their professional competence” (BACB, 2020, p. 9). Due to our ethical obligations, BCBAs must
operate within their scope of competence. As of June 30th, 2023, 75.39% of BCBAs indicated
that their primary professional emphasis was on ASD (BACB, n.d.-b). To align with the ethical
standards, an assumption would be that 75.39% of BCBAs maintain and further their
professional competence in autism and working with autistic clients. As indicated in Table 4,
data from the demographic survey indicates the approximate years of experience working with
autistic clients of the interviewed participants, with half of the participants stating they had 7–10
years of experience and the other half indicating over ten years of experience working with the
autistic community.
Interview responses indicated varied experiences with training related to autism,
neurodivergent-affirming care, and service implementation. Table 5 provides an overview of
interviewees’ training on autism. Four of eight participants received training on the medical
model of autism through coursework, one of eight received training on the social model of
autism, three of the participants received no autism-specific training, primarily learning on the
job, and one participant did not recall if they had coursework related to autism in their graduate
program.

68
Table 5
Participant Responses on the Training They Received on Autism
Participant 1 2 3 4 5 6 7 8
Formal training,
medical model
X X X X
Formal training,
social model
X
On-the-job training X X X
Note. Participant 7 could not recall if she received training on autism in her graduate program.

69
Neurodivergent or neurodiversity-affirming care training provided a stark contrast to
participant experiences. Of eight participants, Participant 5 was the only one who received
formal training on the social model of autism in her coursework, and Participant 3 was the only
one who had received training on neurodivergent-affirming care when she began in the field,
stating it was likely a result of her supervisor having an autistic brother, “I feel like, from early
on, we were trained to be very neurodiverse-affirming. … We started learning about traumainformed care right when the research was coming out.” However, when she relocated to another
company, Participant 3 stated the experiences and knowledge of the BCBAs were different:
“Lots and lots of physical prompting, lots of compliance goals. … These were things I never
even did. I was never even trained on them from the start.”
Participant 1 had varied experiences and knowledge regarding neurodivergent-affirming
care in the sense that she attended a course with a well-known behavior analyst, who is known
for implementing punishment-based procedures and attempting to eliminate autism or autism
characteristics. Participants 5, 6, and 8 sought additional training related to neurodivergentaffirming care, while Participants 4 and 7 had not at the time of their interviews.
The interview data indicated that BCBAs’ knowledge regarding experiences around
neurodivergent-affirming practices could be higher. In all, 12.5% of participants received formal
training on the social model of autism prior to working with autistic clients, 37.5% received
formal autism training on the medical model of the diagnosis alone, focusing on deficits and
symptoms, and 37.5% did not have formal training, only acquiring the knowledge on the
application of ABA in research or on the job. A lack of knowledge and experience implementing
or understanding autism and neurodivergent-affirming care significantly impacts the autistic
community and increases the risk of harm caused through service implementation.

70
Motivation
Motivational experiences of BCBAs consider several factors from three different theories
in addition to the perspective of ABA. Motivational influences consider the determination to
work toward a goal, continue to work toward it, and the effort required to achieve it (Clark &
Estes, 2008). According to expectancy-value theory and self-efficacy theory, the individual’s
perception of competence and likelihood to succeed emphasize expectation. Self-efficacy differs
in the sense that this perception of competence impacts both the goal and the effort expended
(Bandura, 2000), while expectancy-value theory considers the task value such as relevance to
individual self-schema, the enjoyment the person would get from meeting the goal, the beliefs of
its impact on future success, and the cost (Eccles & Wigfield, 2002).
Interview responses indicated that BCBAs’ varied experiences influenced their
motivation to work toward neurodivergent-affirming care. An unexpected overlap occurred
between Participants 1, 3, 4, and 6. Each stated that parents’ wants and needs influenced their
practice implementations. Participant 3 referenced how this changed based on the area she was
in:
When I was in my last area, all of the parents were very on board with neurodiverseaffirming styles and a very naturalistic, incidental style, whereas in another area, a lot of
parents really wanted that restrictive side, wanting to target stimming and to get rid of it.
Participant 1 elaborated to state specific examples of parent concerns, including
aggression, and the parents’ need to “get this under control.” Participant 6 stated a likely cause
that influenced parents’ experiences: “Our parents are going to be the experts on those little kids,
but at the same time, they are kind of bound by those societal pressures.”

71
Other motivational experiences influencing BCBAs include indicators of fear impacting
self-efficacy. This was highlighted by Participant 2, indicating that they consistently work with
several students who question if they can use different approaches:
I think we need to push this, and people need to be more creative. There are times
somebody will make a suggestion and ask if they can do that. Are you following the
general principles of ABA? Are you being ethical? Will it benefit your client in the long
run? Then, of course, you can do that!
Participant 6 shared similar thoughts:
I think behavior analysts are afraid that reading other journals violates our ethical code. I
find it is important to seek out and understand different perspectives; it improves my
practice and ability to collaborate on multidisciplinary teams. Research from other fields
is not inherently bad, and behavioral research is not inherently good. Behavior analysts
must be able to make sound judgments about the evidence base of our practice.
Participant 5 referenced her experience with BCBAs’ fear caused by other BCBAs, stating the
necessity to “stop judging other behavior analysts.”
The interview data regarding motivation impacting experiences with neurodivergentaffirming care is high. Fifty percent of participants indicated that external individuals had shaped
their experiences, while 38% referenced fear. These data indicate that BCBA experiences are
significantly influenced by motivational factors, with 75% of participants referencing
motivational factors unrelated to organizations or educational institutions. A lack of motivation
significantly impacts the likelihood of succeeding in closing the gap between BCBAs
implementing neurodivergent-affirming practices.

72
Educational Institutions
I analyzed documents from five educational institutions. These are ABAI-accredited
ABA programs, a requirement for BCBA applications by the BACB (2022), and listed on the
BACB site for 2022 BCBA examination pass rates listing BCBAs first-time pass rate ranging
from seven to 765 students (BACB, 2024). As stated in Chapter One, graduate degree program
expectations include content in principles of behavior, research methods, conceptual analysis,
applied behavior analysis, fundamental behavior analysis, and ethics, with the addition of
specialized electives for doctoral courses (ABAI, 2023). The content areas most relevant to the
course content that I focused on were conceptual analysis and ethics. Upon analysis, I identified
no specifications on neurodivergent-affirming care or procedure requirements indicative of a
method in a neurodivergent-affirming care direction. Analysis occurred on descriptions listed for
each course, in addition to the program site, and links referenced to additional sites. Table 6
provides data acquired from the document analysis in the following categories: indicators of
neurodivergent-affirming recommendations, possible ableist language (Bottema-Beutel et al.,
2021), formal autism courses, and trauma references.

73
Table 6
Document Analysis Results From Five Educational Institutions
Educational
institution
1 2 3 4 5
Indicators of
neurodivergentaffirming
recommendations
None
identified
None
identified
None
identified
None
identified
Neurodiversity
definition listed;
neurodiversity
movement listed;
references social
and medical
model of autism;
references
professional work
occurring related
to neurodiversityaffirming care;
link to traumainformed care
Possible ableist
language
None
identified
Etiology
focus for
autism
None
identified
None
identified
None identified
Formal autism
course
No courses
on autism
ABA with an
emphasis
of autism
course
content
No mention
of autism
on site or
course
sequence
No mention
of autism
on site or
course
sequence
Social and
emotional
development
course for
children; autism
elective
Trauma references None
identified
None
identified
but
mentions
review of
“current
problems”
in course
description
None
identified:
course
details not
provided
None
identified
None identified

74
Knowledge
Data indicate educational institutions play a significant role in the knowledge, or lack of
knowledge, related to autism, ableism, and the history of trauma reported by the autistic
community as a result of ABA application. One program had indicators of neurodivergentaffirming recommendations, 60% of the programs did not provide training on autism, and 50%
of the programs that did have formal coursework on autism contained ableist language,
discussing the etiology of autism. Additionally, no programs directly identified reviewing the
history of trauma to improve practices in the course descriptions. Interviewees’ BCBA eligibility
pathways indicated that two had attended an ABAI-accredited graduate program, four attended a
program with a verified course sequence, one attended a doctorate program, and one had a
different pathway because it occurred before the BACB guidelines. Combining data from the
document analysis with the data retrieved from interviewees indicated in Table 5, only 46% of
participants’ education contained content on autism, with only 15% discussing autism through a
social model lens. These data indicate a significant gap in knowledge related to autism,
neurodivergent-affirming care viewing autism through the social model lens, and a possible gap
in education regarding the trauma that has occurred through educational institutions.
Motivation
Interconnectivity between knowledge and motivation signifies the likelihood that a lack
of knowledge regarding BCBAs’ experiences contributes to a lack of motivation. Knowledge
gives an individual the information necessary to set and achieve goals, strengthening their selfefficacy and increasing effort toward the goal set (Bandura, 1997). Additionally, an increase in
knowledge enhances the intrinsic value of achieving a goal. In the event that an educational
institution provided course content on neurodivergent-affirming care, autism from a social model
lens, or trauma necessitating listening to autistic voices, it could lead to situational interest that

75
could allow for the development of intrinsic value or motivation (Eccles & Wigfield, 2002). For
BCBAs to be motivated to engage in neurodivergent-affirming practices, knowledge is essential,
and data indicate that it is lacking.
Organizations: Knowledge
Document analysis was conducted on five organizations that provide ABA services to
autistic clients and employ between 1,000 and over 10,000 employees. They provide 1,500 to
2,000 hours of supervised fieldwork, with 5% to 10% of those hours supervised by a BCBA, as
is required for all individuals pursuing board certification (BACB, 2022). Hour accrual often
occurs at the organization where individuals are employed, and all organizations selected have
programs available for this to occur. Outside of employee certification, organizations are not
required to have specific accreditation to provide ABA services. Because of this, the BHCOE
was established. While organizations are not required to attain BHCOE accreditation, the
accreditation improves the facility’s quality and performance, employee retention, and parents’
satisfaction.
Additionally, there are standards for training programs to become accredited by BHCOE
(2022). Outside of the standards set by the BHCOE, fieldwork hours from the BACB (2022) are
focused on the supervisor, not the organization. I utilized maximum variation sampling and
selected a combination of organizations that did and did not have BHCOE accreditation to
provide a varied range. Table 7 summarizes the document data for three categories: indicators of
neurodivergent-affirming care, indicators of ableist language as indicated by Bottema-Beutel et
al. (2021), and training structure.

Table 7
Document Analysis Results for Five Organizations Providing ABA Services to Autistic Clients
Organization 1 2 3 4 5
Indicators of
neurodivergentaffirming care
None identified None identified Neurodiversity
symbol
Reference to
compassionate
care;
Reference to
neurodiversity
and
neurodiversityaffirming
practices;
compassionate
care; prostereotypy
Possible ableist
language
Person first;
treatment;
obsessive
interests;
symptom
reduction
Refers to autism
speaks; puzzle
piece; treatment
Treatment;
symptom
reduction;
stereotypy
indicated as an
interfering
behavior to
reduce
Decreasing severity
of autism
symptoms,
reference to not
being a cure,
references Lovaas
Puzzle piece;
reference to
functioning levels
(high vs low
functioning) in
video on site
Training structure $1000 CEU stipend;
CEU days; annual
clinical
conference
Free CEUs; annual
clinical
conference; $300-
$1000 stipend
Free CEUs providedFree CEUs Free CEUs; $500
stipend
76

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Organizations providing ABA services to autistic clients play a significant role in the
knowledge and experiences of BCBAs. Data indicate organizations influence BCBAs’
approaches to neurodivergent-affirming care, as Participant 8 described, referencing her
experience with her supervisor at a previous organization: “She was trained in a very military
style of ABA. … Whenever I needed guidance when I found a behavior that I didn’t know what
to do with, her first option was, well, we can try punishment.” She further described her
experience at her next organization: “Then, when I came to this company, everything is positive
reinforcement no matter what, and seeing that it works, it is in there, I wish I could see more of
that across the board.” Participant 3 described similar experiences regarding the knowledge she
acquired at her first organization: “I feel like, from early on, we were trained to be very
neurodiverse-affirming. … We started learning about trauma-informed care right when the
research was coming out.” She said that at her next organization, that was not the case: “The
organization I work for now is a private-equity-backed organization, and I will say they are not
pushing for neurodiverse or trauma-informed care.”
An additional way that organizations influence BCBAs’ knowledge occurs through the
training requirements or opportunities within the organization for both current BCBAs and
individuals working toward certification. Table 7 indicates the training structure identified for
the five organizations selected. These data were retrieved from their websites in addition to
LinkedIn and Indeed job listings. All five organizations indicated that they provided free
continuing education to BCBAs, and this aligned with multiple interviewees’ experiences. One
organization suggested training with indicators of neurodivergent-affirming care, including
compassionate care, in addition to emphasizing that training was inclusive and accepting of
commonly occurring behaviors among neurodivergent members, such as stereotypy. At
organizations that have BHCOE accreditation, BCBAs have access to free training, aligning with

78
the experiences of Participant 7: “I do take advantage of the BHCOE and CASP free
memberships to go through training because a lot of free ones that are on there have been
helpful.” I accessed the BHCOE training platform available to employees of a BHCOE
organization. As of May 26th, 2024, 138 training sessions were available, five of which were
related to ABA approaches working toward neurodiversity-affirming care: two trauma-informed
care, two assent-based approaches, one person-centered care, and one on neurodiversityaffirming care. As of May 26th, 2024, CASP had 75 courses available, with five related to
neurodiversity-affirming care: two trauma-informed care, one on an assent-based approach, and
two compassionate care with clients training.
Data indicated that BCBAs may have access to training aligned with reforming ABA
practices at the organization. However, free resources analyzed were limited to organizations
with BHCOE accreditation; training was 4% of the training available, and the BCBA would have
to search for the training themselves. Outside of BHCOE resources, one of five organizations
promoted compassionate care training, indicating it is a prominent training for BCBAs at these
organizations. Excluding Organization 5, data on the four others and the participants’
organizations did not indicate an inclusion of this training.
Another barrier identified was that all of the organizations analyzed, as indicated in Table
7, contained possible ableist language, including labeling interests as excessive, indicating ABA
as a treatment for autism, utilizing a puzzle piece often associated with autism (indicated as
harmful to the autistic community), level of functioning terms, and utilizing ABA to reduce
symptoms of autism (Bottema-Beutel et al., 2021). These data indicate a strong likelihood that
BCBAs at these organizations do not have access to training resources and support aligned with
neurodivergent-affirming care, so they must seek the training content independently. Without the

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organization instructing them on the need to do so, I assert that the likelihood of this occurring is
lowered.
Research Question 2: What Are Behavior Analysts’ KMO Challenges Around
Neurodivergent-Affirming Practices?
I analyzed findings related to BCBA’s KMO challenges around neurodivergent-affirming
practices by following the previous pattern of breaking findings into three categories, with
subcategories in each. This began with BCBAs’ knowledge and motivation challenges using data
from interviews, followed by findings resulting from a combination of interviews and document
analyses regarding challenges acquiring this knowledge within educational institutions and
challenges related to organizations and their influence on BCBAs’ knowledge, motivation, and
resources.
Board-Certified Behavior Analysts
Challenges implementing neurodivergent-affirming care for BCBAs directly relate to the
knowledge they gained in their ABA programs, their organization, and their ability to seek out
the knowledge on their own. In response to the skills necessary to be an effective BCBA,
Participant 7 stated, “Having that drive to always see what else is out there… not being content
with where you’re at.” I wanted to better understand what affects that drive, what types of
avenues BCBAs would be willing to acquire that knowledge, and what could prevent that from
occurring. This influence occurs in relation to their knowledge seeking, acquisition, or
knowledge limitations, their motivation to acquire knowledge related to neurodivergentaffirming care, and to set and achieve goals to modify their practices. Before this analysis, I will
present the requirements for BCBAs to maintain certification related to possible obstacles.
Knowledge acquisition is acquired through different avenues for BCBAs, often beginning
at an educational institution or organization and continuing through an organization, in addition

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to mandatory continuing education. To maintain certification, the BACB (2022) outlined specific
criteria for BCBAs. BCBAs are required to complete 32 CEUs every 2 years in addition to
adhering to the BACB’s ethical requirements. The CEU specifications include four ethics CEUs
and three supervision CEUs and are intended to ensure BCBAs remain up to date in the research
and expand their knowledge and skills. The BACB includes additional specifications:
“Continuing education may address any aspect of behavior analysis: practice, science,
methodology, theory, or the profession. CEUs must cover material that goes beyond the current
BCBA/BCaBA Task List and coursework required to sit for the certification examinations”
(BACB, 2022, p. 40). These CEUs can be learning CEUs acquired through training with an
authorized continuing education (ACE) provider, ABA graduate courses, teaching at an ACE
event or ABA course, or scholarship such as publishing an article. I conducted a document
analysis on the requirements for an ACE provider course requirements, and the BACB (2022)
included the following information on the necessity to ensure topics are behavior-analytic:
Behavior-Analytic in Nature: The majority of a Learning CE event must cover content
that is behavior-analytic in nature. For example, an event covering characteristics and
diagnosis of ASD is not appropriate for Learning CE. However, an event covering
techniques for safely conducting functional assessments of stereotypic behavior is
appropriate. (p. 2)
This information is included in response to the research question addressing KMO
challenges because of the influence it can have on BCBAs seeking training as a part of their
mandatory continuing education on topics necessary to understand the necessity of
neurodivergent-affirming care and, in some instances, the training on what neurodivergentaffirming care is. Additionally, this influences the likelihood BCBAs would acquire knowledge
on autism from a social model lens, ableism, and trauma that has occurred, with the probability

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that this training would meet the CEU requirements outlined by the BACB, impacting their
knowledge and motivation.
Knowledge
Knowledge challenges influencing BCBAs’ likelihood of implementing neurodivergentaffirming care include multiple aspects. Participant 3 stated,
It’s also important to acknowledge that there are a ton of clinicians out there that have not
made that shift, or don’t have access to this new research, just for whatever reason,
they’re unaware, or they don’t have a mentor who’s showing them it’s out there.
Participant 3 expressed a possible cause for this challenge: “I think there’s a really big lack of
mentorship for new BCBAs and for mid-level supervisors who are not yet BCBAs.”
Participant 5 identified an additional challenge in response to a question regarding her training
on neurodiversity or ableism: “I learned for myself. … I’d have to find different avenues. …
There wasn’t anything that was formal that was ever brought up, not even with companies.” She
stated, “They’re almost all to expand my knowledge. There’s nothing that was for CEU credit.”
Participant 6 stated that knowledge challenges go further than what others expressed:
Many behavior analysts appear to prioritize procedures and rules in practice. Singlesubject research is about replication and synthesis; we cannot simply cherry-pick
methods from individual studies without understanding the larger scientific consensus.
When we overemphasize methodology, we miss opportunities to be responsive to our
learners to create a more joyful learning experience and accelerate progress toward
valued outcomes. But data in practice doesn’t need to look like research. Behavior
analysts need effective training to balance being both a scientist and a practitioner.
Data indicate that the limited resources available to BCBAs result in a lack of knowledge,
presenting challenges in implementing neurodivergent-affirming care. Due to the BACB

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expectations for what counts as continuing education, the education necessary to understand the
necessity to reform practices and the steps to reform practices would need to occur in addition to
CEUs necessary to maintain credentialing. BCBAs would likely need a mentor to educate them
on these practices and how and where to seek support to ensure participants were meeting the
BACB guidelines to operate within their clinical scope, creating an additional challenge for
BCBAs to implement neurodivergent-affirming practices.
Motivation
Motivational challenges impacting BCBAs’ ability to implement neurodivergentaffirming practices align with knowledge challenges in multiple aspects. A BCBA’s self-efficacy
contributes to the likelihood of implementing neurodivergent-affirming care in both outcome and
efficacy expectations and ties closely to the BCBA ethical standards. If an individual does not
feel competent in an area, they are not allowed to implement it. An individual who does not feel
competent in an area is not allowed to implement it, and if they do not feel competent and
confident in their skill set, their effort expenditure and persistence toward their goal decreases
(Bandura, 2000). In response to a question regarding reforming her practices, Participant 4
stated, “I don’t feel like I have enough training to do it. I’ve taken training on one, but I still feel
like there’s a lack of resources and information.” Another challenge associated with reforming
practice could be related to length of time in the field and the education acquired when entering
the field. On this topic, Participant 4 stated, “I feel like a lot of BCBAs are still stuck in their old
ways. … I do think resources are out there, but we are not seeking them enough; our older
BCBAs are not seeking them enough.” Participant 1 shared similar challenges, noting her initial
training and a specific instructor: “I was more of a strict behavior analyst, very [discrete trial
training table work]. That’s how I started, and I have become a lot more kind of a mainstream
behavior analyst.”

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Participant 2 shared similar perspectives, as an individual who had been in the field for
multiple decades, regarding his challenges with initially acquiring training in autism” “We didn’t
do anything… it wasn’t as big a deal as it is now.” This led Participant 2 to seek a significant
amount of additional training and surround himself with others knowledgeable in this area, and
even with the additional knowledge, Participant 2 still appeared to struggle with his confidence
related to neurodivergent-affirming. He stated, “I try, and I think I am achieving? I know there
are areas I’m probably not, maybe as sensitive as I should be, in terms of how things are, but
yeah.”
An additional challenge to BCBAs’ motivation to reform their practices references the
additional time it could take to see behavior change. In response to a question about any
limitations to modifying practices based on feedback from the autistic community, two
participants identified a decreased rate of skill acquisition. Participant 7 stated, “I think
limitations would be the rate at which we can make progress.” She discussed the role of
insurance in the process:
If we were to limit certain things, it would be the rate of learning because we are bound
by insurance companies, and so what limitation that would be set based on the autistic
community, I think, would go against what insurance is requiring us to show in order to
be able to continue.
Participant 8 reflected on her practices and stated that there were no limitations to
reforming practices but that families did consider the time it could take to be successful: “They
would see the progress faster because we used punishment.” However, the use of punishment,
defined is discouraged and only indicated as acceptable by the BACB (2020), once a BCBA has
demonstrated that a less intrusive method was ineffective.

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Data indicate motivation challenges include the belief that reforming practices could
result in a slower rate of progress for clients, decreasing their motivation to modify practices.
Additionally, data indicate that BCBA’s experience correlates with both their competence and
confidence in implementing practices, often acquired outside of school, requiring participants to
seek them out independently. Because neurodivergent-affirming content, including content
related to autism through a social model lens, ableism, and the history of trauma in ABA is not
required content of ABA coursework (ABAI, 2023), and several factors do not align with the
expectations set by the BACB (2022) for continuing education, this impact on the motivation of
BCBAs is significant, reducing the likelihood of seeking this content independently in addition
to the 32 CEUs required by the BACB to maintain certification.
Educational Institutions
Analysis of data from five educational institutions and interviews indicate significant
challenges that hinder BCBAs’ ability to implement neurodivergent-affirming practices related
to knowledge acquired at educational institutions. As stated in relation to BCBAs’ knowledge
experiences with educational institutions, combining data from the document analysis with the
data retrieved from interviewees, only 46% of participants’ education contained content on
autism, with only 15% discussing autism through a social model lens. Schools are often BCBAs’
first formal education and training on ABA service implementation, with currently 75.39% of
BCBAs indicating a professional emphasis on autism. However, only 40% of the ABA programs
in the identified educational institutions had training on autism. In addition to this, half of the
schools contained ableist language, presenting challenges in the foundational knowledge BCBAs
receive, in addition to damaging their motivation without the knowledge of the necessity to
reform practices.

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Organizations
Organizations play a pivotal role in BCBAs’ success, including their ability to acquire the
education and training needed to reform their practices and their capacity to succeed in this
endeavor. According to the data on five organizations (Table 7), all organizations indicated some
component of free CEU content or a supplemental stipend to allow purchase of their own. Sixty
percent of organizations included in the document analysis provided CEU stipends to allow
BCBAs to seek training, while all indicated that they had some form of free CEU courses. All
interviewees had one or the other access to select training courses for free, such as BHCOE
courses or a CEU stipend that they could use when selecting their own.
To meet the eligibility criteria to apply to the BACB to sit for the BCBA exam,
individuals must acquire 1,500 to 2,000 supervised fieldwork hours. Supervision must occur
from a qualified supervisor and consist of 30 to 130 hours of fieldwork experience a month, and
the hour accrual can extend up to 5 years. Fieldwork hours can include working directly with
clients for no more than 40% of the total hours and engaging in activities normally performed by
BCBAs directly related to behavior analysis, and specifications are provided on the nature of
supervision and the responsibilities of the supervisor. The supervisor’s responsibility is to
provide content only within their defined competence areas. The BACB places the responsibility
of supervision on the supervisor and the trainee, not on the organization where the BCBA or
trainee is employed, although the organization plays a significant role in these individuals’
training and development. This creates multiple challenges for BCBAs and trainees, and several
of these challenges were presented throughout participant interviews. These challenges included
information specific to knowledge, some indicators of motivational influences, in addition to
organization-specific barriers that impede BCBAs’ ability to dedicate time to the additional
training and modify their practices.

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Knowledge
Participant 3 highlighted the influence of organizations on the practices of BCBAs when
discussing her experiences at her first organization in comparison to her second. While her first
organization provided training and support related to neurodivergent-affirming care, participant
3’s challenge was when she moved to a new organization that did not: “They were still doing lots
and lots of physical prompting, and a lot of compliance goals. … These are things that I never
even did, you know. I was never even trained on from the start.” Participant 8 had a comparable
experience, working at an organization that utilized more aversive strategies, stating when
seeking support regarding her unsuccessful attempts to address a specific behavior, “her first
option was like well, we can try punishment, it worked for her so then I was like well, I guess
that’s the only option we have.”
Knowledge deficits of BCBAs within an organization also influence BCBAs’ ability to
train. Participant 4 experienced this operating as a supervisor of BCBAs who used their
knowledge deficits as the rationale for not training individuals accruing hours, stating her
BCBAs would provide the following rationale: “This supervisee is interested in learning AIM or
ACT [two strategies with more emerging popularity], but I don’t know much, so I told her that I
can’t support her.” Participant 4 attributed this to BCBAs’ capacity: “They have so many other
things to do. They have big caseloads now, everywhere you go.”
Additional challenges expressed by participants on their ability to modify their practices,
or the practices of other BCBAs, referenced mentors, supervisors, and other individuals they
work with within the organization. Participant 7 expressed the importance of the knowledge of
the people in one’s organization:
It stems from within that organization, of having somebody who’s had training to be able
to talking about those different assessments and curricula, if you’re working for a smaller

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company, and even the owner hasn’t had experience in practice, they’re not going to pass
that down to the BCBA.
Participant 7 explained a challenge with organizations limiting the age range of clients
individuals accruing hours are learning on:
That’s what they are producing. They’re producing BCBAs who don’t know how to do
social skills, who don’t know how to work with kids who need to learn those abstract
skills that are very difficult to teach, and they don’t know how to work with kids who
have more aggression.
Data indicated that knowledge related to organizational barriers significantly impacts
BCBA’s ability to implement neurodivergent practices, in addition to their ability to train people
to acquire hours to implement neurodivergent-affirming practices. Participants 3, 4, 5, 6, and 8
all expressed working at an organization that did not provide the knowledge necessary to reform
practices, and 20% of organizations selected for document analysis included information on
strategies aligning with neurodivergent-affirming care on their company pages. Challenges for
BCBAs relate to the lack of knowledge provided within the organization to BCBAs, resulting in
inadequate training in relation to neurodivergent-affirming care and the necessity to reform
practices to individuals accruing hours.
Motivation
Motivational challenges influenced by organizations across interviewees consist of the
following themes: confidence (referenced under the BCBA portion), response effort, cost, and
reward. To prevent redundancy, I will not emphasize the ones discussed in the BCBA section,
specifically regarding self-efficacy, which could be attributed to the organization but is not
necessarily the organization’s responsibility and is detailed under knowledge.

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Response effort and cost played a significant role in the organizational challenges the
participants discussed. Organizations often provide free CEUs limited to specific learning
platforms, such as BHCOE, or a continuing education stipend to BCBAs. 60% of the
organizations selected for the document analysis provided continuing education stipends to their
BCBAs, and 50% of the participants indicated they worked at an organization that provided
stipends for continuing education. Participant 3 indicated that the response effort of utilizing her
stipend was too high: “I haven’t touched my stipend because it is so much effort to pay for things
and get them reimbursed. The level of effort for the reward, I’d rather just do something free.”
Participant 4 shared a similar perspective, stating that while BCBAs have a stipend, “they have
to send it for approval, BCBAs pay for it, and they get reimbursed.”
Another factor influencing BCBA’s motivation to reform is rewards. To effectively
achieve a goal, rewards are often associated with increased motivation across motivational
theories. Attribution theory emphasizes both internal and external causes, with a belief that these
influence future action (Weiner, 1985). In ABA, specifically operant conditioning, there is a
focus on what occurs immediately after the behavior, referred to as the consequence. When the
behavior is reinforced, either by negative reinforcement, such as escaping an aversive stimulus,
or positive reinforcement, such as receiving a reward, it increases the likelihood that the behavior
will occur in the future (Mayer et al., 2014). This plays a significant role in human behavior and
the ability to achieve goals and ties directly into organizational challenges that could be barriers
to BCBAs implementing neurodivergent-affirming care. Organizations often attempt to reinforce
BCBAs based on the number of hours they bill versus the quality of services. Participant 4
referenced her experience as a clinical director at her current company: “If they hit 27 [billable
hours], they start getting bonuses, but 30 is the standard. I have to basically push them to bill 30,
but if they start billing more, then they start getting more.” She stated this had been her

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experience in her past organizations: “I feel like everywhere they are doing it like that now.”
Participant 8 expressed that these billing expectations have been a significant challenge
throughout her career: “The main issue, it has always been finding the company that values the
kid more than the billing process and a billing machine,” supporting the emphasis on billing
expectations within organizations providing ABA services.
Organizations play a large role in the motivation of their employees, and because of the
large role they play in the education of BCBAs, it directly impacts BCBAs’ motivation to
acquire new skills and modify their practices. According to data acquired through BCBA
interviews, the response effort, cost, and rewards impact BCBAs’ motivation. The BCBAs
appear to be more likely to seek free training resources because of the response effort required to
submit for reimbursement and limited funds if the organizations do not provide a stipend.
Depending on the free resources available at the organization, this significantly limits the
likelihood of a BCBA receiving training on neurodivergent-affirming care, presenting a
significant challenge to reforming practices. Additionally, organizations providing bonuses off of
billables versus quality of service implementation emphasize billing versus learning. The more
hours a BCBA is billing, the less time they would have to dedicate to expanding their knowledge
to have the ability to modify their practices.
Organizational Supports
With exceptional knowledge and motivation, BCBAs could only modify their practices
working within an organization if there were adequate resources and support (Clark & Estes,
2008). A common theme in the challenges the participants faced in reforming their practices was
a need for more organizational support and capacity due to organizational expectations.
Participant 3 expressed, “You get this huge sign-on bonus once you’re a BCBA, and you get all
these cases that you can’t handle.” When asked if she felt her organization provided the support

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and resources needed to help people move toward neurodivergent-affirming care, Participant 4
stated, “To be honest, no.” She then stated, “BCBAs have up to eight, nine, 10 kids because it
comes down to how many hours they are billing.” When asked what she felt was the biggest
challenge related to reforming practices within an organization, Participant 4 stated, “Time is the
biggest one. Because if you’re done with work, you don’t want to do anything.” This was
reflected in a response from Participant 5:
It’s just really easy to forget how busy we are … or how easy it is to fall behind on stuff.
Our lives are in a cycle, our life cycle is explosion, explosion, explosion, explosion, we
are doing okay, things are getting a little better, this is nice, and then explosion.
Data indicate organization support and resources are a significant challenge to BCBAs
because of higher caseload numbers and the level of work required to support the high number of
clients on their case; BCBAs have limited capacity to modify their approaches in a way that
allows them to succeed if the organization is not supporting that change.
Research Question 3: How Can Behavior Analysts’ KMO Competencies Around
Neurodivergent-Affirming Practices Be Improved?
This section presents the findings related to BCBAs’ KMO competencies regarding
improving practices to become more neurodivergent-affirming by breaking findings down into
two categories: BCBAs and Organizations. This will begin with BCBAs’ knowledge and
motivation improvement recommendations using data from interviews, followed by
recommendations on improving organizations to better support BCBAs moving toward
neurodivergent-affirming practices. This section excludes educational institutions because data
were not acquired to support assertions from interviewees, so I will focus on this in Chapter Five
recommendations.

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Board-Certified Behavior Analysts
The interviewees provided feedback on improving BCBAs’ abilities to implement
neurodivergent-affirming care in relation to KMO support, which allowed me to identify patterns
and themes in the data analysis. This section will focus on knowledge and motivation
recommendations, and organizational improvement recommendations will occur in the
organization category to prevent redundancy.
Knowledge
The interviewees discussed multiple possible avenues to improve BCBAs’ knowledge
regarding neurodivergent-affirming care and the necessity to reform practices. Common themes
included decreasing the response effort required to locate a broader range of training, increasing
the BCBAs’ flexibility and collaboration, and emphasizing autistic perspectives in our practices.
Most (63%) interviewees referenced the necessity of listening to autistic voices to modify
practices. Participant 1 stated, “I think we are headed in the right direction. I do believe that
having more autistic voices can be really, really helpful to help us shape our programming and
the way that organizations operate.” Participant 6 had a similar recommendation: “We need to
invite and truly hear neurodivergent voices within ABA programs, organizations, research, and
in our field as a whole.” This was also parroted by Participant 8: “Being open to the changing
process of the field, and being open to listening to other neurodivergent people who can open
your eyes.”
Increasing flexibility for BCBAs was another standard recommendation of interviewees.
This began early in interviews with Participant 1, stating the necessity to “think more broadly,
besides just the narrow confines of ABA,” in addition to recommendations. Participant 1 stated
that she “continues and encourages her staff to suggest new things or a different way of thinking”
while including the benefits of hiring a diverse team. Participant 2 referenced the necessity to

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encourage flexibility and creativity in his students. In addition, Participant 6 referenced the
importance of having a growth mindset:
We must recognize that the world extends beyond our individual training and
experiences; we must continuously strive to be more adaptable, collaborative, and
inclusive. Behavior analysts need to be grounded in science, yet willing to compromise
based on the needs and feedback of the individual people and communities we serve.
In addition to flexibility, multiple participants stated the necessity to be lifelong learners, eager to
learn, working to continually improve, and the benefits of collaborating with other professionals
within and outside of ABA.
Motivation
Recommendations for improvement from interviewees regarding motivation were limited
outside of organizational influences discussed in the following sections. However, Participant 6
had multiple recommendations on what the motivation improvements could be:
If we really just see this as an ongoing evolution of human rights. … I think in the past
most services are because people come with a problem. They tend to be problem or
deficit focus and I think that all forms of education need to be just more focused on
building a good quality of life for that individual. I have a huge problem with the
indistinguishable from peers’ outlook and trying to eliminate autism. … I think our field
has to be super honest about the fact that that was a part of our evolution to here, and I
don’t think it’s ABAs fault. I think it’s a societal thing. I think what we’re seeing in terms
of advocacy within the neurodivergent community is really just an extension of disability
rights overall, I think the ball is going to keep rolling, but we need to stay on that. We
can’t say oh, well, we are being criticized by things that happened in the past. We have to

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recognize that was true. Times were different, let’s learn from that and keep the ball
rolling forward.
This response highlights the necessity to consider disability rights in practices and aligns
with the necessity to utilize CDT as a framework for this study. Additionally, it emphasizes the
need to look at autism through a social model lens, educate ourselves on our history and the
history of our field, and lean into that discomfort to modify our practices. Participant 8
referenced this during her interview. Initially, she attempted to dismiss the feedback before
leaning into it and recognizing the hurt that initially occurred when she did:
You read one, and it kind of stings or hurts, and you stop, then, you’re, like, no, I want to
know more, to know what exactly happened that made them feel that way. So it’s
interesting because you learn so much from all the reading that it doesn’t hurt me. It
doesn’t hurt anymore. It helps me see things differently and try to do better every day
with the kiddos.
Organizations
Competencies around how neurodivergent-affirming practices can be improved within an
organization varied based on interview participant responses. Primary improvement
recommendations from participants referenced mentors, leadership, training and access, and
funder requirements.
A common theme among participants was referencing funders and private equities and
their influence on BCBAs’ success. Participant 3 referenced the necessity to get organizations
behind it: “There’s no escaping private equity, the huge corporation businesses, if they could get
behind it, and funders could somehow get behind it, it would be super helpful.” She also
referenced increasing the number of free resources regarding neurodivergent-affirming care
because the response effort of using stipends that required using personal funds before

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submitting approval to get reimbursed provided by organizations is often too high that BCBAs
often turn toward free resources. This sentiment was echoed in Participant 4’s responses as well.
When asked how organizations could better support, she stated, “Money to buy CEUs,” in
addition to the necessity to provide BCBAs with the time needed to take the CEUs.
I asked Participants 5 and 8 what they felt influenced BCBAs’ ability to adjust their
practices. They emphasized leadership and culture. Participant 8 also stated,
I think if you’re going to have a business in ABA working with autistic kids, what better
way than to have a neurodivergent person in the organization to help you guide the
organization and to have leaders who are actual BCBAs?
This thought was also echoed by Participant 6: “We need to be hearing and soliciting
more neurodivergent voices within organizations.” Participants 4 and 6 also felt an important
aspect was modifying training practices, with Participant 6 stating, “I think that it’s super
important for us to train behavior analysts that can look at our learners at the human level.”
Participant 7 focused her feedback on the training in relation to the age and abilities of the clients
BCBAs are learning on, the heavy emphasis on early learners, and the necessity to shift that:
They don’t know how to work with kids who have more challenging behaviors, who have
more aggression, because they say they don’t want the liability, they don’t want to have
to pay to train their staff, so we aren’t going to work with that clientele.”
She emphasized the need for this change by stating that they “are limiting the types and the
number of services that half of this population can access.”
Data indicated that organizations need to modify their training practices, access to
training, and expectations for active BCBAs and individuals acquiring hours toward certification.
Additionally, data indicated that organizations would benefit from having more exposure to
neurodivergent perspectives and that having an autistic person on staff to help shape practices

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could benefit BCBAs in reforming their practices. Lastly, culture and leadership within an
organization significantly contributed to the effectiveness of BCBAs reforming their practices.
Summary
I interviewed BCBAs and analyzed documents from five educational institutions with
approved ABA programs and five organizations providing ABA services to autistic clients.
These data were acquired to answer the research questions on BCBAs’ KMO experiences and
challenges around neurodivergent-affirming care, in addition to their competencies on how
practices could be improved. Data analysis pertained to BCBAs, educational institutions, and
organizations focusing on KMO support. Overall, BCBAs KMO experiences indicate there is a
lack of knowledge on autism, neurodivergent-affirming care, and ableism, and this is reflected in
the data acquired from organizations and educational institutions. Data indicated that BCBAs’
KMO challenges related to the lack of knowledge on autism and neurodivergent-affirming
practices and that it is often a result of inadequate resources, a lack of accessibility of resources,
in addition to motivation related to the pace of skill acquisition, and their confidence to modify
practices.
Educational institutions and organizational challenges mirrored BCBA challenges, with
several additions related to organizational factors, including inadequate training on
neurodivergent practices and competing motivational factors tied to organizational priorities and
expectations. Lastly, regarding BCBA’s KMO competencies around neurodivergent-affirming
practices and how they can be improved, data show a necessity to increase BCBA’s flexibility in
seeking additional training and resources, the necessity to modify training and ensure a humanfirst approach is used in addition to organizational modifications necessary to improve practices.
Organizational modifications include modified training practices, aligning with both BCBA and
educational improvement recommendations, modifying expectations to allow for more training

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opportunities, and seeking autistic perspectives within the organization. Data acquired allowed
me to provide several recommendations to BCBAs, educational institutions, and organizations
providing ABA services to move toward neurodivergent-affirming practices, which will be
discussed in Chapter Five.

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Chapter Five: Recommendations
This study aimed to develop a better understanding of the lived experiences of BCBAs as
they relate to their KMO experiences, challenges, and competencies around neurodivergentaffirming care within ABA. This included the role of educational institutions and organizations
in acquiring the knowledge necessary to implement neurodivergent-affirming care and the
influence of motivation on knowledge acquisition and application. Before conducting this study,
research gaps indicated the necessity to identify these influences to develop a framework to
better support BCBAs in acquiring knowledge and increasing their motivation. The findings
indicated in Chapter Four allowed me to determine influences on BCBAs’ ability to implement
neurodivergent-affirming care related to the lack of knowledge provided by the organizations
and educational institutions, decreasing motivation, in addition to differing perspectives on the
organizational supports impacting BCBAs’ ability to acquire these skills, and the role
organizations have on providing this content to individuals working toward certification. This
information has allowed me to develop four recommendations. These recommendations will be
discussed after reviewing the likely impact if reform does not happen to support this study’s
necessity.
Potential Impacts of Not Reforming
When considering the effects of reforming or not, there are three different perspectives to
consider: the community we serve, the ABA field and its future, and the organizations providing
services. Data are limited regarding these effects, which is part of what led me to begin this
study. I will be discussing the consequences of not reforming based on this study’s findings,
additional platforms regarding ABA opposition for clients and providers, and the cost of services
based on data acquired on insurance funding.

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Impact on the Autistic Community
The current impact on the autistic community, as mentioned previously, is trauma. In
addition, there is potential for the number of families seeking services for their children to
decrease as more information from the autistic community associates trauma and ABA. Chapter
Two discusses the trauma that has been reported as a result of ABA implementation in detail, in
addition to the necessity to ensure autistic clients are getting the care and support they need to
increase their independence and support a high quality of life.
Impact on the Field of ABA
When conducting a Google search of “applied behavior analysis,” the first post was from
Autism Speaks, which lacks support from the autistic community (Autistic Self Advocacy
Network, 2023). This is followed by pages of research supporting ABA, organizations providing
services, and educational institutions providing education to become certified in ABA. The
Thinking Person’s Guide to Autism (Des Roches Rosa, 2020) discusses trauma due to services
and cautions parents against medical recommendations to place their children in the services
because of the likelihood of trauma and the emphasis on compliance (Des Roches Rosa, 2020).
A parent who looks up trauma in ABA would find multiple first-person perspectives on trauma
that occurred through ABA, comparing it to conversion therapy and discussing the necessity to
abolish ABA. As a newer field, this could significantly impact the number of families that seek
services, an increase in children and adults being traumatized, individuals reporting trauma, an
increase in employees unintentionally causing trauma, and a potentially short life span for the
field overall as a result.
Impact on an Organization
The following sections will address the potential impact on an organization in two ways:
staff retention and the quantity of clients served.

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Impact on Staff Retention
As of July 1, 2024, the BACB reported 69,645 BCBAs. In the last 5 years, the number of
BCBAs has increased by 54% from 37,859 BCBAs to 69,645. When researching the shift in
ABA and the divide between BCBAs who are pushing for reform versus BCBAs who may not
feel it is necessary, there is an indicator that newer BCBAs tend to lean toward reform, while
more established BCBAs who have been in the field for a significant amount of time, appear to
dispute the necessity or have concerns regarding data reliability of personal accounts of trauma
occurring (e.g., Leaf et al., 2011). This was also indicated in the interviews, where two
participants emphasized the impact older generations had on the ability and necessity for
reforming services. Because of the significant increase in newer BCBAs and the higher
prevalence of trauma reports coming out from the autistic community, there is potential for an
increase in turnover for organizations not moving toward reform or providers leaving the field
because of the harm that has occurred or continues to occur. Multiple online sources document
this phenomenon: Stop ABA, Support Autistics: Why Professionals Behavior Analysts are
Leaving the Field (2019); Socially Anxious Advocate: Why I Left ABA (2015); I am a
Disillusioned BCBA: Autistics are Right About ABA (Ram, 2020). Additionally, when
negotiating insurance rates, the primary service payment method, employee turnover impacts the
organization’s ability to increase rates for insurance claims.
Impact on Quantity of Clients Served
In all, 75.39% of BCBAs have a professional emphasis on working with autistic clients
(BACB, n.d.-b). The primary source of income for organizations providing ABA services is the
billable services provided, primarily paid by insurance companies or at great expense to the
client’s family. Table 8 represents an example of the income generated by a single client
(dependent on funding source) and the number of hours provided, reflecting that ABA is known

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for its higher intensity of service implementation. This began with Lovaas’s (1987) statement
about the benefits of 40 hours a week for autistic clients. However, the hour range can vary
significantly depending on the client’s needs in addition to the organization’s expectations. The
table highlights the range of hours often provided within organizations: 10 to 40 hours per week.
Additional factors include the necessity to provide 20% oversight in addition to caregiver
guidance (BACB, 2020).

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Table 8
Sample Income for an Organization Serving Autistic Clients
Insurance BCBA
assessment
cost range
(6–8 hours
biannual)
Direct
therapy
(15 min
units)
BCBA
protocol
mod
(15 min
units)
Caregiver
guidance
(15 min
units)
Weekly income range
per client
*10–40 hours of DT,
20% supervision, 1 cg
per week
Aetna $900–$1200 $25 $37.50 $37.50 $1450–$5350
Anthem $859–$1145 $28 $34 $34 $1528–$5704
Beacon $920–$1227 $29 $37.50 $34 $1596–$5976
BCBS $1350–$1800 $25.70 $35.60 $36.50 $1458–$5397
Cigna $1700–$2267 $24.60 $38.50 $38.50 $1446–$5322
Evernorth $1515–$2020 $26 $30 27.50 $1390–$5230
Magellan $2100–$2800 $30 $40 $40 $1680–$6240
Optum $846–$1128 $32.75 $38 $38 $1766–$6608
Tricare $915–$1220 $29.80 $37.50 $37.50 $1642–$6,118
United Health Care $855–$1140 $28.50 $37.50 $37.50 $1590–$5910
Private pay $900–$1200 $18.75 $37.50 $37.50 $1200–$4350
The information in Table 8 is separated into commonly billed units of 15-minute
increments for 10 and 40 hours of services, in addition to BCBA supervision totaling 20% of the
direct therapy hours and 1 hour weekly of caregiver guidance, with the total income range in the
column on the right. These numbers do not include the cost of service in the organization, such
as staff salary. As indicated by Table 8, one client receiving 10 hours of services a week
produces, on average, $81,832 of income a year. One client, receiving 40 hours of services a
week, with the recommended oversight, produces $296,561 of income a year. Depending on the

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size of the organization, and the number of BCBAs on staff, the profit to the organization can
vary significantly. Many organizations require a range of BCBA billable hours and a number of
client hour oversight they must have. A typical range is clients totaling 200 hours a week,
producing, on average, $1,469,173 a year of revenue.
Because data were not available on the number of families turning away from ABA due
to trauma, I located data regarding the loss of potential income. According to a survey sent to
160,000 email subscribers of Autism Parenting Magazine, 72.4% identified as parents of autistic
children, and 36.5% of families reported they have their children in ABA. Also, 93.7% reported
that they would recommend ABA to other autism caregivers (Elfer, 2024). Whether an
individual focuses on the total number of parents who have children who do not attend ABA or
the number who would not recommend it to others, the potential loss of income is substantial. In
a study examining patterns of services received and patient outcomes, 334 participants were
selected with the outcome measure of length of time in services and adaptive behaviors. In this
study, 66% of participants remained in therapy for 12 months, and 46% remained in services for
24 months. Another study indicated that 31% of participants discontinued services, regardless of
the insurance coverage for ABA, with 18 other studies noting both low utilization rates and high
rates of discontinuing services (Choi et al., 2022). Choi et al. (2022) recommended future
research to explore the reasons for high rates of service discontinuation in ABA, even though
studies support services and the higher intensity producing high outcomes.
In her journey to discover the impact of trauma on individuals receiving services and how
it relates to organizational success, I located an autistic-led social media page created in 2018.
This group is described as autistic-led and used for parents and caregivers with autistic children
to ask questions and better understand how to support their children. This group is centered
around autistic voices, and at the time I accessed the group, it had over 159,000 members. To

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access the group, an individual must follow the group’s rules. Of the ten rules provided, the 3rd
rule is that members are not allowed to have discussions supporting ABA. When someone agrees
and accesses the page, they will quickly discover that once it is mentioned, it is tied directly to
trauma and shares resources on how to access more information on trauma, with 64 anti-ABA
posts shared with the members in the month I accessed it. I am a part of this group to learn how
to better understand and support my son and respect the rules of the group and the opinions of
the autistic individuals in the group. This information is provided as an example of the
prevalence of the opposition to ABA and the number of families with recently diagnosed
children who join this group and receive this information, likely influencing their decision to
seek or continue services. Of these posts, multiple families are discussing that they have pulled
their children from ABA very recently due to the methods utilized and trauma occurring.
Discussion of Findings
Research findings outlined in Chapter Four identify KMO supports that influence
BCBAs’ ability to implement neurodivergent-affirming care, and educational institutions and
organizations contribute to these influences. Research findings align with the conceptual
framework chosen for this study, outlined in Figure 1, in all facets. Aligning with CDT, for
BCBAs to effectively implement neurodivergent-affirming care, understanding the trauma that
has occurred as a result of services, ableism and the harm it causes, and viewing autism through
the social model lens is pivotal. This is the foundational knowledge necessary to increase
motivation to acquire additional knowledge to implement neurodivergent-affirming care.
Knowledge and motivation play a pivotal role in implementing neurodivergent-affirming care.
Acquiring knowledge consistent with the revision of Bloom’s taxonomy knowledge and
cognitive domains would greatly benefit BCBAs’ ability to reform their practices (Krathwohl,
2002). Additionally, because of the reciprocal relationship between knowledge and motivation,

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findings align with the necessity to develop a better understanding of motivational theories to
support researcher recommendations. The knowledge acquired from the literature review,
interviews, and document analysis provided the information necessary to develop several
recommendations to assist BCBAs in reforming their practices and implementing
neurodivergent-affirming care.
Recommendations for Practice
If reform were to occur, the autistic community, their families, staff, the field, and
organizations would benefit. Children would no longer be exposed to traumatic ABA practices,
resulting in service implementation as intended and benefiting their development and their
mental health. Staff providing services would benefit from knowing that they are helping their
clients without potentially causing harm, and organizations would benefit because it would
continue to increase revenue if families were open to participate and remain in ABA services to
help their children learn and grow. The field of ABA would benefit because it would prevent
harm from occurring due to our strategies and allow insurance companies and physicians to
continue to recommend and fund therapies for children. To reform ABA, I conducted this study
to better understand BCBAs’ KMO experiences and challenges around neurodivergent-affirming
care, in addition to their competencies on how practices could be improved. Based on data
acquired through her research and information acquired from her literature review, the research
will provide four recommendations. This will begin with brief recommendations for the BACB
and educational institutions and will conclude with organizational recommendations, including
training strategies to implement for BCBAs within an organization, followed by
recommendations for BCBAs that do not have organizations supporting this change.

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Recommendation 1: Behavior Analyst Certification Board Recommendation to Modify
Continuing Education Expectations
The BACB has established standards, ethical guidelines, disciplinary systems, and
examination expectations for individuals working toward certification or those who maintain
certification. Based on this research, I identified a significant area that needed improvement to
ensure that BCBAs are better able to operate effectively in their professional capacity. The
BACB has an evolving set of ethical guidelines that require BCBAs to operate within their scope
of competence, ensure they actively work to maintain competence and seek continuing
education, training, and support to develop competence in a new area. While CEUs are a
requirement every 2 years, specifications on the type of CEU are limited to ethics and
supervision, with limited guidance and oversight on the additional continuing education training
as long as it meets BACB standards. According to data, 75.39% of BCBAs indicated a
professional emphasis on autism when renewing their certification. However, only 40% of ABA
programs analyzed had training on autism, 12.5% of interviewees had training on the social
model of autism, and 37.5% had no formal training on autism.
Data indicate a significant deficit in the competence of BCBAs working with autistic
individuals on what autism is, indicating a need for training on the social and medical model of
autism to support the autistic community better and meet the BACB ethical guideline
expectations of operations within their scope of competence. I recommend that the BACB
require an additional expectation for BCBA recertification to include training relevant to the
professional focus. Additionally, I recommend that the BACB modify their expectation of
content being “behavior analytic in nature” and disclude the training on a specialty such as
autism (BACB, 2022, p. 2) for a portion of their continuing education. This recommendation is
to ensure BCBAs have an in-depth understanding of the area of focus before applying behavior

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analysis. If the BACB were to modify this expectation, BCBAs working with the autistic
community would be required to acquire training related to autism, and this training could count
toward their continuing education. Currently, several training sessions on autism, the social
model of autism, neurodiversity, and ableism are not counted toward BCBA continuing
education, decreasing the motivation for BCBAs to acquire this knowledge and increasing the
likelihood there will be a knowledge gap among BCBAs, contributing to harm caused to the
autistic community by setting goals assumed to be socially significant from an ableist
perspective based on societal expectations.
Recommendation 2: Educational Institutions, Improve Educational Content for Students
Working Toward Certification to Work With Autistic Clients
The BACB requires educational institutions providing coursework and programs in ABA
to be ABAI-accredited. ABAI accreditation standards include expectations in nine areas:
mission, curriculum, outcomes assessment, administration, resources, faculty, student services,
public disclosure, and degree programs (ABAI, 2023). Degree program expectations for graduate
degrees include content in the following areas: principles of behavior, research methods,
conceptual analysis, ABA, fundamental behavior analysis, and ethics, with the addition of
specialized electives for doctoral courses. Document analysis data show that one of five
programs had indicators of neurodivergent-affirming recommendations, 60% did not provide
training on autism, and 50% of the programs that did have formal coursework on autism
contained ableist language, discussing the etiology of autism. Additionally, no programs directly
identified reviewing the history of trauma to improve practices in the course descriptions state
each recommendation for practice. To acquire the knowledge and develop the motivation
necessary to implement neurodivergent-affirming care, BCBAs must be aware of this

107
information, and data indicates that students are not provided this information at a significant
number of educational institutions.
I recommend that educational institutions offer specialty-specific courses that teach the
skills necessary to succeed in that professional area. If the student is accruing hours with autistic
clients and has chosen that specialty, the student should be required to take course content
regarding autism. Within a course or course sequence focusing on autism, I recommend that
educational institutions teach autism using a social and medical model and discuss neurodiversity
and ableism and the role of a practitioner in relation to these concepts. Furthermore, the course
content should include the history of ABA, the harm that has occurred due to its application, and
the necessity to ensure that it does not occur in the future. As indicated by Mathur et al. (2024), a
large portion of the history of ABA did not advocate for ableist practices and was not intended to
apply the science to make autistic people appear neurotypical to meet societal expectations; the
goal was building off strengths (Goldiamond, 1974) and maximizing positive reinforcement.
Mathur et al. (2024) highlighted writing core to the inception of ABA and heavily referenced in
coursework, which should be highlighted and emphasized in coursework in a way that directly
addresses ableism and how to ensure it does not occur. I recommend that ABA professors
reference Mathur et al. (2024) to start or continue their journey toward neurodivergent-affirming
care within ABA and include it as a requirement within their program.
Recommendation 3: Organization Recommendations to Develop a SMART Goal and
Implement Kirkpatrick and Kirkpatrick’s Four Levels of Training to Achieve the Goal
Data indicate that organizations play a significant role in influencing BCBAs’ knowledge
and motivation regarding implementing neurodivergent-affirming care. This ranges from access
to free training resources, stipend approval process, time, and capacity. Additional influences
include the training the organization provides for current BCBAs and individuals acquiring hours

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toward certification, and the mentors and supervisors supporting their growth. All organizations
analyzed contained ableist language, with only one indicating an emphasis on service
implementation aligning with neurodivergent-affirming care. This finding indicates the necessity
to reform practices within and throughout an organization for BCBAs to implement
neurodivergent-affirming care successfully. I recommend that organizations implement
mandatory training for BCBAs, increase access to training by developing internal training or
providing funds to access the training, hire autistic consultants to assist with modifying clinical
expectations, and adjust the criteria for bonuses to include clinical quality versus billable
expectations. Because of the necessity and depth of this recommendation, I developed a fourlevel training plan to assist an organization with implementing neurodivergent-affirming care,
following Kirkpatrick and Kirkpatrick’s (2016) recommendation.
Key Stakeholders
The key stakeholders of focus in this recommendation are the BCBAs within an
organization; however, for this to succeed on a larger scale, it is written as a recommendation for
organizations. The BCBAs are the selected stakeholders of focus because they determine what
procedures to use with their clients, making them the stakeholders with the most significant
impact on the strategic goal outlined, and organizations play a significant role in the education
and training of BCBAs. The BCBAs follow outlined strategies and ethical guidelines provided
by the BACB. However, many decisions regarding what areas to target and how procedures are
used are up to the BCBA overseeing the client cases and the organizational training and support
put in place (BACB, 2020). An example of this is identifying and addressing socially significant
behaviors. A BCBA can determine if self-stimulatory behaviors (e.g., hand flapping) are socially
significant behaviors to target for reduction, even if the autistic community has stated doing so is

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harmful to them because it helps regulate their bodies and the expectations are ableist (Shyman,
2016). Neurodiversity-affirming services are services that allow autistic people to be themselves
without attempting to hide parts of them that make them different, such as self-stimulatory
behaviors. Focusing on this stakeholder within an organization would ensure that the targeted
goal was met by ensuring neurodivergent-affirming practices were used at every clinic within the
organization.
SMART Goal
To meet the strategic goal of providing neurodivergent-affirming services, additional
goals will need to be identified to ensure BCBAs have the skills to do so in addition to
identifying accountability goals. This first goal recommendation is as follows: By a given date,
100% of an organization’s BCBAs will have completed a minimum of two training sessions (one
on ableism and one on neurodivergent-affirming practices) and removed ableist goals (e.g.,
reducing non-harmful stereotypy) from their goals identified in their intake and progress reports,
and their targets listed in their data collection platform.
This goal was developed by first ensuring BCBAs are aware of what ableism is, how it
influences services within the company, and how it impacts the clients. Data indicate that of the
eight BCBAs interviewed, 12.5% received training on the social model of autism, 12.5%
indicated they learned it through their organization, and 75% indicated they had not received the
training or sought the training outside of the organization or educational institution. Once the
knowledge on neurodivergent-affirming care and ableism is obtained, the BCBAs would then be
required to apply that to their practice by ensuring their current goals were not ableist, and if they
were, removing them from their reports and replacing them with appropriate neurodivergent-

110
affirming goals. To effectively meet the strategic goal and ensure no harm is caused to clients
and the providers are living their mission, less than 100% adherence to the critical behaviors is
unacceptable. I located some neurodivergent/neurodiversity-affirming training to give
organizations an idea of the cost to the organization. These costs are indicated in Table 9.

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Table 9
Cost Analysis of Neurodivergent-Affirming Care Training Outside of the Organization
Neurodiversity/
neurodivergent-affirming care
training link
Cost Modality Unit Length Organization
cost
100 BCBAs
Https://neurodiversitytraining.therapistndc.org/pr
oduct-category/on-demandcourses/
$10 Recording 1 1 hr $1,000
Https://neurodiversitytraining.therapistndc.org/pr
oduct-category/live-courses/
$30 Live 1 2 hrs $3,000
Https://www.kellymahler.com/product/ondemand-courseimplementing-a-neuroaffirming-model/
$59.25
(group rate)
Online 1 2 hrs $5,925
Https://register.gotowebinar.c
om/register/3011639753197
840223
Free Online 1.5 1.25 hrs $0
Recommended Training Strategies
To effectively accomplish an organizational goal of becoming a neurodivergent-affirming
organization, several levels should be considered, and goals and strategies within each level
should be created to achieve them. Kirkpatrick and Kirkpatrick’s (2016) model will be used to
establish the requirements and tools used at each level for the most successful outcome. This will
align with Clark and Estes’s (2008) gap analysis to ensure that KMO support is in place to
achieve the goal set and implement neurodivergent-affirming care.
Level 4: Results and Leading Indicators. Kirkpatrick and Kirkpatrick (2016) modified
the four levels of training approach created by Dr. Don Kirkpatrick in the 1950s by enhancing

112
the four levels to accommodate the changes that have occurred since their development and
presenting the levels in reverse. Considering the levels in reverse allows an individual and
organization to identify the intended outcome, Level 4, and develop a plan working backward to
meet that outcome. Focusing on the desired results begins with creating a clear and concise goal
for an organization. The importance of this level must be recognized because it will determine
what steps the organization needs to take to meet this goal and provide clarity for the personnel
to ensure everyone is actively working toward the goal. The primary objective for the
organization would be to ensure the clients receive neurodivergent-affirming services of the
highest quality. Identifying this goal and analyzing the intended outcome, the metrics to
highlight what exactly to measure, and the methods that will be used to measure them will assist
with moving through the additional phases (Table 10).
Table 10
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metrics Methods
External outcomes
Increase diversity among
individuals providing
training in the organization.
The variety of diversity
among training participants
Track the number of training
participants and the content
provided across multiple
similar organizations.
Increase diversity among staff
to include neurodivergent
staff members
The number of
neurodivergent staff at any
given time
Track diversity of new hires,
current diversity of staff,
and neurodivergent staff
members across multiple
organizations to use as
benchmarks.
Improve relationships with
the autistic community.
Positive and negative
feedback from members of
the autistic community
Release training provided to
behavior analysts, the
strategies used, and solicit
data on improvements and
modifications made and
compare them to outside
organizations.

113
Outcome Metrics Methods
Internal outcomes
Diversified training provided
to behavior analysts
including up-to-date
research on ableism and
harmful practices.
The number of diverse
training sessions provided
and the content of the
training
Analyze the organizational
training monthly and track
the training completion by
the number of behavior
analysts.
Training on developing nonableist goals
The quality of the goals with
neurodivergent-affirming
targets
Provide training until each
behavior analyst reaches
metacognition and is able to
reflect on their progress
toward neurodivergentaffirming practices.
The number of goals that are
not neurodivergentaffirming
Audit reports monthly until
each location has 0% of
goals that are not
neurodivergent-affirming
(e.g., eye contact, response
blocking for non-harmful
stereotypy).
Training on teaching
strategies that are not
harmful to the patients
(e.g., not using escape
extinction or punishment
procedures or strategies that
are considered
manipulative)
The number of harmful and
non-harmful teaching
strategies identified
Conduct a post-test with
example scenarios until
behavior analysts meet
mastery criteria to ensure
they are able to identify
what procedures have been
reported as harmful. Audit
program books to reach
100%.
Provide additional nonbillable time to attend
training.
The number of hours
provided to allow for
additional training.
Run monthly reports to
determine the time allotted
for additional training and
how much of that time was
utilized.

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Level 3: Behavior. Level 3, as identified by Kirkpatrick and Kirkpatrick (2016), focuses
on key behaviors involved in a training and evaluation program’s success. This level is the most
important because it covers the application of content learned in training to the day-to-day role to
ensure results occur. To evaluate behavior in Level 3, it is critical to define the most important
behaviors that connect to the intended outcome and assist with determining acceptable
performance levels. In Level 4, external and internal outcomes were identified to meet the
organization’s primary objective. In Level 3, behaviors are identified as critical if they must
occur to meet those outcomes and the organization’s objective. Identifying a behavior as critical
means that it is only acceptable that the behavior is always performed to ensure the results
outlined in Level 4 are met (Kirkpatrick & Kirkpatrick, 2016). The critical behaviors identified
for the organization to meet the intended outcome of ensuring all services are neurodivergentaffirming are listed in Table 11.
Table 11
Critical Behaviors, Metrics, Methods, and Timing for Evaluation of Behavior Analysts
Critical behavior Metrics Data collection Timing
1. Attend identified
training sessions.
The number of
training sessions
attended out of the
total number of
training provided.
The supervisor and
company clinical
director will track the
completed training
through the training
platform and assign
monthly training
each month. The
supervisor will
address incomplete
requirements.
During the first 60
days of
employment,
then monthly if
training has been
attended as
required.

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Critical behavior Metrics Data collection Timing
2. Identify ableist
targets.
The ability to identify
if a target is or is
not ableist.
The supervisor will
assess targets during
all required report
reviews and take data
on the percentage of
accuracy of targets.
During the first 30
days of
employment and
upon
reauthorizations
occurring every 6
months per client
(averaging 1 a
month).
3. Identify harmful
teaching strategies.
The ability to identify
harmful teaching
strategies
The supervisor will
audit behavior
analyst program
books and follow up
with the behavior
analyst if any
teaching strategies
are identified as
harmful and retrain
as necessary.
During the first 30
days of
employment,
during each
initial treatment
plan for the 1st
year, and upon
reauthorizations
occurring every 6
months per client
(averaging 1 a
month)
4. Develop targets that
are neurodivergentaffirming
The ability to
develop targets that
are neurodivergentaffirming
The supervisor will
assess targets during
all required report
reviews and take data
on the percentage of
accuracy of targets.
During the first 30
days of
employment and
upon
reauthorizations
occurring every 6
months per client
(averaging 1 a
month)
5. Develop teaching
strategies that are
not harmful
The ability to identify
appropriate
teaching strategies
that are not
harmful to the
patient
The supervisor will
audit behavior
analyst program
books and follow up
with the behavior
analyst to reinforce
appropriate
strategies.
During the first 30
days of
employment,
during each
initial report for
the 1st year, and
upon
reauthorizations
occurring every 6
months per client
(averaging 1 a
month).

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Critical behavior Metrics Data collection Timing
6. Be able to recognize
the
interconnectedness
of neurodivergentaffirming targets,
programming, and
patient outcomes.
The ability to identify
how the skills
relate to one
another and the
outcomes of the
patient.
The supervisor will go
through questions
with the behavior
analyst to allow them
to self-assess and
reflect on the
interconnectedness.
Bi-weekly until
mastery criteria
have been met
Note. The behaviors are numbered for easier identification in Table 12.
Critical Behaviors. The key behaviors that behavior analysts will need to demonstrate to
achieve the intended outcome include attending training, identifying ableist targets and harmful
teaching strategies, developing neurodivergent-affirming targets and programs, and recognizing
the interconnectedness of these targets and programs and the outcomes achieved. Table 11
outlines the critical behavior, what should be measured, how it could be measured, and how
frequently it should be evaluated.
Required Drivers. To achieve the results identified in Level 4, Level 3 must be
successful. Identifying critical behaviors is a necessary step to succeed in Level 3, in addition to
identifying systems that ensure the behaviors continue to occur, referred to by Kirkpatrick and
Kirkpatrick (2016) as required drivers. Required drivers include drivers for support and drivers
for accountability. Aligning these drivers with the KMO influences that assist with leading to
achievement allows individuals to determine what methods are needed across areas. Knowledge
and motivation fall primarily under the support area of reinforcing, encouraging, and rewarding
behaviors, while organizational influences fall under accountability, specifically monitoring
(Kirkpatrick & Kirkpatrick, 2016).
Table 12 highlights the identified methods in each area, the timing of each, and the
critical behaviors supported. Reinforcing, related to knowledge and support, outlines methods

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that would occur to reinforce the knowledge attained by the behavior analysts. Both encouraging
and rewarding cover required drivers to continue to motivate the behavior analyst. Motivation
plays a significant role in the success of an initiative and is deemed one of the most challenging
areas in the management of employees (Erceg & Šuljug, 2016). According to research, the most
critical areas regarding motivation include compensation, relationships, the conditions of the
environment, and fulfillment in the role (Erceg & Šuljug, 2016). Table 12 consists of methods
that attempt to cover each area identified by Erceg and Šuljug (2016). Lastly, monitoring ties
into self-efficacy and metacognition by encouraging self-monitoring and self-assessments.
Table 12
Required Drivers to Support Critical Behaviors of Behavior Analysts
Methods Timing Critical behaviors supported
Reinforcing (K-related)
Supervision meetings with
behavior analyst and
clinical manager
Weekly 2–6
Job aids covering information
on components of
neurodivergent-affirming
practices
Ongoing 2–6
On-the-job training with
clinical manager
overlapping
Monthly 3, 5, and 6
Follow-up information:
ongoing emails or
messages that include
information on the benefits
of neurodivergent-affirming
services and training
reminders
Ongoing 1–6
Encouraging (M-related)
Mentoring: identifying a
mentor who has mastered
developing neurodivergent
tasks and program
development
Ongoing 1–6

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Methods Timing Critical behaviors supported
Positive feedback on
neurodivergent-affirming
targets and protocols when
reviews occur
Ongoing 2–6
Rewarding (M-related)
Recognition: recognizing the
completion of training and
the growth in areas trained
Ongoing 1–6
Bonuses: tying bonuses to the
completion of training and
implementation of training
materials in developing
targets and programs
Ongoing 1–6
Promote to mentor: when
mastery criteria have been
met, promote an individual
into a mentorship role each
quarter.
Quarterly 1–6
Reinforce with previously
identified tangible based on
completion of training and
mastery of skill set.
Bi-weekly 1–6
Monitoring (O-related)
Encourage self-monitoring on
the completion of training
and the development of the
skills.
Weekly 1–6
Provide opportunities to share
the progress that they have
made, and their clients have
made with their
neurodivergent-affirming
procedures and goals.
Monthly 1–6
Self-assess current progress
toward goals.
Monthly 1–6

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Required Learning and Reaction. After determining the organizational goal, the desired
outcome, the key stakeholders required to meet this goal, and the critical behaviors to do so, the
next step is to determine what the key stakeholders need to learn, how they will learn, and how to
ensure the training is effective and leaves the stakeholders motivated and satisfied. This will
assist with addressing Clark and Estes’ (2008) knowledge and the motivational aspects necessary
to close the gap. According to data acquired from the literature review and this study, data
indicate gaps in knowledge and motivation for BCBAs within an organization. The remaining
two levels will discuss the knowledge and motivation utilizing Kirkpatrick and Kirkpatrick
(2016).
Level 2: Learning. Level 2 consists of multiple components of learning that ensure an
individual cannot just repeat the information acquired but genuinely understand the information
provided during the training and adjust their behavior accordingly. This section aligns with
Bloom’s revised taxonomy, addressing the knowledge and cognitive process domains, and
includes knowledge and skill (Krathwohl, 2002). This is an area that people can inaccurately
assume is the problem leading to poor performance, referring to if the person knows how to do
something. However, data indicate this is an accurate barrier in this study. Next is the attitude, or
how important the trainee believes the skill is, and their confidence and commitment. This aligns
with the motivational theories outlined in the literature review, and data indicate that this was an
additional barrier to BCBAs’ implementation of neurodivergent-affirming care. The level of
confidence a person has in performing the skill taught is indicated in expectancy-value theory
(Wigfield & Eccles, 2020) and self-efficacy theory (Bandura, 1997), and the intended application
of the skill taught (Kirkpatrick & Kirkpatrick, 2016) includes the utility value (Wigfield &
Eccles, 2020). This level works with prior levels addressed above because the key stakeholders
must have or acquire the knowledge, skill, attitude, confidence, and commitment through

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training to effectively modify their behavior as stated in Level 3, and meet the goal identified in
Level 4 to become a neurodivergent-affirming organization (Kirkpatrick & Kirkpatrick, 2016).
For an organization to effectively eliminate ableist practices, behavior analysts must modify their
behaviors as outlined in Level 3, which requires the components addressed in the second level.
Learning Goals. To have adequate training and perform the critical behaviors outlined in
Table 11, behavior analysts must acquire different levels of knowledge. They must have concrete
and abstract knowledge as outlined in Krathwohl’s revised Bloom’s taxonomy and discussed in
the literature review. The knowledge dimensions and cognitive processes provided in this
taxonomy give a guide to both clarify and determine the learning objectives and activities that
will assist with developing different levels of thinking skills and mixing concrete knowledge
types and abstract knowledge types. Beginning with the knowledge dimensions, behavior
analysts must have factual, conceptual, procedural, and metacognitive knowledge (Anderson &
Krathwohl, 2001).
In the cognitive process dimension outlined by Anderson and Krathwohl (2001), six
categories ranging from lower to higher-order thinking skills are outlined, with 19 identified
processes to clarify each skill. For a BCBA to perform the identified critical behaviors, they
would need to acquire training that results in them remembering the information provided as
shown by recalling the information and understanding the information provided, as evidenced by
cognitive processes, including summarizing, comparing, explaining, and interpreting, and
applying what was learned through execution. Additionally, BCBAs must acquire the ability to
analyze the skills taught in training, analyze goals and teaching strategies to determine if they are
or are not neurodivergent-affirming, and evaluate their ability to do so. Lastly, an essential
higher-order thinking skill necessary for the BCBA is the ability to create goals and teaching
strategies that are neurodivergent-affirming and train others on how to do so. The following list

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outlines specific learning goals necessary for BCBAs and how they align with Krathwohl’s
revised version of Bloom’s Taxonomy (Anderson & Krathwohl, 2001):
• Summarize the contents of the training provided on ableism and neurodivergence
(factual, conceptual, remembering, understanding)
• Apply the contents of the training by developing neurodivergent-affirming targets and
practices (factual, conceptual, procedural, remember, understand, apply, create)
• Apply the contents of the training provided by identifying and removing ableist
targets and practices (factual, conceptual, procedural, remember, understand, apply,
create)
• Analyze implemented targets in reports and their corresponding teaching instructions
and modify as necessary (factual, conceptual, procedural, remember, understand,
apply, analyze. evaluate, create)
• Self-evaluate their progress toward the goal and their peers and seek additional
evaluations of their work from others (factual, conceptual, procedural, metacognitive,
remember, understand, apply, analyze, evaluate)
Program. To meet the learning objectives and ensure the critical behaviors necessary to
achieve the outlined goal for the organization, training recommendations are in three separate
components, all provided within a set period. I will use 4 weeks in this recommendation
example. The first component would be a 3-hour training session on ableism, identifying ableist
practices, and the necessity of removing ableist targets and teaching strategies. This portion of
the training should include multiple presentations from autistic individuals to provide knowledge
to BCBAs and spark motivation for the need for change. It is recommended that this group
consists of individuals who have received services and are advocates on the harmful impact ABA
has had, an individual who has never received services but is willing to share their lived

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experiences with ableism and the harm it causes, and someone who has had a positive experience
in ABA and what strategies were used to produce that. After the presentation, a panel for
behavior analysts to learn more from participant experiences is recommended.
The second component of training should be on neurodivergent-affirming services. This
should provide in-depth information on outside fields that have reformed their services and
provide neurodivergent-affirming services, how this change began and evolved, and the
outcomes. This portion of the training is recommended to include multiple presentations from
individuals who have received neurodivergent-affirming services, including autistic people who
have had both positive and negative outcomes from services with ableist practices, to allow for a
comparison of the strategies used. A panel should occur at the end to allow BCBAs to ask
additional questions about the process and experiences of the presenters.
The final component of training is recommended to be split into two parts and consist of
in-depth training that should include a review, application, and analysis followed by a 1-week
period of implementation ending with a final review and reflection. During the first part of the
training, BCBAs should summarize the information acquired from the previous training to
ensure they remember and understand the content. The BCBAs should then receive mock reports
of ableist and neurodivergent-affirming goals and teaching strategies and will identify which
falls within each category. Next, they should develop their own targets and teaching instructions
that are neurodivergent-affirming and analyzing each other’s. Once these targets and teaching
strategies are reviewed and approved, they should then receive consent from clients and spend a
week implementing what they have learned with the oversight of an identified mentor who will
provide guidance and feedback.
During the final portion of this component, at the end of the four weeks, the
recommendation is that the BCBAs reconvene, evaluate their progress, share successes, discuss

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barriers, and reflect on the process. Then, the BCBAs should conduct a self-evaluation to
determine what areas they need additional support and guidance on and what areas they feel
confident moving forward with, with weekly supervision meetings to ensure consistency and
success. Follow-up reflections with the clinical manager and/or director are recommended to
occur monthly and consist of reinforcement for successful implementation and self-assessments
on current skills and needs. Once 3 consecutive months have passed and the BCBA has shown
mastery, they could have the opportunity to become a mentor themselves. Table 13 highlights
this phase’s recommended evaluation components, including the methods and timing of each
dimension.

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Table 13
Evaluation of the Components of Learning for the Program
Methods or activities Timing
Declarative knowledge: “I know it.”
Knowledge checks During and after each component
Summarize the contents learned during each
component
During and after each component
Discussions on terms and topics During and after each component
Group activity
Procedural skills: “I can do it right now.”
Role play During the final component
Simulation with scenarios During the final component
Analysis of goals and programs to practice by
presenter
During the final component
Feedback from presenter on progress During the final component
Attitude: “I believe this is worthwhile.”
Discussion on necessity for change During and after each component
Discussion of anything negative things that
have occurred in personal experiences due
to lack of reform
during and after each component
Discussions of hesitations to reforming and
potential solutions
During and after the second and final
component
Confidence: “I think I can do it on the job.”
Action planning During final component
Discussing barriers During and after each component
Small group activity developing and providing
feedback on progress
During and after final component
Self-analysis of strengths and deficits During and after final component
Commitment: “I will do it on the job.”
Self-reflection and reports of progress After
Reflection on progress and barriers After
Action plan for how to address barriers After
Level 1: Reaction. Ensuring that training satisfies the intended audience is necessary to
an extent because of a positive correlation between satisfaction and learning and the role this
plays in motivation to assist with beginning working toward their goal in addition to energizing,
directing, and sustaining progress toward the goal (Schunk et al., 2008). To effectively measure

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this, it is essential to use a purposeful approach, and I recommend an approach outlined in
Kirkpatrick and Kirkpatrick (2016) to ensure the participants are engaged and the content is
relevant to their job. It is essential to have these components to increase the effectiveness of the
training to provide the participants with the necessary information to effectively meet the goals
outlined in the learning program that will support the critical behaviors necessary to meet the
primary goal for the organization, in Level 4, by making it an organization that only provides
neurodivergent-affirming services. I recommend utilizing multiple reaction measures throughout
this level, highlighted in Table 14, focusing on engagement, relevance, and satisfaction
(Kirkpatrick & Kirkpatrick, 2016).

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Table 14
Components to Measure Reactions to the Program
Methods or tools Timing
Engagement
Attending all three training components At the beginning and end of each training
component
Responding to questions During each component of the training
Participating in activities and knowledge
checks
During each component of the training
Engaging in discussions During each component of the training
Asking questions During each component of the training
Expressing barriers and needs During the final component of the training
Relevance
Ensure only case-managing behavior analysts
are required to attend
Prior to the training
Take a pulse check At the beginning of the first component of
training on where their current knowledge
and skillset related to the topics lie
Anonymous live surveys on relevance with
rationale
At the beginning of the training to provide
guidance on how to potentially modify the
approach and the end of the training
Customer satisfaction
Observing the audience for active responding
and affect
During each component of training
Survey After each component of training
Follow-up surveys 1 week after all components of training have
been completed, 1 month after, and 3
months after to determine relevance,
application, and necessary modifications
Organizational Support. Accountability will be necessary to meet the goals and
expectations outlined within each level effectively. According to data acquired in this study, the
participants indicated a significant focus on revenue, billing expectations within organizations,
and the role that private equities are playing in influencing BCBA’s ability to succeed in
acquiring the knowledge necessary to implement neurodivergent-affirming care, including a
financial component, in addition to the time and capacity of the BCBAs. According to these data,

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current accountability measures primarily surround organizational profitability, excluding the
quality of services and the need to eliminate ableist practices and provide strictly neurodivergentaffirming services. To hold the organization and the BCBAs accountable, different factors need
to be addressed.
When analyzing the code of ethical conduct, the rights approach, focusing on respecting
human dignity, aligns nicely with the need for reform, CDT and BACB ethical guidelines.
BCBAs are required to adhere to the ethical guidelines outlined by our governing board, and the
most recent version states that behavior analysts are ethically required to obtain assent from their
clients (BACB, 2020). This is giving the client, regardless of their level of ability, the right to
choose if they want to participate in services and a particular situation. If a client is showing
signs of resistance, BCBAs are ethically obligated to respect that resistance, which was not
previously outlined. Due to this, an organization can be held accountable by the BACB to reform
practices because if BCBAs are not meeting those standards, their licensure is at stake, which
would negatively impact the organization’s profits.
Additional measures of accountability are recommended for organizations to shift to
conscious accountability (Tate et al., 2022). Conscious accountability was utilized as a guide,
beginning with clarity in creating this recommendation. For an organization to implement these
recommendations, as recommended by Tate et al. (2022), I advise the organization to create a
safe space for conversations with key stakeholders, following through with the levels outlined
and increasing motivation by providing recognition. Within the literature review, motivation in
relation to ABA was discussed, and aligning these methods with ABA principles to increase
motivation will increase the organization’s likelihood of success. Additionally, I recommend that
built-in measures for feedback for BCBAs and their supervisors also occur for clinical managers,
regional directors, and the director of clinical services. These conversations should include

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discussions on deficits and areas needed for improvement, in addition to encouraging ownership
of participants on areas of concern to ensure changes will occur to continue to move forward and
improve to ensure all BCBAs are implementing neurodivergent-affirming care.
To continue to improve toward these goals and ensure the BCBAs receive the support
they need to succeed, I recommend the organization monitor progress toward meeting the critical
behaviors by doing weekly audits on each clinic’s progress as tracked by the clinical managers at
each location and discuss progress and barriers in the recommended meetings noted above.
Lastly, I recommend during any monthly internal town halls hosted by the organization’s
leadership that updates toward this goal are provided to all employees, in addition to advertising
this progress on the organization’s social media platform and sending status updates monthly to
current clients and their families. This will allow individuals to hold the organization accountable
and allow the organization to hold itself accountable to meet the outlined goal. Once the goal has
been met and maintained for a minimum of 6 months, I recommend continuous monitoring
quarterly to ensure it remains a top priority and that ableist goals and practices do not begin to
reappear.
Recommendation 4: Board-Certified Behavior Analyst Recommendations
In the event that a BCBA is unable to locate an organization working toward or currently
providing neurodivergent-affirming care, data indicate the need to seek training to acquire the
knowledge and motivation to effectively implement neurodivergent-affirming practices.
Additionally, data indicate the focus should be on increasing flexibility when seeking knowledge
and not limiting oneself to strictly ABA research while still ensuring it meets evidence-based
requirements. I recommend that the BCBA seek training and support independently, increase
their flexibility with the variation of material sought to include varied specialties and diversity
among the trainers, and ensure they are investing time into content developed by autistic people.

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To decrease the response effort, I provide a training recommendation following the format of an
organizational recommendation but written for a BCBA seeking the training independently.
Because of this modification, self-management strategies, as opposed to management oversight,
will be included throughout the recommendation. According to research, to effectively selfmanage, BCBAs should select their own goals and procedures, implement the procedures,
reinforce their progress, and self-evaluate (Mayer et al., 2014). This recommendation was
developed to assist with that process.
SMART Goal
For a BCBA to implement neurodivergent-affirming care, the first recommendation
would be to develop a goal that can be used as a tool to allow an effective self-management
system. An example of goals necessary to implement neurodivergent-affirming care that can be
utilized include the following:
● Within the next 30 days, I will complete a minimum of two training sessions (one on
ableism and one on neurodivergent-affirming practices) and review two articles on
each topic with at least 50% of the content, including an autistic person’s perspective.
● Upon completion of the training, I will use a social model lens of autism and remove
all goals that indicate ableist emphasis from my goals identified in my intake and
progress reports and replace them with neurodivergent-affirming goals within 14 days
of completing the training.
● I will audit 100% of the teaching protocols utilized in my skill acquisition
programming, remove all strategies that have been reported to cause harm, and
develop appropriate assent and reinforcement-based practices utilizing a social model
lens for selection.

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● For behavior reduction targets, I will research the behavior from an autistic person’s
perspective to assist with determining the necessity for addressing it and consult the
research within other specialties (e.g., child development).
Data in this study indicate that each of these goals is necessary due to a lack of
knowledge regarding autism and neurodivergent-affirming practices as indicated by interviews
and document analysis in addition to motivational influences.
Recommended Training Strategies
To effectively accomplish an individual goal of becoming a neurodivergent-affirming
provider, as written above, several levels should be considered, including goals and strategies
within each level to achieve them. Because Kirkpatrick and Kirkpatrick’s (2016) model is
intended for organizations, a modified version will be used to establish the requirements and
tools used at each level for the most successful outcome while embedding ABA selfmanagement recommendations retrieved from Mayer et al. (2014) and Cooper et al. (2007)
versus external observations or oversight. These recommendations will align with Clark and
Estes’s (2008) gap analysis to ensure the knowledge and motivation are addressed to assist with
a BCBA implementing neurodivergent-affirming care.
Level 4: Results and Leading Indicators. As stated previously, Kirkpatrick and
Kirkpatrick (2016) recommend working backward, beginning with the final objective to meet the
intended goal. For this portion, I recommend looking at the intended outcomes to achieve the
smart goal of implementing neurodivergent-affirming care and specifying outcomes, metrics on
what exactly to measure, and the measurement method recommended for self-monitoring Table
15).

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Table 15
Outcomes, Metrics, and Methods
Outcome Metrics Methods
Increase diversity among
individuals providing the
training or material chosen
to access.
The variety of diversity
among trainers
Track the number of
educational materials
accessed in different
specialties and the number
of training and/or resources
accessed by diverse
teachers.
Increase neurodivergent
perspectives in the research
and/or training accessed.
The number of
neurodivergent presenters
or authors of the material
accessed.
Track the number of
neurodivergent versus
neurotypical perspectives
on reform accessed.
Improve understanding of
autism from a social model
lens and increase
knowledge of autistic
perspectives.
Positive and negative
feedback from members of
the autistic community.
Seek out training that includes
autistic perspectives, have
autistic creators, or solicit
feedback on training
recommendations from
autistic people and ensure at
least 90% of training
highlights autistic voices.
Diversified training, including
up-to-date research on
ableism and harmful
practices
The number of diverse
training provided and the
content of the training
Analyze the training quarterly
and self-monitor training
completions.
Training on developing goals
that are not ableist
The quality of the goals with
neurodivergent-affirming
targets
Increasing training until
metacognition is met and
you are able to reflect on
your own progress toward
neurodivergent-affirming
practices.
The number of goals that are
not neurodivergentaffirming
Conduct audits specifically
looking at targets for all
completed reports prior to
submission to ensure 0% of
goals that are not
neurodivergent-affirming
(e.g., eye contact, response
blocking for non-harmful
stereotypy).
Complete training on teaching
strategies that are not
harmful to the patients
The number of harmful
teaching strategies
identified and the number
Conduct a post-test on goals
addressed in ABA articles
until you meet mastery

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Outcome Metrics Methods
(e.g., not using escape
extinction or punishment
procedures or strategies that
are considered
manipulative)
of non-harmful teaching
strategies identified
criteria to ensure you are
able to identify what
procedures have been
reported as harmful.
Level 3: Behavior. Key behaviors are a critical aspect of achieving the goal of
implementing neurodivergent-affirming care for a BCBA. Critical behaviors are behaviors that
must occur to meet the goal (Kirkpatrick & Kirkpatrick, 2016). The key behaviors that BCBAs
would need to demonstrate to achieve the intended outcome include attending training,
identifying ableist targets and harmful teaching strategies, developing neurodivergent-affirming
targets and programs, and recognizing the interconnectedness of these targets and programs and
the outcomes achieved. Table 16 outlines the critical behavior, what should be measured, how it
could be measured, and how frequently it should be evaluated.

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Table 16
Critical Behaviors, Metrics, Methods, and Timing for Self-Evaluation
Critical behavior Metrics Data collection Timing
1. Attend identified
training sessions.
The number of
training sessions
attended out of the
total number of
provided
The BCBA will track
their completed
training through an
Excel sheet and seek
additional training
each month until
mastery criteria have
been met.
During the first 60
days of
establishing the
goal, then
monthly if
training has
occurred as
intended
2. Identify ableist
targets
The ability to identify
if a target is or is
not ableist
The BCBA will assess
targets during all
required report
completions prior to
submission and take
data on the
percentage of
accuracy of targets.
During the first 30
days of
establishing the
goal for all
current
authorizations
and during
reauthorizations
or initial
authorizations
3. Identify harmful
teaching strategies
The ability to identify
harmful teaching
strategies
The BCBA will audit
their program books
and document if
teaching strategies
are identified as
harmful, modify
teaching strategies,
and seek additional
training if harmful
strategies are
indicated in any
goals.
During the first 30
days of
establishing the
goal, every 14
days for current
client targets,
during each
initial program
development,
and upon
reauthorizations
4. Develop targets that
are neurodivergentaffirming
The ability to
develop targets that
are neurodivergentaffirming
The BCBA will assess
targets during all
required report
reviews and take data
on the percentage of
accuracy of targets,
modify as necessary,
and complete
additional training if
less than 90% of
goals are
During the first 30
of establishing
the goal, upon
initial
authorizations
and
reauthorizations

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Critical behavior Metrics Data collection Timing
neurodivergentaffirming.
5. Develop teaching
strategies that are
not harmful
The ability to identify
appropriate
teaching strategies
that are not
harmful to the
patient.
The BCBA will audit
their program books
and utilize a
previously identified
reinforcer to
reinforce appropriate
strategies.
During the first 30
days of
establishing the
goal, during each
initial report for
the 1st year, and
upon
reauthorizations.
6. Be able to recognize
the
interconnectedness
of neurodivergentaffirming targets,
programming, and
patient outcomes.
The ability to identify
how the skills
relate to one
another and the
outcomes of the
patient.
The BCBA will go
through questions on
neurodivergentaffirming targets and
practices, self-assess
and reflect on the
interconnectedness.
Bi-weekly until
mastery criteria
have been met.
Note. The behaviors are numbered for easier identification in Table 17.
Required drivers are an essential component of Level 3 because they allow for ensuring
that there are support drivers in place in addition to accountability drivers. Aligning these drivers
with the knowledge and motivation factors that lead to achievement will better prepare the
BCBA to know what is needed to succeed. Knowledge and motivation fall primarily under the
support area relating to reinforcing, encouraging, and rewarding behaviors and self-monitoring,
known to influence an individual’s behaviors (Mayer et al., 2014), improving self-efficacy and
metacognition (Erceg & Šuljug, 2016) will fall under accountability (Kirkpatrick & Kirkpatrick,
2016). Table 17 highlights the methods in each area, the timing of each, and the critical
behaviors supported.

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Table 17
Required Drivers to Support Critical Behaviors of BCBAs
Methods Timing Critical behaviors supported
Reinforcing (K-related)
Job aids/visual prompts
covering information on
components of
neurodivergent-affirming
practices
Ongoing 2–6
Follow-up information:
subscribing to emails or
following social media
platforms that include
information on the benefits of
neurodivergent-affirming
services and training
reminders
Ongoing 1–6
Encouraging (M-related)
Mentoring - identifying a
mentor who has mastered
developing neurodivergent
task and program
development
Ongoing 1–6
Share positive feedback with
mentor on neurodivergentaffirming targets and
protocols when conducting
self-monitoring
Ongoing 2–6
Rewarding (M-related)
Recognition: recognizing your
own completion of training
and the growth in areas
trained
Ongoing 1–6
Self-delivery of reinforcers:
develop short-term goals and
deliver reinforcers when you
reach them.
Ongoing 1–6
Promote to mentor: when
competent and confident in
your abilities, mentor others
and check in quarterly to
determine if you are ready for
this next step.
Quarterly 1–6

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Methods Timing Critical behaviors supported
Reinforce with previously
identified tangible based on
completion of training and
mastery of skill set.
Bi-weekly 1–6
Monitoring (O-related)
Conduct self-monitoring on the
completion of training and the
development of the skills.
Weekly 1–6
Share the progress you have
made with their
neurodivergent-affirming
procedures and goals with
other BCBAs and people in
your life.
Monthly 1–6
Self-assess current progress
toward goals regularly.
Monthly 1–6
Level 2: Learning. Level 2 consists of multiple components of learning that ensure an
individual can repeat the information acquired, truly understand it, and adjust their behavior
accordingly. This section aligns with Bloom’s revised taxonomy, addressing the knowledge and
cognitive process domains, and includes knowledge and skill (Krathwohl, 2002).
Learning Goals. For BCBAs to effectively implement neurodivergent-affirming care,
concrete and abstract knowledge is required, and with limited data confirming this information is
taught in organizations and schools, it is a significant area of focus for the recommendations. To
have both concrete and abstract knowledge, BCBAs must have factual, conceptual, procedural,
and metacognitive knowledge on the topic of focus. Another component is the cognitive
dimension process; to meet this level of comprehension, BCBAs must go beyond the ability to
recall information. They must have a level of comprehension that allows them to summarize,
compare, explain, interpret, and apply what they are learning. Additionally, especially in a selfled journey, the BCBAs have to acquire the ability to analyze what they have learned and

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analyze goals, teaching strategies, and ABA methodologies overall to determine what is or is not
neurodivergent-affirming. The following list outlines specific learning goals necessary for
BCBAs and how they align with Krathwohl’s revised version of Bloom’s taxonomy, also
highlighted in the prior recommendation (Anderson & Krathwohl, 2001):
• Summarize the contents of the training provided on ableism and neurodivergence
(factual, conceptual, remembering, understanding)
• Apply the contents of the training by developing neurodivergent-affirming targets and
practices (factual, conceptual, procedural, remember, understand, apply, create)
• Apply the contents of the training provided by identifying and removing ableist
targets and practices (factual, conceptual, procedural, remember, understand, apply,
create)
• Analyze implemented targets in reports and their corresponding teaching instructions
and modify as necessary (factual, conceptual, procedural, remember, understand,
apply, analyze. evaluate, create)
• Self-evaluate their progress toward the goal and their peers and seek additional
evaluations of their work from others (factual, conceptual, procedural, metacognitive,
remember, understand, apply, analyze, evaluate)
Embedding evaluation components into the learning process is a useful tool when
acquiring this level of concrete and abstract knowledge. This can look different when operating
or acquiring the skills within an organization versus independently and requires a significant
amount of motivation and determination to continue to work toward the end goal. Table 18
includes recommended methods and activities to complete and reflect on throughout the training
acquisition process.

138

139
Table 18
Evaluation of the Components of Learning for the Program
Components Methods or activities
Declarative knowledge: “I know it.” Knowledge checks
Summarize the contents learned during each
component.
Discussions on terms and topics with other
BCBAs
Procedural skills: “I can do it right now.” Simulation with scenarios
Analysis of goals and programs to practice
Feedback from presenter on progress
Attitude: “I believe this is worthwhile.” Reflection on necessity for change
Reflection on anything negative things that
have occurred in personal experiences due
to lack of reform
Reflections on hesitations to reforming and
potential solutions
Confidence: “I think I can do it on the job.” Action planning
Reflecting on barriers
Independent activity developing
goals/teaching strategies and reflecting on
progress
Self-analysis of strengths and deficits
Commitment: “I will do it on the job.” Self-reflection and reports of progress
Reflection on progress and barriers
Action plan for how to address barriers

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Level 1: Reaction. Level 1 is specific to training development and content, ensuring
participants are engaged and enjoying the training, which assists with motivation. Because of the
nature of this recommendation, I will focus solely on increasing motivation, utilizing
motivational theories to assist with acquiring the knowledge and confidence necessary to
implement neurodivergent-affirming care.
Increasing Motivation. Clark and Estes (2008) identified three common motivational
processes that influence motivation based on the research collected: choice, persistence, and
mental effort. Choosing to work toward this goal may be simple; however, persisting in the face
of additional work goals can be a barrier, as indicated by data acquired from interviewees, in
addition to the mental effort. When discussing mental effort, it can be influenced by the
individual’s under and overconfidence, and the interviewees discussed both as barriers to moving
toward neurodivergent-affirming care. In this aspect, self-efficacy can increase or decrease the
motivation of the individual working toward their goals (Bandura, 1997). A common overlap
between motivational theories indicates that an individual’s self-schema plays a role in their
motivation, influenced by personal beliefs and previous experiences.
Recommendations to increase motivation include increasing confidence by setting small
achievable goals at a level comparable to their abilities, ensuring they are not too easy or
difficult. In addition to confidence, values play a significant role in motivation. To increase
motivation, the value of the goal must be increased, and it can be approached in three ways:
interest, skill, and utility. Increasing the interest value requires determining what interests the
individual about moving toward neurodivergent-affirming care. Skill value relates to aligning the
goal and one of their skills. I recommend that BCBAs consider this when working toward their
goal. What skills, whether it be their soft skills or their scientific skills, can assist with
motivation while working toward improving both areas. Lastly, utility value looks at the benefits

141
of meeting the goal (Eccles & Wigfield, 1995). Within organizations, this is clear in references to
tangible incentives; this can also occur for BCBAs, reinforcing their success toward short-term
goals, as suggested above. However, I included recommendations on seeking research on trauma
and autistic perspectives to assist with increasing the utility value of reforming practices to
increase motivation to ensure harm does not occur to the clients served. With that being said,
incorporating tangible incentives to increase motivation throughout the process of acquiring the
skills to implement neurodivergent-affirming care is recommended if it assists with persistence.
Limitations and Delimitations
Outlining the limitations and delimitations of a study allows for disclosing potential
limiting factors affecting the study and demonstrating an in-depth understanding of the topic.
This information can strengthen a study by allowing me to make future recommendations to
improve these areas and determine other methods to ensure the study’s validity (Merriam &
Tisdell, 2015). These limitations were considered and will be used to guide recommendations for
future research within this chapter.
Limitations
Potential weaknesses or limitations of the study that were not within my control are
factors to consider and disclose in all forms of research. An anticipated limitation of this study is
the methodology chosen. Because of the limited research available regarding neurodivergentaffirming care in ABA, I conducted a qualitative study, giving me the inability to determine
causation (PhDStudent.com, 2023). Doing so also allowed me to develop a better understanding
to test further after concluding this study. Additional limitations include the varied perspectives
of the participants. I used varied sampling methods, including maximum variation and snowball
sampling, to vary the perspectives as much as participant engagement allowed her to. A
significant limitation of this study is the time I had to conduct the study to ensure I met the

142
dissertation timelines. Because of this time constraint, I anticipate conducting an additional study
after the completion of this study to allow for a more in-depth mixed methods or quantitative
approach to occur using the data acquired from this study.
Delimitations
Disclosing delimitations within a study allows a researcher to present the boundaries set
to ensure the purpose of the study is achievable within the constraints of circumstances
(PhDStudent.com, 2023). Before disclosing delimitations, it is recommended to inform readers
of the justification for the chosen topic of study and the methods chosen (PhDStudent.com,
2023). In this study, I conducted interviews to better understand the lived experiences of BCBAs
and the KMO supports that influence becoming neurodivergent-affirming. Additionally, I
completed document analyses on multiple educational institutions to understand the content
provided in coursework related to neurodivergent-affirming care and history of trauma, how it
trains individuals working toward certification, and organizational support and training in place
regarding the same topics. These specific areas were chosen to provide me with a range of
information related to the training of individuals working toward certification, organizational
supports and training, and the perspective from multiple BCBAs to better understand the impact
and influences of these supports or lack thereof. This study included five delimitations:
● Due to time constraints and researcher capacity, the number of organizations analyzed
was five, significantly lower than the total number of ABA organizations.
● The number of educational institutions’ course content analyzed was five. This is
significantly lower than the number of ABAI-accredited ABA programs but was
limited due to time constraints.

143
● This study focused solely on BCBAs because of the required expectations to acquire
and maintain certification. This excluded individuals practicing in behavioral sciences
who do not hold this certification.
● I only conducted interviews remotely. This limited participants’ privacy but expanded
the number of participants with varied experiences who could participate.
● I used a qualitative approach, while the field she analyzes focuses on experimental
design. This limited my influence on change but provided data to develop a better
understanding of the topic studied before moving toward a quantitative approach after
the conclusion of the current study.
Recommendations for Future Research
Future recommendations, given the limitations of this study, vary. First, I recommend a
quantitative study after the completion of this study using the data acquired from the study. This
could assist in determining the cause of the lack of reform within ABA at this time. A
quantitative study would also allow for a larger sample size, likely varying participants’
responses (Merriam & Tisdell, 2015). Additionally, I recommend conducting additional studies
on neurodivergent-affirming care by developing a survey determining what does or does not
constitute neurodivergent-affirming care that could be applicable across industries. This would
allow for an objective list of what does and does not qualify under neurodivergent-affirming care
to increase participants’ motivation by making it more objective and achievable. Lastly, I
recommend future research on the directions of ABA to identify if recommended interventions
align with neurodivergent-affirming practices when analyzed in their entirety.
Conclusion
A lack of neurodiversity-affirming care is a significant barrier to providing autistic clients
the care and support they deserve when receiving services intended to increase their

144
independence and quality of life. This problem is significant because the autistic community has
expressed that ABA has caused significant harm to their identity and how others receive them
due to inadequate and ableist practices. A lack of reform puts current and future autistic clients at
risk of trauma and poses a risk to the future of the field of ABA and our practitioners. This study
used CDT to identify ableist aspects of service implementation and emphasize the necessity to
reform practices and Clark and Estes’s (2008) gap analysis to identify BCBAs’ KMO
experiences, challenges, and recommendations around neurodivergent-affirming practices. Based
on findings acquired through interviews and document analysis on organizations and educational
institutions, recommendations were proposed to assist with BCBAs’ ability to implement
neurodivergent-affirming practices.
Since the inception of this dissertation, multiple additional resources have become
available to assist BCBAs with moving toward neurodivergent-affirming care. We, as BCBAs,
are taking the steps necessary to improve practices and better support the autistic community.
However, we have a long way to go as a field, and that requires us to look at the past and to
listen to autistic voices. I hope that more of my fellow BCBAs, organizations, and educational
institutions will continue to take those steps and that this research will assist and decrease the
response effort needed to move toward change.

145
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Appendix A: Institutional Review Board at the University of Southern California Approval

160

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Appendix B: Research Invitation and Participant Information Sheet

162
Appendix C: Qualtrics Demographic Survey Informed Consent and Questions
Demographic Survey Questions
What eligibility pathway did you take to become a BCBA/BCBA-D?
What is your current certification status?
What year did you pass your certification exam?
Are you currently eligible to supervise individuals pursuing certification in accordance
with BACB guidelines?
Do you currently work with autistic clients, or have you worked with autistic clients in
ABA?
Approximately how long have you worked with the autistic community?

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Please include your preferred contact information below if you would like to participate
further in this study and volunteer for an interview.
End of Survey Note
The survey can be accessed anonymously at the link below:
https://usc.qualtrics.com/jfe/form/SV_1YRXZnwgWQ8rJNc

164
Appendix D: Informed Consent Disclosure
Title: Neurodivergent-Affirming Care Within Applied Behavior Analysis
Purpose of the Study: The purpose of this study is to understand the lived experiences of
different BCBAs regarding their experiences, challenges, and competencies related to the current
necessity for reform within ABA to move toward neurodivergent-affirming care and the
knowledge, motivation, and organizational factors influencing this decision. This information
will be acquired through interviewing BCBAs and analyzing documentation provided by
educational institutions and organizations to determine educational and training opportunities
and/or limitations.
Researcher Information: The researcher, Kristina Judie, is a doctoral candidate at the
University of Southern California. Additionally, Kristina Judie holds a role as a BCBA and
Clinical Manager at an organization providing ABA services to autistic clients. Kristina can be
contacted through email at judie@usc.edu.
Consent Form Purpose: The purpose of this consent form is to provide potential participants
with the information necessary to allow them to determine if they would like to participate in this
study voluntarily. Please ask any questions you may have at any time. The researcher would
prefer to give you all the information you need to make an informed decision before beginning
the research process to ensure you have all the information necessary to make your decision and
feel confident doing so. Important information to keep in mind:
● Your participation is entirely voluntary.
● You can withdraw from the study at any time without repercussions or judgment.
Participation: If you decide to participate in this study, you will be asked to do the following
additional activities:
● Participate in a recorded interview conducted online via Zoom for 30 to 60 minutes.
● Engage in member checks, allowing the researcher to reach out to confirm your interview
responses are interpreted as you intended.
Participant Potential Risks
● Participating in this study can cause distress if/when recalling unpleasant experiences
related to service implementation.
● The researcher, like the participant, is a mandated reporter meaning confidentiality
cannot be guaranteed if related to mandated reporting criteria.

165
Participant Benefits
● Ability to influence the necessity and steps toward neurodivergent-affirming care in
applied behavior analysis.
Confidentiality
Maintaining participant confidentiality is at the forefront of the researcher’s mind. The
researcher will publish the results of this study in her dissertation however participant
information will not be identified. Reasonable measures will be taken to protect the security of
personal information. All data will be de-identified prior to any publications or presentations.
Data may be shared, de-identified, with other researchers in the future. Please see below for
measures the research will be following to maintain confidentiality:
● Pseudonyms: Pseudonyms will be used for all research participants. Any indicative
information that could connect to the researcher (e.g., current position if uncommon,
current or former organization names) will be removed from interview transcripts, and a
pseudonym will be used in data analysis and confirmed with participants. Coded
pseudonyms will be kept in a separate location from the data.
● Data Management: Interview recordings will be backed up to the researcher’s passwordprotected computer and relocated to her student SharePoint account. Any printed data
with identifiable information will be kept in a locked file cabinet.
● Participants will be encouraged to choose their own interview location for the virtual
interview process for maximum privacy.
● The researcher will ensure she is in a private location to conduct the virtual interviews.
Consent
Please read the following statements. Mark each box if you agree to the information included to
the right of the box:
I understand the purpose of this study and have had any questions answered needed to
feel confident in participating.
I understand that I can withdraw from this study at any time.
I consent to participate in this research study.
I consent to participate in a recorded interview.
I consent to the researcher following up with me to confirm the information I provided
during the interview was understood as I intended.
I understand that there is no cost to me for participating in this study.
Participant Printed Name: ________________________________________
Participant Signature: ____________________________________________ Date: __________

166
Appendix E: Interview Questions
Appendix E: Interview Questions
Interview questions Potential probes
Please describe your profession and
experience in the field.
What led you to want to pursue becoming a
BCBA and working with autistic
individuals?
What characteristics do you feel make a
quality behavior analyst working with
autistic individuals?
Can you elaborate on that?
What areas do you feel you are doing well in
regarding working with autistic individuals?
What areas do you feel you need to grow in?
Can you please describe what your training
looked like regarding autism?
Where did this training occur?
Have you had other training related to autism?
Neurodivergence, or ableism?
How do you determine what training to take
for continuing education and growing your
skillset?
Is this a decision you make on your own, or
does your organization influence it?
With an update in our ethical guidelines
regarding client assent, can you describe
how your training has shifted if they have?
If yes, what are your perspectives on it and the
support you have or haven’t been given to
modify your approach?
If you are aware of the controversy
surrounding ABA based on feedback from
the autistic community, how do you
respond to it?
Can you elaborate on how your practices have
been influenced by feedback from the
autistic advocates reporting that targeting
things such as forced eye contact and
reducing stereotypy is harmful?
If yes, how does your organization support
these changes?
What do you view as limitations to shaping
practices based on feedback from the
autistic community?
Benefits?
What factors do you feel influence your
ability to adjust your practices based on
feedback from the autistic community?
In what ways do you feel supported or not
regarding that?
What factors do you feel influence other
behavior analysts’ ability to adjust their
practices?
What leads you to that thought process?
What organizational factors do you feel
influence your ability to adjust your
practices?
In what ways do you feel support or not
regarding that?

167
Interview questions Potential probes
What organizational factors do you feel could
influence other behavior analysts’ ability to
adjust their practices? What leads you to that thought process?
Before we conclude, is there anything you’d
like to discuss relating to this topic that
wasn’t addressed?

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Asset Metadata

Creator Judie, Kristina S. (author)

Core Title Neurodivergent-affirming care within applied behavior analysis

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2024-08

Publication Date 09/05/2024

Defense Date 07/10/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag ableism,Applied Behavior Analysis,autism,board-certified behavior analyst,knowledge,motivation,neurodivergent,neurodivergent-affirming care,neurodiversity,neurodiversity-affirming care,OAI-PMH Harvest,organization,Trauma

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Language English

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Advisor Boveja Riggio, Marsha (committee chair), Page, Erika (committee member), Trahan, Don (committee member)

Creator Email judie@usc.edu,kristina.judie@icloud.com

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Format theses (aat)

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