Aba austism & law

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 After reading Fong (2016) and Kornack, Cernius, & Persicke (2019), 

1. describe how you will become more culturally aware in your behavior analytic practice. 

2. Discuss how cultural competency will benefit your clients. 

3. Is it unethical if a behavior analyst does not develop cultural awareness skills? 

4. List all applicable ethics codes. Provide the rationale for the chosen code(s). 

Minimum 200 words. Maximum 250 words. Course hero has an answered discussion. It cant be the same as that one.

Behavior Analysis in Practice (2019) 12:879–886
https://doi.org/10.1007/s40617-019-00377-y

SPECIAL SECTION: DIVERSITY AND INCLUSION

The Diversity Is in the Details: Unintentional Language
Discrimination in the Practice of Applied Behavior Analysis

Julie Kornack1 & Ariana Cernius2 & Angela Persicke3

Published online: 9 August 2019
# Association for Behavior Analysis International 2019

Abstract
Individuals with limited English proficiency face more challenges accessing applied behavior analysis (ABA) than their English-
speaking counterparts. Many federal and state laws have been enacted to ensure the civil rights of protected classes, and
Section 1557 of the Affordable Care Act (ACA, 2010) builds on those laws and explicitly establishes a cause of action (i.e., a
basis to sue) against health care providers, including ABA providers, who discriminate against patients on the basis of race, color,
national origin, sex, age, or disability. A patient’s language falls under the scope of national origin, and most health care
providers, including behavior analysts who deliver ABA as medically necessary treatment, have a duty to ensure that patients
who are Limited English Proficient (LEP) have the same access to the provider’s services as English-speaking patients.
Knowledge of this provision of the ACA is critical to its compliance and, more importantly, to ensuring that behavior analysts
rise to the challenge that the goal of true diversity represents. Note: Many terms are used interchangeably to describe insurance
carriers, insurance issuers, health plans, and managed care organizations, as well as practitioners of applied behavior analysis. In
this article, insurance carriers, insurance issuers, health plans, and managed care organizations are referred to as payors, and
practitioners of applied behavior analysis are referred to as behavior analysts or ABA providers.

Keywords Applied behavior analysis, ABA . Autism, ASD . Affordable Care Act, ACA . Obamacare, Section 1557, diversity,
interpreter, health care, discrimination . LEP, Limited English Proficient

How we define diversity likely informs how we manifest it in
our lives and in the practice of behavior analysis. If diversity is
defined too narrowly or contemplated too briefly, unintention-
al discrimination may adversely impact access to health care
for patients with limited English proficiency, including indi-
viduals seeking access to applied behavior analysis (ABA).
Simply put, if an English-speaking patient can access ABA
services more easily than a non-English-speaking patient, then
a discriminatory practice is likely in place. Ensuring diversity
in the practice of health care, including ABA, is especially

This manuscript has not been previously published and has not been or
will not be submitted elsewhere during the review process.

* Julie Kornack
[email protected]

1 Center for Autism and Related Disorders, 21600 Oxnard Street, 18th
Floor, Woodland Hills, CA 91367, USA

2 Bet Tzedek Legal Services, Los Angeles, CA, USA

complex, replete with ethical and practical implications for
patient access to care, best practices, and provider
sustainability.

The field of ABA and the population it serves have histor-
ically endured discrimination to such an extent that nonprofit
organizations, advocacy groups, bodies of law, and even re-
search exist purely to ensure that people who need ABA have
access to it (Unumb & Unumb, 2011). With a focus on indi-
vidualized, data-driven treatment, goals, and priorities to ad-
dress each patient’s unique challenges and deficits, behavior
analysis would seem inherently diverse; yet, data show that
individuals who are limited English proficient (LEP) access
ABA later, less often, and for shorter durations than their
English-speaking counterparts (Zuckerman et al., 2017).

LEP is defined to include “individuals who do not speak
English as a primary language and who have a limited ability
to read, speak, write, or understand English” (LEP.gov, n.d.).
The percentage of LEP families varies broadly from state to
state and from one community to the next. Yu and Singh
(2009) report that nearly 14% of children come from house-

Pepperdine University, Malibu, CA, USA holds where the primary language is not English. Patients and 3

880 Behav Analysis Practice (2019) 12:879–886

their families who speak English are likely to encounter fewer
barriers to accessing ABA. This more challenging access for
LEP families raises important questions about which practices
currently in place may be discriminatory and draws attention
to potential legal and ethical issues for ABA providers.

Given that patients who receive ABA earlier, at greater
intensity, and for a longer duration are more likely to have
better outcomes (Eikeseth, Smith, Jahr, & Eldevik, 2007;
Granpeesheh, Dixon, Tarbox, Kaplan, & Wilke, 2009;
Linstead et al., 2017; Virues-Ortega, Rodríguez, & Yu,
2013), equal access to ABA across all demographics is not
only a requirement under federal law (Affordable Care Act
[ACA], 2010) but also an important goal in the effort to ad-
vance diversity in ABA among providers and patients alike.
The next frontier, in other words, is to ensure that access to
ABA is the same for both English-speaking and LEP
populations.

Although ABA is used to treat a variety of diagnoses, a
majority of behavior analysts treat the behaviors and deficits
associated with the core diagnostic criteria of autism spectrum
disorder (ASD), and predictions for growth in the field of
ABA rely on the preservation and expansion of autism insur-
ance reform laws and on data regarding autism prevalence
rates (Deochand & Fuqua, 2016). As such, this discussion
about ABA providers in the context of a benefit covered by
health insurance and Medicaid is primarily—and necessari-
ly—focused on access to ABA by individuals diagnosed with
ASD and their families.

Disparity in Access to ABA

Autism insurance reform, the ACA, and clarification that
ASD treatment is a covered benefit for Medicaid’s pediatric
population have collectively increased access to ABA (ACA,
2010; Cernius, 2016; Mann, 2014;). Yet, families frequently
face practical barriers to accessing ABA therapy programs for
their children despite their legal right to coverage. Many of the
barriers experienced by patients (e.g., lack of insurance,
excessive cost sharing, difficulty understanding and nav-
igating the health care system, provider shortages) are
not typically within the control of an ABA provider.
Once a patient contacts an ABA provider, though, fed-
eral law mandates that the patient must be able to com-
municate with the behavior analyst and his or her staff
regardless of the patient’s language (ACA, 2010).

Indeed, Yu and Singh (2009) cited “linguistically concor-
dant providers” and access to interpreters as two potential
variables that may increase access to medically necessary
treatment for children from LEP homes. Zuckerman et al.
(2017) identified English proficiency as a significant variable
in access to autism treatment in Spanish-speaking families,
meaning that LEP families encounter more barriers to

treatment than their English-speaking counterparts. In a retro-
spective review of 152 children with ASD, St. Amant,
Schrager, Pena-Ricardo, Williams, and Vanderbilt (2018)
identified language as a potential barrier to health care for
children in the study whose parents’ primary language was
not English.

Role of Behavior Analysts in Ensuring
Equitable Access to ABA

With increasing recognition of the effectiveness of ABA and
the growing prevalence rate of ASD (Baio et al., 2018), be-
havior analysts may find themselves with an abundance of
prospective patients. Indeed, behavior analysts qualified to
treat ASD are in short supply (Behavior Analyst
Certification Board, 2018). That abundance of patients may
make it less likely for a behavior analyst to have a practice that
reflects his or her community demographics. For example, if a
behavior analyst only speaks English, then she or he may be
inclined to treat only those patients who speak English and
may very well build a successful practice serving only
English-speaking patients. That is, ASD’s high prevalence
rate may contribute to a process in which ABA providers have
the option to be selective about the patients they treat. Yet,
what may be viewed by an ABA provider as an efficient
business practice or professional focus may, in fact, be dis-
crimination, both in the eyes of the federal government and in
the experience of the LEP community.

Quite possibly, in an effort to comply with the
Behavior Analyst Certification Board’s Professional
and Ethical Compliance Code for Behavior Analysts
(2017, Code 1.05[b–c]), a behavior analyst who encoun-
ters an LEP patient may determine that she or he is
unable to “use language that is fully understandable to
the recipient of those services while remaining concep-
tually systematic with the profession of behavior analy-
sis” or obtain the appropriate “training, experience, con-
sultation, and/or supervision necessary to ensure the
competence of their services” and will refer the patient
to another provider. An ABA provider may view this
practice as an effort to honor the compliance code, but
Section 1.05(d) of the compliance code clearly states
that behavior analysts may not “engage in discrimina-
tion against individuals or groups based on . . . national
origin . . . or any basis proscribed by law.” Behavior
analysts should take necessary steps to understand their
responsibility to ensure that patients who seek medically
necessary ABA have equitable access to treatment, irre-
spective of their primary language. In addition to the
clear ethical duty to provide such access, most behavior
analysts are required by law to take proactive steps to
ensure equitable access to the services they provide.

881 Behav Analysis Practice (2019) 12:879–886

Overview of the ACA and Section 1557

In 2010, Congress passed the Patient Protection and
Affordable Care Act and, shortly after, the Health Care and
Education Reconciliation Act of 2010. Together, these acts
became known as the Affordable Care Act (ACA), commonly
known as Obamacare, setting in motion a major overhaul of
the health insurance system in America, with many implica-
tions for health care and insurance coverage (Unumb &
Unumb, 2011). Section 1557 is the nondiscrimination provi-
sion of the ACA that extends nondiscrimination protections to
individuals in accessing health care by building upon long-
standing and well-known federal civil rights laws, such as
Title VI of the Civil Rights Act of 1964, which prohibits
discrimination on the basis of race, color, and national origin;
Title IX of the Education Amendments of 1972, which pro-
hibits discrimination on the basis of sex; Section 504 of the
Rehabilitation Act of 1973, which prohibits discrimination on
the basis of disability; and the Age Discrimination Act of
1975, which prohibits discrimination on the basis of age
(Department of Health and Human Services [HHS] Office
for Civil Rights, 2016). Section 1557 is meant to advance
and protect the ACA’s goals of widening access to health care
and coverage, eliminating barriers, and reducing health dis-
parities (HHS Office for Civil Rights, 2016). By creating new
obligations for covered health care providers and payors to
ensure that people have equitable access to health care ser-
vices and do not face discrimination, Section 1557 extends
the protections of civil rights laws to the U.S. health care
system (Seng, Jakubowski, & Compton-Brown, 2016).

In relevant part, Section 1557 provides that

an individual shall not . . . be excluded from participa-
tion in, be denied the benefits of, or be subjected to
discrimination under, any health program or activity,
any part of which is receiving Federal financial assis-
tance, or under any program or activity that is adminis-
tered by an Executive Agency or any entity established
under Title I of the Act or its amendments.

(Nondiscrimination in Health Programs and Activities,
Final Rule, 2016)

In simpler terms, under Section 1557, most health pro-
grams and activities, including most medically necessary
ABA, are prohibited from discriminating on the basis of race,
color, national origin, sex, age, or disability (HHS Office for
Civil Rights, 2016).

Although Section 1557 has always existed as part of the
ACA law that was passed in 2010, implementing regulations
were not finalized until 2016, extending the principle of non-
discrimination to health care and health insurance. In
May 2016, HHS issued a rule describing precisely what cov-
ered providers must do in order to comply with Section 1557

(Seng et al., 2016). These regulations, t i tled
“Nondiscrimination in Health Programs and Activities, Final
Rule” and found at 42 CFR Part 92, became effective on
July 18, 2016, and offer guidance as to which populations
are protected under Section 1557, which health care providers
are required to comply and how they may do so, and the
various remedies individuals may seek if they experience dis-
crimination from covered entities.

Understanding Section 1557 and Its
Relevance to ABA

The first step to understanding the impact of Section 1557 of
the ACA is to understand which ABA providers are covered
under its command. Section 1557 applies to all health pro-
grams and activities that receive federal financial assistance
from HHS and that are administered by HHS or by entities
created under Title I of the ACA (HHS Office for Civil Rights,
2016; Nondiscrimination in Health Programs and Activities,
Final Rule, 2016). Essentially, ABA providers who participate
to any extent in federally funded programs (e.g., TRICARE,
Medicaid, managed care organizations administering
Medicaid benefits, most commercial plans, etc.) are subject
to Section 1557 and are required to comply with its nondis-
criminatory mandate.

Although the autism community recognized early on that
Section 1557’s nondiscrimination provisions have great po-
tential to eliminate age discrimination in the funding of
ABA-based treatment, resources to increase awareness of pro-
vider responsibilities under Section 1557 have not been wide-
ly disseminated in the field of ABA (Lello, 2015).
Compliance with Section 1557 requires thoughtful planning,
development of new policies and procedures, employee edu-
cation and training, and implementation of an ongoing com-
pliance program. Additionally, the costs associated with com-
pliance with Section 1557 should be contemplated when ABA
providers contract with payors to provide services. As the
population seeking ABA grows, ABA providers should be
conscious of the linguistic diversity that exists within the pa-
tient base they serve and of any duties they may have to
improve the accessibility of their services to LEP families,
whom the law incorporates and protects under the category
of national origin.

Compliance

The Section 1557 provision outlines clear guidance and spe-
cific steps to help covered providers deliver health care to the
populations they serve in a way that is equitable and nondis-
criminatory. Under Section 1557, a covered provider may not
“segregate, delay or deny services or benefits based on an

882 Behav Analysis Practice (2019) 12:879–886

individual’s race, color or national origin, or delay or deny
effective language assistance services to individuals with lim-
ited English proficiency (LEP)” (HHS Office for Civil Rights,
2016; Nondiscrimination in Health Programs and Activities,
Final Rule, 2016). Covered providers, including ABA pro-
viders, have a duty to take reasonable steps to provide “mean-
ingful access” to care and coverage for each individual with
LEP who is eligible to be served or likely to be encountered in
their health programs and activities (Nondiscrimination in
Health Programs and Activities, Final Rule, 2016).
Examples of reasonable steps include the provision of lan-
guage assistance services, such as oral-language assistance
or written translations (HHS Office for Civil Rights, 2016).

Given the importance of complying with
Section 1557, both to serve the diverse population that
comprises those seeking ABA therapy and to avoid trig-
gering the legal ramifications of violating this nondis-
crimination provision, it is critical for covered ABA
providers to understand the steps that must be taken to
comply with the law. To meet the language access re-
quirements to communicate with families who are LEP,
covered entities must:

& provide oral interpretation and written translation services
at no cost to the individual and in a timely manner
(Nondiscrimination in Health Programs and Activities,
Final Rule, 2016; Schuh, 2017);

& adhere to certain quality standards in delivering language
assistance services—for instance, a covered entity may
not require an individual to provide his or her own inter-
preter; rely on a minor child to interpret, except in a life-
threatening emergency where there is no qualified inter-
preter immediately available; rely on interpreters that the
individual prefers when there are competency, confidenti-
ality, or other concerns; rely on unqualified bilingual or
multilingual staff; or use low-quality video remote
interpreting services (HHS Office for Civil Rights, 2016;
Nondiscrimination in Health Programs and Activities,
Final Rule, 2016; Schuh, 2017);

& post notices of nondiscrimination in offices, on websites,
and in any significant publications and communications
(Center for Medicare and Medicaid Services, 2016;
Nondiscrimination in Health Programs and Activities,
Final Rule, 2016); and

& post translated taglines (short statements in non-English
languages spoken in the state in which the entity is located
or conducts business) in significant publications and post
in prominent locations and on its website, indicating
the availability of language support services (Center
for Medicare and Medicaid Services, 2016; HHS
Office for Civil Rights, 2016; Nondiscrimination in
Health Programs and Activities, Final Rule, 2016;
Schuh, 2017).

Additionally, covered providers who have 15 employees or
more must:

& appoint or hire a Section 1557 compliance coordinator to
carry out the provider’s compliance efforts and responsi-
bilities, including the investigation of any grievance com-
municated to it alleging noncompliance with Section 1557
(Nondiscrimination in Health Programs and Activities,
Final Rule, 2016); and

& adopt grievance procedures that provide for the prompt
and equitable resolution of grievances alleging violations
of Section 1557 (Nondiscrimination in Health Programs
and Activities, Final Rule, 2016).

Sample notices, taglines, and other materials drafted by the
HHS Office of Civil Rights (OCR) are included in the appen-
dices following the regulations 42 CFR Part 92.

If ever a question is raised about a covered provider’s com-
pliance with Section 1557, many factors are taken into con-
sideration to determine whether the provider has met its obli-
gations, such as the “nature and importance of the health pro-
gram or activity and the particular communication at issue to
the individual with [LEP],” whether the provider has “devel-
oped and implemented an effective written language access
plan that is appropriate to its particular circumstances,” and
whether the provider has demonstrated an effort to meet its
obligations to take reasonable steps to provide meaningful
access to LEP families (Nondiscrimination in Health
Programs and Activities, Final Rule, 2016). With this in mind,
ABA providers should evaluate their compliance with
Section 1557 and make adjustments as necessary.

Consequence of Noncompliance

Covered ABA providers should be aware of the consequences
of noncompliance with Section 1557. Section 1557 explicitly
establishes a cause of action (i.e., right to sue) against health
care entities, including ABA providers, who discriminate
against patients on the basis of race, color, national origin,
sex, age, or disability (Rosenbaum, 2016). If an individual ex-
periences discrimination in accessing health care services by a
health care provider or insurer covered by Section 1557, the law
affords him or her several remedies, including (a) pursuing a
civil suit against the covered provider, (b) reporting instances of
discrimination by a covered provider to the OCR for investiga-
tion, (c) having the OCR revise the policies and procedures of
the covered provider, (d) requiring the covered provider to pay
compensatory damages to the individual who experienced dis-
crimination, (e) suspending or terminating federal financial as-
sistance allotted to providers who refuse to take corrective ac-
tion, and/or (f) referring the covered provider to the U.S.
Department of Justice for further enforcement action (HHS

883 Behav Analysis Practice (2019) 12:879–886

Office for Civil Rights, 2016; Nondiscrimination in Health
Programs and Activities, Final Rule, 2016).

Costs Associated with Section 1557

In addition to administrative costs, the primary cost arising
from the effort to ensure equal access to ABA for LEP families
is the cost of the interpreter, but whether the provider or payor
is responsible for that cost can depend on a number of vari-
ables, including the state where the services are delivered, the
funding source, and the inclination of the payor to incentivize
providers to make their services accessible to the payor’s LEP
population (Jacobs, Shepard, Suaya, & Stone, 2004;
Nondiscrimination in Health Plans and Activities, Final
Rule, 2016). Both the behavior analyst and the payor have a
duty to ensure that patients can access treatment regardless of
their primary language. In many instances, payors will provide
access to an interpreter service when the health care provider
requests it. Prior to identifying a patient’s funding source,
however, behavior analysts should be prepared to communi-
cate with prospective LEP patients.

Therefore, employees who initially communicate with pro-
spective patients or their families should be trained and
equipped to communicate with and collect information from
English-proficient and nonproficient patients alike at the ABA
provider’s expense. Once a patient’s funding source is identi-
fied, the cost of the interpreter may shift to the payor.
Importantly, though, the failure of a payor to provide an inter-
preter does not relieve the behavior analyst of the duty to ensure
equal access to ABA by LEP patients and their families.

HHS makes clear that its preference is for the cost of the
interpreter to be borne by the payors but stops well short of
imposing any sort of requirement on the payors to bear that cost.
In the Final Rule implementing Section 1557, HHS reminds
payors that the ACA requires qualified health plans to incentivize
providers for “the implementation of activities to reduce health
and health care disparities, including through the use of language
services” (Nondiscrimination in Health Programs and Activities,
Final Rule, 2016). HHS goes on to encourage payors to “con-
sider health care providers’ expenses in providing language as-
sistance services” when structuring reimbursement rates.

State Medicaid agencies have the option of securing
matching federal funds for the cost of the interpreter, but the
National Health Law Program (NHeLP) reports that only 14
states and the District of Columbia appear to have taken advan-
tage of this resource, including Connecticut, Iowa, Idaho,
Kansas, Maine, Minnesota, Montana, New Hampshire, New
York, Texas (sign language interpreters only), Utah, Vermont,
Washington, and Wyoming (Youdelman, 2017). Additionally,
Arizona Medicaid explicitly requires the managed care organi-
zations administering its Medicaid benefit to pay for the inter-
preter (Arizona Health Care Cost Containment System

[AHCCCS], 2017). Anecdotally, providers report state
Medicaid agencies, in addition to those identified by NHeLP,
as providing access to interpreter services funded by the state or
managed care organization contracting with the state to deliver
the Medicaid benefit, including California, Colorado,
Louisiana, Michigan, Minnesota, Oregon, and Washington.

Behavior analysts who contract with payors as in-network
providers should address Section 1557 requirements in the
contracting process to ensure that reimbursement rates reflect
the projected cost of providing services to the payor’s benefi-
ciaries in compliance with Section 1557. Although all patients
who require an interpreter must have access to an interpreter
when contacting their payor, the process to sustain that access
continues to evolve as health care providers seek guidance
from the payors and become more familiar with their respon-
sibilities under Section 1557.

Considerations

Section 1557 is replete with positive implications for ensuring
equitable access to ABA across diverse populations.
Compliance with Section 1557 requires providers to take spe-
cific steps (see Appendix Table 1). Even so, as the field of
behavior analysis endeavors to comply with Section 1557,
existing and new processes and procedures should be evalu-
ated to ensure that best practices are not diluted.

Length of Visit with Interpreter Involvement

Several studies evaluate the increased duration of clinic visits
associated with the use of an interpreter and report minimal to
no increase in visit length (Fagan, Diaz, Reinert, Sciamanna,
& Fagan, 2003; Jacobs, Ryan, Henrichs, & Weiss, 2018).
Behavior analysts who use interpreters for assessment,
parent/caregiver training, or one-to-one ABA may be in a
position to collect and disseminate data specific to the use of
interpreters in the delivery of ABA to help the field identify
whether the use of an interpreter significantly extends the
duration of a service. To ensure that LEP patients have access
to the same intensity of treatment as their English-proficient
counterparts, ABA providers may want to seek additional
hours or flexibility from payors to avoid inadequate treatment
authorizations. Additionally, the need for interpreters may be
minimized if ABA providers undertake intentional efforts to
hire and train individuals who reflect the cultural and linguis-
tic diversity of the community in which they practice.

Separate Billing Codes and Modifiers

If the payor has agreed to pay for the interpreter, ABA pro-
viders should be cognizant of billing codes and modifiers
associated with the interpreter activity to ensure proper claims

884 Behav Analysis Practice (2019) 12:879–886

submissions and timely reimbursement. If the cost of the in-
terpreter is borne by the provider, providers may want to ask
their accountants to check for tax subsidies and/or tax credits
that may be available for such expenditures.

Medically Unlikely Edits

Medically Unlikely Edits (MUEs), developed by CMS for
most billing codes to reduce the number of erroneously paid
claims, set the likely number of units for each billing code in a
day (Center for Medicare and Medicaid Services, 2018). An
MUE is the maximum number of units that a provider is likely
to report for one patient in one day. Interpreter services should
not be counted toward the MUEs for the billable service that
requires the interpreter. If payors do not offer a separate billing
code or modifier for the interpreter service, ABA providers
should be alert to the possibility of rejected claims that require
an appeal and the delay associated with such a process. MUEs
should not be used to limit medically necessary treatment,
regardless of the language status of the patient.

Rate Negotiations

Rate negotiations should be undertaken only with a full un-
derstanding of whether the payor or provider is financially
responsible for the interpreter and translation of medical re-
cords and forms, where necessary. Staff training, interpreter,
translator, and development of materials represent some of the
costs that should be contemplated when negotiating rates. If
the cost of the interpreter is not explicitly denoted in the con-
tract, seek clarification and update the contract to reflect any
clarification provided. Absent sufficient rates or clarification,
providers should be wary of contracts that do not allow them
to make informed decisions that ensure the sustainability of
their ABA practice.

Conclusion

The realm of health care is an area where lack of diversity is
particularly visible, often because the serious consequences

that arise from inadequate access to quality health care ser-
vices have measurable deleterious effects for years to come.
As ABA providers increasingly comply with the requirements
of Section 1557, access to ABA is likely to become more
equitable and more likely to reflect the diversity of the com-
munities in which services are provided.

Behavior analysts should continue to develop and dissem-
inate resources to increase awareness of Section 1557 and
should build on existing research that currently identifies
LEP as a barrier to ABA. In states where Medicaid agencies
have not pursued federal matching funds for the cost of inter-
preters for Medicaid enrollees, behavior analysts may want to
ensure their state is aware of this funding source and of the
impracticality of shifting such a cost to ABA providers. This
task will require active and engaged participation from stake-
holders, including families, providers, lawmakers, and advo-
cates, to ensure equitable access to ABA that reflects best
practices and optimizes outcomes.

The principle of nondiscrimination embodied in
Section 1557 aligns with ongoing efforts in the field of
behavior analysis to encourage and embrace diversity and
is critical to ensuring equitable access to ABA. Given that
significant barriers were overcome in order to create ac-
cess to medically necessary ABA, the goal to eliminate
discriminatory provider practices, both in compliance
with Section 1557 and in keeping with the aspirations of
the field, would seem well within reach. Laws and regu-
lations that affect ABA providers are always subject to
change, and behavior analysts should have a plan in place
to stay informed about their legal obligations as health
care providers.

Funding No funding was received for this study.

Compliance with Ethical Standards

Conflict of Interest Julie Kornack declares that she has no conflict of
interest. Ariana Cernius declares that she has no conflict of interest.
Angela Persicke declares that she has no conflict of interest.

Ethical Approval This article does not contain any studies with human
participants or animals performed by any of the authors.

Appendix

Table 1 Language diversity and
section 1557 compliance toolkit Anticipate the

language needs of
your community.

� Identify the top 15 non-English languages in your state by going to https://www.cms.
gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Appendix-A-Top-15.
pdf.

� Solicit information from health plans and insurers regarding primary languages of
beneficiaries.

� Ask other health care providers and schools to share data about dominant languages in
the community where your practice is located.

885 Behav Analysis Practice (2019) 12:879–886

Table 1 (continued)

� Visit https://www.lep.gov/maps/ to get specific information about LEP in your
community.

Identify compliance � Depending on the number of employees, appoint or hire a Section 1557 coordinator.
tools. � Customize and post the nondiscrimination notice and non-English taglines in your

office and on your website and include them in significant publications.

� Contract with an interpreter service.

For providers with 15 employees or more:

� Appoint or hire a Section 1557 compliance coordinator.

� Adopt grievance procedures for incidents of noncompliance.

Increase awareness. � Train all staff who communicate with patients, prospective patients, and their families
to be aware of patient rights and provider responsibilities.

� Familiarize employees with posted notices and interpreter resources.

� Share your knowledge with colleagues.

Ensure sustainability. � Collect data on the time and cost associated with compliance.

� Ensure payors authorize sufficient hours for each element of treatment that requires an
interpreter.

� Negotiate rates with payors that contemplate the additional costs (e.g., interpreter,
translator, staff training, personnel, materials).

� Review payor contracts to identify whether the payor or provider bears the cost of the
interpreter.

References

Arizona Health Care Cost Containment System. (2017). Cultural compe-
tency, language access plan, and family/patient centered care. In
AHCCCS contractor operations manual (Chapter 405). Retrieved
from https://www.azahcccs.gov/shared/downloads/acom/acom.pdf.

Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J.,
Warren, Z., et al. (2018). Prevalence of autism spectrum disorder
among children aged 8 years—Autism and developmental disabil-
ities monitoring network, 11 sites, United States, 2014. MMWR
Surveillance Summaries, 67(6), 1. https://doi.org/10.15585/mmwr.
ss6706a1.

Behavior Analyst Certification Board. (2017). Professional and ethical
compliance code for behavior analysts. Retrieved from https://
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Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.

  • The Diversity Is in the Details: Unintentional Language Discrimination in the Practice of Applied Behavior Analysis
    • Abstract
    • Disparity in Access to ABA
    • Role of Behavior Analysts in Ensuring Equitable Access to ABA
    • Overview of the ACA and �Section�1557
    • Understanding �Section�1557 and Its Relevance to ABA
    • Compliance
    • Consequence of Noncompliance
    • Costs Associated with �Section�1557
    • Considerations
      • Length of Visit with Interpreter Involvement
      • Separate Billing Codes and Modifiers
      • Medically Unlikely Edits
      • Rate Negotiations
    • Conclusion
    • Appendix
    • References

Professional and Ethical
Compliance Code for
Behavior Analysts

BEHAVIOR ANALYST CERTIFICATION BOARD®
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The Behavior Analyst Certification Board’s (BACB’s) Professional and Ethical Compliance Code for
Behavior Analysts (the “Code”) consolidates, updates, and replaces the BACB’s Professional
Disciplinary and Ethical Standards and Guidelines for Responsible Conduct for Behavior Analysts.
The Code includes 10 sections relevant to professional and ethical behavior of behavior analysts,
along with a glossary of terms. Effective January 1, 2016, all BACB applicants and certificants will
be required to adhere to the Code.

_________________________

In the original version of the Guidelines for Professional Conduct for Behavior Analysts, the authors acknowledged
ethics codes from the following organizations: American Anthropological Association, American Educational Research
Association, American Psychological Association, American Sociological Association, California Association for Behavior
Analysis, Florida Association for Behavior Analysis, National Association of Social Workers, National Association of School
Psychologists, and Texas Association for Behavior Analysis. We acknowledge and thank these professional organizations
that have provided substantial guidance and clear models from which the Code has evolved.

Approved by the BACB’s Board of Directors on August 7, 2014.

This document should be referenced as: Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for
behavior analysts. Littleton, CO: Author.

© 2014 Behavior Analyst Certification Board,® Inc. (BACB®), all rights reserved. Ver. March 18, 2019.

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Contents

1.0
1.01
1.02
1.03
1.04
1.05
1.06
1.07

2.0
2.01
2.02
2.03
2.04
2.05
2.06
2.07
2.08
2.09
2.10
2.11
2.12
2.13
2.14
2.15

3.0
3.01
3.02
3.03
3.04
3.05

4.0
4.01
4.02
4.03
4.04
4.05
4.06
4.07
4.08
4.09
4.10
4.11

Responsible Conduct of Behavior Analysts
Reliance on Scientific Knowledge
Boundaries of Competence
Maintaining Competence through Professional Development
Integrity
Professional and Scientific Relationships
Multiple Relationships and Conflicts of Interest
Exploitative Relationships

Behavior Analysts’ Responsibility to Clients
Accepting Clients
Responsibility
Consultation
Third-Party Involvement in Services
Rights and Prerogatives of Clients
Maintaining Confidentiality
Maintaining Records
Disclosures
Treatment/Intervention Efficacy
Documenting Professional Work and Research
Records and Data
Contracts, Fees, and Financial Arrangements
Accuracy in Billing Reports
Referrals and Fees
Interrupting or Discontinuing Services

Assessing Behavior
Behavior-Analytic Assessment
Medical Consultation
Behavior-Analytic Assessment Consent
Explaining Assessment Results
Consent-Client Records

Behavior Analysts and the Behavior-Change Program
Conceptual Consistency
Involving Clients in Planning and Consent
Individualized Behavior-Change Programs
Approving Behavior-Change Programs
Describing Behavior-Change Program Objectives
Describing Conditions for Behavior-Change Program Success
Environmental Conditions that Interfere with Implementation
Considerations Regarding Punishment Procedures
Least Restrictive Procedures
Avoiding Harmful Reinforcers
Discontinuing Behavior-Change Programs and Behavior-Analytic
Services

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Contents, continued

5.0
5.01
5.02
5.03
5.04
5.05
5.06
5.07

6.0
6.01
6.02

7.0
7.01
7.02

8.0
8.01
8.02
8.03
8.04
8.05
8.06

9.0
9.01
9.02
9.03
9.04
9.05
9.06
9.07
9.08
9.09

Behavior Analysts as Supervisors
Supervisory Competence
Supervisory Volume
Supervisory Delegation
Designing Effective Supervision and Training
Communication of Supervision Conditions
Providing Feedback to Supervisees
Evaluating the Effects of Supervision

Behavior Analysts’ Ethical Responsibility to the Profession of Behavior Analysts
Affirming Principles
Disseminating Behavior Analysis

Behavior Analysts’ Ethical Responsibility to Colleagues
Promoting an Ethical Culture
Ethical Violations by Others and Risk of Harm

Public Statements
Avoiding False or Deceptive Statements
Intellectual Property
Statements by Others
Media Presentations and Media-Based Services
Testimonials and Advertising
In-Person Solicitation

Behavior Analysts and Research
Conforming with Laws and Regulations
Characteristics of Responsible Research
Informed Consent
Using Confidential Information for Didactic or Instructive Purposes
Debriefing
Grant and Journal Reviews
Plagiarism
Acknowledging Contributions
Accuracy and Use of Data

10.0 Behavior Analysts’ Ethical Responsibility to the BACB
10.01 Truthful and Accurate Information Provided to the BACB
10.02 Timely Responding, Reporting, and Updating of Information Provided to the BACB
10.03 Confidentiality and BACB Intellectual Property
10.04 Examination Honesty and Irregularities
10.05 Compliance with BACB Supervision and Coursework Standards
10.06 Being Familiar with This Code
10.07 Discouraging Misrepresentation by Non-Certified Individuals

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1.0 Responsible Conduct of Behavior Analysts.

Behavior analysts maintain the high standards of behavior of the profession.

1.01 Reliance on Scientific Knowledge.
Behavior analysts rely on professionally derived knowledge based on science and behavior analysis when
making scientific or professional judgments in human service provision, or when engaging in scholarly or
professional endeavors.

1.02 Boundaries of Competence.

(a) All behavior analysts provide services, teach, and conduct research only within the boundaries of their
competence, defined as being commensurate with their education, training, and supervised experience.

(b) Behavior analysts provide services, teach, or conduct research in new areas (e.g., populations,
techniques, behaviors) only after first undertaking appropriate study, training, supervision, and/or
consultation from persons who are competent in those areas.

1.03 Maintaining Competence through Professional Development.

Behavior analysts maintain knowledge of current scientific and professional information in their areas
of practice and undertake ongoing efforts to maintain competence in the skills they use by reading the
appropriate literature, attending conferences and conventions, participating in workshops, obtaining
additional coursework, and/or obtaining and maintaining appropriate professional credentials.

1.04 Integrity.

(a) Behavior analysts are truthful and honest and arrange the environment to promote truthful and honest
behavior in others.

(b) Behavior analysts do not implement contingencies that would cause others to engage in fraudulent,
illegal, or unethical conduct.

(c) Behavior analysts follow through on obligations, and contractual and professional commitments with
high quality work and refrain from making professional commitments they cannot keep.

(d) Behavior analysts’ behavior conforms to the legal and ethical codes of the social and professional
community of which they are members. (See also, 10.02a Timely Responding, Reporting, and Updating
of Information Provided to the BACB)

(e) If behavior analysts’ ethical responsibilities conflict with law or any policy of an organization with
which they are affiliated, behavior analysts make known their commitment to this Code and take steps
to resolve the conflict in a responsible manner in accordance with law.

Professional and Ethical Compliance Code
for Behavior Analysts

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1.05 Professional and Scientific Relationships.
(a) Behavior analysts provide behavior-analytic services only in the context of a defined, professional,

or scientific relationship or role.
(b) When behavior analysts provide behavior-analytic services, they use language that is fully

understandable to the recipient of those services while remaining conceptually systematic with
the profession of behavior analysis. They provide appropriate information prior to service delivery
about the nature of such services and appropriate information later about results and conclusions.

(c) Where differences of age, gender, race, culture, ethnicity, national origin, religion, sexual
orientation, disability, language, or socioeconomic status significantly affect behavior analysts’ work
concerning particular individuals or groups, behavior analysts obtain the training, experience,
consultation, and/or supervision necessary to ensure the competence of their services, or they make
appropriate referrals.

(d) In their work-related activities, behavior analysts do not engage in discrimination against
individuals or groups based on age, gender, race, culture, ethnicity, national origin, religion, sexual
orientation, disability, language, socioeconomic status, or any basis proscribed by law.

(e) Behavior analysts do not knowingly engage in behavior that is harassing or demeaning to persons
with whom they interact in their work based on factors such as those persons’ age, gender, race,
culture, ethnicity, national origin, religion, sexual orientation, disability, language, or socioeconomic
status, in accordance with law.

(f) Behavior analysts recognize that their personal problems and conflicts may interfere with their
effectiveness. Behavior analysts refrain from providing services when their personal circumstances
may compromise delivering services to the best of their abilities.

1.06 Multiple Relationships and Conflicts of Interest.

(a) Due to the potentially harmful effects of multiple relationships, behavior analysts avoid multiple
relationships.

(b) Behavior analysts must always be sensitive to the potentially harmful effects of multiple
relationships. If behavior analysts find that, due to unforeseen factors, a multiple relationship has
arisen, they seek to resolve it.

(c) Behavior analysts recognize and inform clients and supervisees about the potential harmful effects
of multiple relationships.

(d) Behavior analysts do not accept any gifts from or give any gifts to clients because this constitutes a
multiple relationship.

1.07 Exploitative Relationships.

(a) Behavior analysts do not exploit persons over whom they have supervisory, evaluative, or other
authority such as students, supervisees, employees, research participants, and clients.

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(b) Behavior analysts do not engage in sexual relationships with clients, students, or supervisees,
because such relationships easily impair judgment or become exploitative.

(c) Behavior analysts refrain from any sexual relationships with clients, students, or supervisees, for at
least two years after the date the professional relationship has formally ended.

(d) Behavior analysts do not barter for services, unless a written agreement is in place for the barter that
is (1) requested by the client or supervisee; (2) customary to the area where services are provided;
and (3) fair and commensurate with the value of behavior-analytic services provided.

2.0 Behavior Analysts’ Responsibility to Clients.

Behavior analysts have a responsibility to operate in the best interest of clients. The term client as used
here is broadly applicable to whomever behavior analysts provide services, whether an individual
person (service recipient), a parent or guardian of a service recipient, an organizational representative, a
public or private organization, a firm, or a corporation.

2.01 Accepting Clients.

Behavior analysts accept as clients only those individuals or entities whose requested services are
commensurate with the behavior analysts’ education, training, experience, available resources,
and organizational policies. In lieu of these conditions, behavior analysts must function under the
supervision of or in consultation with a behavior analyst whose credentials permit performing such
services.

2.02 Responsibility.

Behavior analysts’ responsibility is to all parties affected by behavior-analytic services. When multiple
parties are involved and could be defined as a client, a hierarchy of parties must be established and
communicated from the outset of the defined relationship. Behavior analysts identify and
communicate who the primary ultimate beneficiary of services is in any given situation and advocate
for his or her best interests.

2.03 Consultation.

(a) Behavior analysts arrange for appropriate consultations and referrals based principally on the best
interests of their clients, with appropriate consent, and subject to other relevant considerations,
including applicable law and contractual obligations.

(b) When indicated and professionally appropriate, behavior analysts cooperate with other
professionals, in a manner that is consistent with the philosophical assumptions and principles of
behavior analysis, in order to effectively and appropriately serve their clients.

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2.04 Third-Party Involvement in Services.

(a) When behavior analysts agree to provide services to a person or entity at the request of a third
party, behavior analysts clarify, to the extent feasible and at the outset of the service, the nature of
the relationship with each party and any potential conflicts. This clarification includes the role of
the behavior analyst (such as therapist, organizational consultant, or expert witness), the probable
uses of the services provided or the information obtained, and the fact that there may be limits to
confidentiality.

(b) If there is a foreseeable risk of behavior analysts being called upon to perform conflicting roles
because of the involvement of a third party, behavior analysts clarify the nature and direction of
their responsibilities, keep all parties appropriately informed as matters develop, and resolve the
situation in accordance with this Code.

(c) When providing services to a minor or individual who is a member of a protected population at the
request of a third party, behavior analysts ensure that the parent or client-surrogate of the ultimate
recipient of services is informed of the nature and scope of services to be provided, as well as their
right to all service records and data.

(d) Behavior analysts put the client’s care above all others and, should the third party make
requirements for services that are contraindicated by the behavior analyst’s recommendations,
behavior analysts are obligated to resolve such conflicts in the best interest of the client. If said
conflict cannot be resolved, that behavior analyst’s services to the client may be discontinued
following appropriate transition.

2.05 Rights and Prerogatives of Clients.

(a) The rights of the client are paramount and behavior analysts support clients’ legal rights and
prerogatives.

(b) Clients and supervisees must be provided, on request, an accurate and current set of the behavior
analyst’s credentials.

(c) Permission for electronic recording of interviews and service delivery sessions is secured from
clients and relevant staff in all relevant settings. Consent for different uses must be obtained
specifically and separately.

(d) Clients and supervisees must be informed of their rights and about procedures to lodge complaints
about professional practices of behavior analysts with the employer, appropriate authorities, and the
BACB.

(e) Behavior analysts comply with any requirements for criminal background checks.

2.06 Maintaining Confidentiality.

(a) Behavior analysts have a primary obligation and take reasonable precautions to protect the
confidentiality of those with whom they work or consult, recognizing that confidentiality may be
established by law, organizational rules, or professional or scientific relationships.

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(b) Behavior analysts discuss confidentiality at the outset of the relationship and thereafter as new
circumstances may warrant.

(c) In order to minimize intrusions on privacy, behavior analysts include only information germane
to the purpose for which the communication is made in written, oral, and electronic reports,
consultations, and other avenues.

(d) Behavior analysts discuss confidential information obtained in clinical or consulting relationships,
or evaluative data concerning clients, students, research participants, supervisees, and employees,
only for appropriate scientific or professional purposes and only with persons clearly concerned
with such matters.

(e) Behavior analysts must not share or create situations likely to result in the sharing of any identifying
information (written, photographic, or video) about current clients and supervisees within social
media contexts.

2.07 Maintaining Records.

(a) Behavior analysts maintain appropriate confidentiality in creating, storing, accessing, transferring,
and disposing of records under their control, whether these are written, automated, electronic, or in
any other medium.

(b) Behavior analysts maintain and dispose of records in accordance with applicable laws, regulations,
corporate policies, and organizational policies, and in a manner that permits compliance with the
requirements of this Code.

2.08 Disclosures.

Behavior analysts never disclose confidential information without the consent of the client, except
as mandated by law, or where permitted by law for a valid purpose, such as (1) to provide needed
professional services to the client, (2) to obtain appropriate professional consultations, (3) to protect
the client or others from harm, or (4) to obtain payment for services, in which instance disclosure is
limited to the minimum that is necessary to achieve the purpose. Behavior analysts recognize that
parameters of consent for disclosure should be acquired at the outset of any defined relationship and is
an ongoing procedure throughout the duration of the professional relationship.

2.09 Treatment/Intervention Efficacy.

(a) Clients have a right to effective treatment (i.e., based on the research literature and adapted to the
individual client). Behavior analysts always have the obligation to advocate for and educate the
client about scientifically supported, most-effective treatment procedures. Effective treatment
procedures have been validated as having both long-term and short-term benefits to clients and
society.

(b) Behavior analysts have the responsibility to advocate for the appropriate amount and level of

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service provision and oversight required to meet the defined behavior-change program goals.
(c) In those instances where more than one scientifically supported treatment has been established,

additional factors may be considered in selecting interventions, including, but not limited to,
efficiency and cost-effectiveness, risks and side-effects of the interventions, client preference, and
practitioner experience and training.

(d) Behavior analysts review and appraise the effects of any treatments about which they are aware that
might impact the goals of the behavior-change program, and their possible impact on the behavior-
change program, to the extent possible.

2.10 Documenting Professional Work and Research.

(a) Behavior analysts appropriately document their professional work in order to facilitate provision
of services later by them or by other professionals, to ensure accountability, and to meet other
requirements of organizations or the law.

(b) Behavior analysts have a responsibility to create and maintain documentation in the kind of detail
and quality that would be consistent with best practices and the law.

2.11 Records and Data.

(a) Behavior analysts create, maintain, disseminate, store, retain, and dispose of records and data
relating to their research, practice, and other work in accordance with applicable laws, regulations,
and policies; in a manner that permits compliance with the requirements of this Code; and in a
manner that allows for appropriate transition of service oversight at any moment in time.

(b) Behavior analysts must retain records and data for at least seven (7) years and as otherwise required
by law.

2.12 Contracts, Fees, and Financial Arrangements.

(a) Prior to the implementation of services, behavior analysts ensure that there is in place a signed
contract outlining the responsibilities of all parties, the scope of behavior-analytic services to be
provided, and behavior analysts’ obligations under this Code.

(b) As early as is feasible in a professional or scientific relationship, behavior analysts reach an
agreement with their clients specifying compensation and billing arrangements.

(c) Behavior analysts’ fee practices are consistent with law and behavior analysts do not misrepresent
their fees. If limitations to services can be anticipated because of limitations in funding, this is
discussed with the client as early as is feasible.

(d) When funding circumstances change, the financial responsibilities and limits must be revisited with
the client.

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2.13 Accuracy in Billing Reports.

Behavior analysts accurately state the nature of the services provided, the fees or charges, the identity of
the provider, relevant outcomes, and other required descriptive data.

2.14 Referrals and Fees.

Behavior analysts must not receive or provide money, gifts, or other enticements for any professional
referrals. Referrals should include multiple options and be made based on objective determination
of the client need and subsequent alignment with the repertoire of the referee. When providing or
receiving a referral, the extent of any relationship between the two parties is disclosed to the client.

2.15 Interrupting or Discontinuing Services.

(a) Behavior analysts act in the best interests of the client and supervisee to avoid interruption or
disruption of service.

(b) Behavior analysts make reasonable and timely efforts for facilitating the continuation of behavior-
analytic services in the event of unplanned interruptions (e.g., due to illness, impairment,
unavailability, relocation, disruption of funding, disaster).

(c) When entering into employment or contractual relationships, behavior analysts provide for orderly
and appropriate resolution of responsibility for services in the event that the employment or
contractual relationship ends, with paramount consideration given to the welfare of the ultimate
beneficiary of services.

(d) Discontinuation only occurs after efforts to transition have been made. Behavior analysts
discontinue a professional relationship in a timely manner when the client: (1) no longer needs the
service, (2) is not benefiting from the service, (3) is being harmed by continued service, or (4) when
the client requests discontinuation. (See also, 4.11 Discontinuing Behavior-Change Programs and
Behavior-Analytic Services)

(e) Behavior analysts do not abandon clients and supervisees. Prior to discontinuation, for whatever
reason, behavior analysts: discuss service needs, provide appropriate pre-termination services,
suggest alternative service providers as appropriate, and, upon consent, take other reasonable steps

to facilitate timely transfer of responsibility to another provider.

3.0 Assessing Behavior.

Behavior analysts using behavior-analytic assessment techniques do so for purposes that are
appropriate given current research.

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3.01 Behavior-Analytic Assessment.

(a) Behavior analysts conduct current assessments prior to making recommendations or developing
behavior-change programs. The type of assessment used is determined by client’s needs and consent,
environmental parameters, and other contextual variables. When behavior analysts are developing a
behavior-reduction program, they must first conduct a functional assessment.

(b) Behavior analysts have an obligation to collect and graphically display data, using behavior-analytic
conventions, in a manner that allows for decisions and recommendations for behavior-change
program development.

3.02 Medical Consultation.

Behavior analysts recommend seeking a medical consultation if there is any reasonable possibility that a
referred behavior is influenced by medical or biological variables.

3.03 Behavior-Analytic Assessment Consent.

(a) Prior to conducting an assessment, behavior analysts must explain to the client the procedure(s) to
be used, who will participate, and how the resulting information will be used.

(b) Behavior analysts must obtain the client’s written approval of the assessment procedures before
implementing them.

3.04 Explaining Assessment Results.

Behavior analysts explain assessment results using language and graphic displays of data that are
reasonably understandable to the client.

3.05 Consent-Client Records.

Behavior analysts obtain the written consent of the client before obtaining or disclosing client records
from or to other sources, for assessment purposes.

4.0 Behavior Analysts and the Behavior-Change
Program.
Behavior analysts are responsible for all aspects of the behavior-change program from conceptualization
to implementation and ultimately to discontinuation.

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4.01 Conceptual Consistency.

Behavior analysts design behavior-change programs that are conceptually consistent with behavior-
analytic principles.

4.02 Involving Clients in Planning and Consent.

Behavior analysts involve the client in the planning of and consent for behavior-change programs.

4.03 Individualized Behavior-Change Programs.

(a) Behavior analysts must tailor behavior-change programs to the unique behaviors, environmental
variables, assessment results, and goals of each client.

(b) Behavior analysts do not plagiarize other professionals’ behavior-change programs.

4.04 Approving Behavior-Change Programs.

Behavior analysts must obtain the client’s written approval of the behavior-change program before
implementation or making significant modifications (e.g., change in goals, use of new procedures).

4.05 Describing Behavior-Change Program Objectives.

Behavior analysts describe, in writing, the objectives of the behavior-change program to the client
before attempting to implement the program. To the extent possible, a risk-benefit analysis should be
conducted on the procedures to be implemented to reach the objective. The description of program
objectives and the means by which they will be accomplished is an ongoing process throughout the
duration of the client-practitioner relationship.

4.06 Describing Conditions for Behavior-Change Program Success.

Behavior analysts describe to the client the environmental conditions that are necessary for the
behavior-change program to be effective.

4.07 Environmental Conditions that Interfere with Implementation.

(a) If environmental conditions prevent implementation of a behavior-change program, behavior
analysts recommend that other professional assistance (e.g., assessment, consultation or therapeutic
intervention by other professionals) be sought.

(b) If environmental conditions hinder implementation of the behavior-change program, behavior
analysts seek to eliminate the environmental constraints, or identify in writing the obstacles to
doing so.

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4.08 Considerations Regarding Punishment Procedures.

(a) Behavior analysts recommend reinforcement rather than punishment whenever possible.
(b) If punishment procedures are necessary, behavior analysts always include reinforcement procedures

for alternative behavior in the behavior-change program.
(c) Before implementing punishment-based procedures, behavior analysts ensure that appropriate

steps have been taken to implement reinforcement-based procedures unless the severity or
dangerousness of the behavior necessitates immediate use of aversive procedures.

(d) Behavior analysts ensure that aversive procedures are accompanied by an increased level of training,
supervision, and oversight. Behavior analysts must evaluate the effectiveness of aversive procedures
in a timely manner and modify the behavior-change program if it is ineffective. Behavior analysts
always include a plan to discontinue the use of aversive procedures when no longer needed.

4.09 Least Restrictive Procedures.

Behavior analysts review and appraise the restrictiveness of procedures and always recommend the
least restrictive procedures likely to be effective.

4.10 Avoiding Harmful Reinforcers.
Behavior analysts minimize the use of items as potential reinforcers that may be harmful to the health

and development of the client, or that may require excessive motivating operations to be effective.

4.11 Discontinuing Behavior-Change Programs and Behavior-Analytic Services.

(a) Behavior analysts establish understandable and objective (i.e., measurable) criteria for the
discontinuation of the behavior change program and describe them to the client. (See also, 2.15d
Interrupting or Discontinuing Services)

(b) Behavior analysts discontinue services with the client when the established criteria for
discontinuation are attained, as in when a series of agreed-upon goals have been met. (See also,
2.15d Interrupting or Discontinuing Services)

5.0 Behavior Analysts as Supervisors.

When behavior analysts are functioning as supervisors, they must take full responsibility for all facets
of this undertaking. (See also, 1.06 Multiple Relationships and Conflict of Interest, 1.07 Exploitative
Relationships, 2.05 Rights and Prerogatives of Clients, 2.06 Maintaining Confidentiality, 2.15
Interrupting or Discontinuing Services, 8.04 Media Presentations and Media-Based Services, 9.02
Characteristics of Responsible Research, 10.05 Compliance with BACB Supervision and Coursework
Standards)

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5.01 Supervisory Competence.

Behavior analysts supervise only within their areas of defined competence.

5.02 Supervisory Volume.

Behavior analysts take on only a volume of supervisory activity that is commensurate with their ability
to be effective.

5.03 Supervisory Delegation.

a) Behavior analysts delegate to their supervisees only those responsibilities that such persons can
reasonably be expected to perform competently, ethically, and safely.

b) If the supervisee does not have the skills necessary to perform competently, ethically, and safely,
behavior analysts provide conditions for the acquisition of those skills.

5.04 Designing Effective Supervision and Training.

Behavior analysts ensure that supervision and trainings are behavior-analytic in content, effectively and
ethically designed, and meet the requirements for licensure, certification, or other defined goals.

5.05 Communication of Supervision Conditions.

Behavior analysts provide a clear written description of the purpose, requirements, evaluation criteria,
conditions, and terms of supervision prior to the onset of the supervision.

5.06 Providing Feedback to Supervisees.
a) Behavior analysts design feedback and reinforcement systems in a way that improves supervisee

performance.
b) Behavior analysts provide documented, timely feedback regarding the performance of a supervisee

on an ongoing basis. (See also, 10.05 Compliance with BACB Supervision and Coursework
Standards)

5.07 Evaluating the Effects of Supervision.

Behavior analysts design systems for obtaining ongoing evaluation of their own supervision activities.

6.0 Behavior Analysts’ Ethical Responsibility to the Profession of
Behavior Analysis.

Behavior analysts have an obligation to the science of behavior and profession of behavior analysis.

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6.01 Affirming Principles.

a) Above all other professional training, behavior analysts uphold and advance the values, ethics, and
principles of the profession of behavior analysis.

b) Behavior analysts have an obligation to participate in behavior-analytic professional and scientific
organizations or activities.

6.02 Disseminating Behavior Analysis.

Behavior analysts promote behavior analysis by making information about it available to the public
through presentations, discussions, and other media.

7.0 Behavior Analysts’ Ethical Responsibility to Colleagues.

Behavior analysts work with colleagues within the profession of behavior analysis and from other
professions and must be aware of these ethical obligations in all situations. (See also, 10.0 Behavior
Analysts’ Ethical Responsibility to the BACB)

7.01 Promoting an Ethical Culture.

Behavior analysts promote an ethical culture in their work environments and make others aware of this
Code.

7.02 Ethical Violations by Others and Risk of Harm.

(a) If behavior analysts believe there may be a legal or ethical violation, they first determine whether
there is potential for harm, a possible legal violation, a mandatory-reporting condition, or an
agency, organization, or regulatory requirement addressing the violation.

(b) If a client’s legal rights are being violated, or if there is the potential for harm, behavior analysts
must take the necessary action to protect the client, including, but not limited to, contacting
relevant authorities, following organizational policies, and consulting with appropriate
professionals, and documenting their efforts to address the matter.

(c) If an informal resolution appears appropriate, and would not violate any confidentiality rights,
behavior analysts attempt to resolve the issue by bringing it to the attention of that individual and
documenting their efforts to address the matter. If the matter is not resolved, behavior analysts
report the matter to the appropriate authority (e.g., employer, supervisor, regulatory authority).

(d) If the matter meets the reporting requirements of the BACB, behavior analysts submit a formal
complaint to the BACB. (See also, 10.02 Timely Responding, Reporting, and Updating of
Information Provided to the BACB)

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8.0 Public Statements.

Behavior analysts comply with this Code in public statements relating to their professional services,
products, or publications, or to the profession of behavior analysis. Public statements include, but are not
limited to, paid or unpaid advertising, brochures, printed matter, directory listings, personal resumes or
curriculum vitae, interviews or comments for use in media, statements in legal proceedings, lectures and
public presentations, social media, and published materials.

8.01 Avoiding False or Deceptive Statements.

(a) Behavior analysts do not make public statements that are false, deceptive, misleading, exaggerated,
or fraudulent, either because of what they state, convey, or suggest or because of what they omit,
concerning their research, practice, or other work activities or those of persons or organizations with
which they are affiliated. Behavior analysts claim as credentials for their behavior-analytic work, only
degrees that were primarily or exclusively behavior-analytic in content.

(b) Behavior analysts do not implement non-behavior-analytic interventions. Non-behavior-analytic
services may only be provided within the context of non-behavior-analytic education, formal
training, and credentialing. Such services must be clearly distinguished from their behavior-analytic
practices and BACB certification by using the following disclaimer: “These interventions are not
behavior-analytic in nature and are not covered by my BACB credential.” The disclaimer should be
placed alongside the names and descriptions of all non-behavior-analytic interventions.

(c) Behavior analysts do not advertise non-behavior-analytic services as being behavior-analytic.
(d) Behavior analysts do not identify non-behavior-analytic services as behavior-analytic services on

bills, invoices, or requests for reimbursement.
(e) Behavior analysts do not implement non-behavior-analytic services under behavior-analytic service

authorizations.

8.02 Intellectual Property.

(a) Behavior analysts obtain permission to use trademarked or copyrighted materials as required by
law. This includes providing citations, including trademark or copyright symbols on materials,
that recognize the intellectual property of others.

(b) Behavior analysts give appropriate credit to authors when delivering lectures, workshops, or other
presentations.

8.03 Statements by Others.

(a) Behavior analysts who engage others to create or place public statements that promote their
professional practice, products, or activities retain professional responsibility for such statements.

(b) Behavior analysts make reasonable efforts to prevent others whom they do not oversee (e.g.,

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employers, publishers, sponsors, organizational clients, and representatives of the print or broadcast
media) from making deceptive statements concerning behavior analysts’ practices or professional
or scientific activities.

(c) If behavior analysts learn of deceptive statements about their work made by others, behavior
analysts correct such statements.

(d) A paid advertisement relating to behavior analysts’ activities must be identified as such, unless it is
apparent from the context.

8.04 Media Presentations and Media-Based Services.

(a) Behavior analysts using electronic media (e.g., video, e-learning, social media, electronic
transmission of information) obtain and maintain knowledge regarding the security and limitations
of electronic media in order to adhere to this Code.

(b) Behavior analysts making public statements or delivering presentations using electronic media
do not disclose personally identifiable information concerning their clients, supervisees, students,
research participants, or other recipients of their services that they obtained during the course of
their work, unless written consent has been obtained.

(c) Behavior analysts delivering presentations using electronic media disguise confidential information
concerning participants, whenever possible, so that they are not individually identifiable to others
and so that discussions do not cause harm to identifiable participants.

(d) When behavior analysts provide public statements, advice, or comments by means of public
lectures, demonstrations, radio or television programs, electronic media, articles, mailed material,
or other media, they take reasonable precautions to ensure that (1) the statements are based on
appropriate behavior-analytic literature and practice, (2) the statements are otherwise consistent
with this Code, and (3) the advice or comment does not create an agreement for service with the
recipient.

8.05 Testimonials and Advertising.

Behavior analysts do not solicit or use testimonials about behavior-analytic services from current
clients for publication on their webpages or in any other electronic or print material. Testimonials from
former clients must identify whether they were solicited or unsolicited, include an accurate statement
of the relationship between the behavior analyst and the author of the testimonial, and comply with all
applicable laws about claims made in the testimonial.

Behavior analysts may advertise by describing the kinds and types of evidence-based services they
provide, the qualifications of their staff, and objective outcome data they have accrued or published, in
accordance with applicable laws.

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8.06 In-Person Solicitation.

Behavior analysts do not engage, directly or through agents, in uninvited in-person solicitation of
business from actual or potential users of services who, because of their particular circumstances, are
vulnerable to undue influence. Organizational behavior management or performance management
services may be marketed to corporate entities regardless of their projected financial position.

9.0 Behavior Analysts and Research.

Behavior analysts design, conduct, and report research in accordance with recognized standards of
scientific competence and ethical research.

9.01 Conforming with Laws and Regulations.

Behavior analysts plan and conduct research in a manner consistent with all applicable laws and
regulations, as well as professional standards governing the conduct of research. Behavior analysts also
comply with other applicable laws and regulations relating to mandated-reporting requirements.

9.02 Characteristics of Responsible Research.

(a) Behavior analysts conduct research only after approval by an independent, formal research review
board.

(b) Behavior analysts conducting applied research conjointly with provision of clinical or human
services must comply with requirements for both intervention and research involvement by client-
participants. When research and clinical needs conflict, behavior analysts prioritize the welfare of
the client.

(c) Behavior analysts conduct research competently and with due concern for the dignity and welfare of
the participants.

(d) Behavior analysts plan their research so as to minimize the possibility that results will be misleading.
(e) Researchers and assistants are permitted to perform only those tasks for which they are

appropriately trained and prepared. Behavior analysts are responsible for the ethical conduct of
research conducted by assistants or by others under their supervision or oversight.

(f) If an ethical issue is unclear, behavior analysts seek to resolve the issue through consultation with
independent, formal research review boards, peer consultations, or other proper mechanisms.

(g) Behavior analysts only conduct research independently after they have successfully conducted
research under a supervisor in a defined relationship (e.g., thesis, dissertation, specific research
project).

(h) Behavior analysts conducting research take necessary steps to maximize benefit and minimize risk
to their clients, supervisees, research participants, students, and others with whom they work.

(i) Behavior analysts minimize the effect of personal, financial, social, organizational, or political factors

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that might lead to misuse of their research.
(j) If behavior analysts learn of misuse or misrepresentation of their individual work products, they

take appropriate steps to correct the misuse or misrepresentation.
(k) Behavior analysts avoid conflicts of interest when conducting research.
(l) Behavior analysts minimize interference with the participants or environment in which research is

conducted.

9.03 Informed Consent.

Behavior analysts inform participants or their guardian or surrogate in understandable language about
the nature of the research; that they are free to participate, to decline to participate, or to withdraw
from the research at any time without penalty; about significant factors that may influence their
willingness to participate; and answer any other questions participants may have about the research.

9.04 Using Confidential Information for Didactic or Instructive Purposes.

(a) Behavior analysts do not disclose personally identifiable information concerning their individual or
organizational clients, research participants, or other recipients of their services that they obtained
during the course of their work, unless the person or organization has consented in writing or
unless there is other legal authorization for doing so.

(b) Behavior analysts disguise confidential information concerning participants, whenever possible,
so that they are not individually identifiable to others and so that discussions do not cause harm to
identifiable participants.

9.05 Debriefing.

Behavior analysts inform the participant that debriefing will occur at the conclusion of the participant’s
involvement in the research.

9.06 Grant and Journal Reviews.

Behavior analysts who serve on grant review panels or as manuscript reviewers avoid conducting any
research described in grant proposals or manuscripts that they reviewed, except as replications fully
crediting the prior researchers.

9.07 Plagiarism.

(a) Behavior analysts fully cite the work of others where appropriate.
(b) Behavior analysts do not present portions or elements of another’s work or data as their own.

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9.08 Acknowledging Contributions.

Behavior analysts acknowledge the contributions of others to research by including them as co-authors
or footnoting their contributions. Principal authorship and other publication credits accurately reflect
the relative scientific or professional contributions of the individuals involved, regardless of their
relative status. Minor contributions to the research or to the writing for publications are appropriately
acknowledged, such as, in a footnote or introductory statement.

9.09 Accuracy and Use of Data.

(a) Behavior analysts do not fabricate data or falsify results in their publications. If behavior analysts
discover errors in their published data, they take steps to correct such errors in a correction, retraction,
erratum, or other appropriate publication means.

(b) Behavior analysts do not omit findings that might alter interpretations of their work.
(c) Behavior analysts do not publish, as original data, data that have been previously published. This does

not preclude republishing data when they are accompanied by proper acknowledgment.
(d) After research results are published, behavior analysts do not withhold the data on which their

conclusions are based from other competent professionals who seek to verify the substantive
claims through reanalysis and who intend to use such data only for that purpose, provided that the
confidentiality of the participants can be protected and unless legal rights concerning proprietary data
preclude their release.

10.0 Behavior Analysts’ Ethical Responsibility to the BACB.

Behavior analysts must adhere to this Code and all rules and standards of the BACB.

10.01 Truthful and Accurate Information Provided to the BACB.

(a) Behavior analysts only provide truthful and accurate information in applications and documentation
submitted to the BACB.

(b) Behavior analysts ensure that inaccurate information submitted to the BACB is immediately corrected.

10.02 Timely Responding, Reporting, and Updating of Information Provided to
the BACB.

Behavior analysts must comply with all BACB deadlines including, but not limited to, ensuring that the
BACB is notified within thirty (30) days of the date of any of the following grounds for sanctioning status:
(a) A violation of this Code, or disciplinary investigation, action or sanction, filing of charges, conviction

or plea of guilty or no contest (i.e., nolo contendere) by a governmental agency, health care
organization, third-party payer or educational institution. Procedural note: Behavior analysts
convicted of a felony directly related to behavior analysis practice and/or public health and safety

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shall be ineligible to apply for BACB registration, certification, or recertification for a period
of three (3) years from the exhaustion of appeals, completion of parole or probation, or final
release from confinement (if any), whichever is later; (See also, 1.04d Integrity)

(b) Any public health- and safety-related fines or tickets where the behavior analyst is named on the
ticket;

(c) A physical or mental condition that would impair the behavior analysts’ ability to competently
practice; and

(d) A change of name, address or email contact.

10.03 Confidentiality and BACB Intellectual Property.

Behavior analysts do not infringe on the BACB’s intellectual property rights, including, but not limited
to the BACB’s rights to the following:
(a) BACB logo, VCS logo, ACE logo, certificates, credentials and designations, including, but not

limited to, trademarks, service marks, registration marks and certification marks owned and
claimed by the BACB (this includes confusingly similar marks intended to convey BACB
affiliation, certification or registration, or misrepresentation of an educational ABA certificate
status as constituting national certification);

(b) BACB copyrights to original and derivative works, including, but not limited to, BACB copyrights
to standards, procedures, guidelines, codes, job task analysis, Workgroup reports, surveys; and

(c) BACB copyrights to all BACB-developed examination questions, item banks, examination
specifications, examination forms and examination scoring sheets, which are secure trade secrets of
the BACB. Behavior analysts are expressly prohibited from disclosing the content of any BACB
examination materials, regardless of how that content became known to them. Behavior analysts
report suspected or known infringements and/or unauthorized access to examination content and/
or any other violation of BACB intellectual property rights immediately to the BACB. Efforts for
informal resolution (identified in Section 7.02 c) are waived due to the immediate reporting
requirement of this Section.

10.04 Examination Honesty and Irregularities.

Behavior analysts adhere to all rules of the BACB, including the rules and procedures required by
BACB approved testing centers and examination administrators and proctors. Behavior analysts must
immediately report suspected cheaters and any other irregularities relating to the BACB examination
administrations to the BACB. Examination irregularities include, but are not limited to, unauthorized
access to BACB examinations or answer sheets, copying answers, permitting another to copy answers,
disrupting the conduct of an examination, falsifying information, education or credentials, and
providing and/or receiving unauthorized or illegal advice about or access to BACB examination
content before, during, or following the examination. This prohibition includes, but is not limited
to, use of or participation in any “exam dump” preparation site or blog that provides unauthorized

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access to BACB examination questions. If, at any time, it is discovered that an applicant or certificant
has participated in or utilized an exam dump organization, immediate action may be taken to
withdraw eligibility, cancel examination scores, or otherwise revoke certification gained through use of
inappropriately obtained examination content.

10.05 Compliance with BACB Supervision and Coursework Standards.

Behavior analysts ensure that coursework (including continuing education events), supervised
experience, RBT training and assessment, and BCaBA supervision are conducted in accordance with
the BACB’s standards if these activities are intended to comply with BACB standards (See also, 5.0
Behavior Analysts as Supervisors)

10.06 Being Familiar with This Code.

Behavior analysts have an obligation to be familiar with this Code, other applicable ethics codes,
including, but not limited to, licensure requirements for ethical conduct, and their application to
behavior analysts’ work. Lack of awareness or misunderstanding of a conduct standard is not itself a
defense to a charge of unethical conduct.

10.07 Discouraging Misrepresentation by Non-Certified Individuals.

Behavior analysts report non-certified (and, if applicable, non-registered) practitioners to the
appropriate state licensing board and to the BACB if the practitioners are misrepresenting BACB
certification or registration status.

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Glossary

Behavior Analyst
Behavior analyst refers to an individual who holds BCBA or BCaBA certification or an individual who has
submitted a complete application for BCBA or BCaBA certification.

Behavior-Analytic Services
Behavior-analytic services are those that are explicitly based on principles and procedures of behavior analysis
(i.e., the science of behavior) and are designed to change behavior in socially important ways. These services
include, but are not limited to, treatment, assessment, training, consultation, managing and supervising
others, teaching, and delivering continuing education.

Behavior-Change Program
The behavior-change program is a formal, written document that describes in technological detail every
assessment and treatment task necessary to achieve stated goals.

Client
The term client refers to any recipient or beneficiary of the professional services provided by a behavior
analyst. The term includes, but is not limited to:

(a) The direct recipient of services;
(b) The parent, relative, legal representative or legal guardian of the recipient of services;
(c) The employer, agency representative, institutional representative, or third-party contractor for

services of the behavior analyst; and/or
(d) Any other individual or entity that is a known beneficiary of services or who would normally be

construed as a “client” or “client-surrogate”.

For purposes of this definition, the term client does not include third-party insurers or payers, unless the
behavior analyst is hired directly under contract with the third-party insurer or payer.

Functional Assessment
Functional assessment, also known as functional behavior assessment, refers to a category of procedures
used to formally assess the possible environmental causes of problem behavior. These procedures include
informant assessments (e.g., interviews, rating scales), direct observation in the natural environment (e.g., ABC
assessment), and experimental functional analysis.

Multiple Relationships
A multiple relationship is one in which a behavior analyst is in both a behavior-analytic role and a non-
behavior-analytic role simultaneously with a client, supervisee, or someone closely associated with or related to
the client.

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Public Statements
Public statements include, but are not limited to, paid or unpaid advertising, brochures, printed matter, directory
listings, personal resumes or curriculum vitae, interviews or comments for use in media, statements in legal
proceedings, lectures and public presentations, social media, and published materials.

Research
Any data-based activity designed to generate generalizable knowledge for the discipline, often through
professional presentations or publications. The use of an experimental design does not by itself constitute
research. Professional presentation or publication of already collected data are exempt from elements in section
9.0 (Behavior Analysts and Research) that pertain to prospective research activities (e.g., 9.02a). However, all
remaining relevant elements from section 9.0 apply (e.g., 9.01 Conforming with Laws and Regulations; 9.03
Informed Consent relating to use of client data).

Research Review Board
A group of professionals whose stated purpose is to review research proposals to ensure the ethical treatment
of human research participants. This board might be an official entity of a government or university (e.g.,
Institutional Review Board, Human Research Committee), a standing committee within a service agency, or an
independent organization created for this purpose.

Rights and Prerogatives of Clients
Rights and prerogatives of clients refers to human rights, legal rights, rights codified within behavior analysis,
and organizational and administrative rules and regulations designed to benefit the client.

Risk-Benefit Analysis
A risk-benefit analysis is a deliberate evaluation of the potential risks (e.g., limitations, side effects, costs) and
benefits (e.g., treatment outcomes, efficiency, savings) associated with a given intervention. A risk-benefit
analysis should conclude with a course of action associated with greater benefits than risks.

Service Record
A client’s service record includes, but is not limited to, written behavior-change plans, assessments, graphs, raw
data, electronic recordings, progress summaries, and written reports.

Student
A student is an individual who is matriculated at a college/university. This Code applies to the student during
formal behavior-analytic instruction.

Supervisee
A supervisee is any individual whose behavior-analytic services are overseen by a behavior analyst within the
context of a defined, agreed-upon relationship.

Copyright © 2014 by the Behavior Analyst Certification Board,® Inc. (“BACB®”). Electronic and/or paper copies of part or all of this
work may be made for personal, educational, or policymaking purposes, provided such copies are not made or distributed for profit or
commercial advantage. All copies, unless made for regulatory or licensure purposes, must include this notice on the first
page. Abstracting with proper credit is permitted, so long as the credit reads “Copyright © 2014 by the Behavior Analyst Certification
Board,® Inc. (“BACB®”), all rights reserved.” All other uses and/or distributions in any medium require advance written permission of the
BACB. To request permission complete the Copyright and/or Trademark Permission Request form.

Behav Analysis Practice (2016) 9:84–94
DOI 10.1007/s40617-016-0111-6

DISCUSSION AND REVIEW PAPER

Developing the Cultural Awareness Skills of Behavior Analysts

Elizabeth Hughes Fong1 & Robyn M. Catagnus2 & Matthew T. Brodhead3 &
Shawn Quigley4 & Sean Field5

Published online: 4 February 2016
# Association for Behavior Analysis International 2016

Abstract All individuals are a part of at least one culture.
These cultural contingencies shape behavior, behavior that
may or may not be acceptable or familiar to behavior analysts
from another culture. To better serve individuals, assessments
and interventions should be selected with a consideration of
cultural factors, including cultural preferences and norms. The
purpose of this paper is to provide suggestions to serve as a
starting point for developing behavior analysts’ cultural
awareness skills. We present strategies for understanding be-
havior analysts’ personal cultural values and contingencies
and those of their clients, integrating cultural awareness
practices into service delivery, supervision, and professional
development, and becoming culturally aware in everyday
practice.

Keywords Culture . Cultural awareness . Applied behavior
analysis . Diversity

Skinner (1953) defined culture as variables Barranged by other
people^ (p. 419). That is, humans control contingencies of

Elizabeth Hughes Fong, Robyn M. Catagnus, and Matthew T. Brodhead
shared first author

* Robyn M. Catagnus
[email protected]

1 Arcadia University, Glenside, PA, USA
2 The Chicago School of Professional Psychology, Chicago, IL, USA
3 Purdue University, West Lafayette, IN, USA
4 The University of New Mexico Medical Group, Albuquerque, NM,

USA
5 Western Michigan University, Kalamazoo, MI, USA

reinforcement and punishment that affect the behavior and
learned reinforcers and punishers of a person or a group of
people. Culture may be further defined as Bthe extent to which
a group of individuals engage in overt and verbal behavior
reflecting shared behavioral learning histories, serving to dif-
ferentiate the group from other groups, and predicting how
individuals within the group act in specific setting conditions^
(Sugai et al. 2012, p. 200). Distinguishable stimuli and re-
sponse classes that occur in cultures include race, socioeco-
nomic class, age, religion, sexual orientation, ethnicity, dis-
ability, nationality, and geographic context (Sugai et al.
2012). An individual’s unique set of distinguishable stimuli
and response classes are collectively referred to as an individ-
ual’s cultural identity. One benefit of determining cultural
identity is it can allow behavior analysts to develop an aware-
ness of a client’s personal cultural values, preferences (i.e.,
learned reinforcers), characteristics, and circumstances
(contingencies at the third level of selection; Skinner 1981).
There are possible benefits for society, too, such as to better
guide assessment and intervention practices. By acknowledg-
ing the importance of culture, behavior analysts can help
achieve socially meaningful goals such as reducing disparities
in access to services and improving the quality of services
for diverse populations in behavioral health systems
(U.S. Department of Health and Human Services 2001).

Culturally aware behavior analysts should understand their
own cultural values, preferences, characteristics, and
circumstances and seek to learn about those of their clients.
That is, behavior analysts should be aware about their own
personal biases and how they compare to and may affect their
relationship with their client. This awareness of both self and
clients may be important because, as Spring (2007) suggests,
evidence-based services require a combination of clinical ex-
pertise and knowledge of the client’s preferences and learning
histories. Behaviorally, cultural awareness may be defined as

85 Behav Analysis Practice (2016) 9:84–94

the discriminated operant of tacting contingencies of rein-
forcement and punishment administered by a group of indi-
viduals. In other words, a behavior analyst who is culturally
aware is able to identify the reinforcement and punishment
contingencies that have been established by themselves, their
colleagues, their family, and any other social group they may
belong to or identify with. Behavior analysts’ ability to tact
contingencies for self and others may facilitate development
of a behavior change program that is informed by their clients’
specific cultural contingencies.

Further, cultural awareness may be important because be-
havioral patterns that are viewed as problematic in our own
culture may be the norm in other cultures (Goldiamond 2002;
Vandenberghe 2008). Consider the following example of a
child who was referred for a functional assessment for
Bwithdrawn^ behavior. The behavior analyst and a special
education observed the student became Bwithdrawn^ after re-
ceiving verbal praise. In fact, the student ultimately stopped
engaging in any appropriate behavior which lead to the verbal
praise. While collaborating with the family to gather data dur-
ing the functional assessment, they determined that the stu-
dent’s Bwithdrawn^ behavior occurred because of child’s lack
of comfort with receiving individual attention. In the child’s
culture, the whole (i.e., community) comes before the individ-
ual. However, neither the behavior analyst nor the special
education teacher questioned their personal assumption that
the behavior is inappropriate for the classroom or their prefer-
ences about how children should act after receiving praise.
Because the student’s withdrawn behavior is maintained by
a lack of attention, the behavior analyst and special education
teacher suggest administering praise privately. In this case,
their lack of understanding about how the cultural contingen-
cies support the client’s Binappropriate behavior^ may have
resulted in a treatment recommendation that was incongruent
with cultural values. However, a culturally aware intervention,
which seeks understanding of client values, characteristics,
preferences, and circumstances would honor the client’s cul-
ture and allow the client to successful in a given environment.

A thorough behavior analytic intervention may be effective
with individuals across various cultures (Kauffman et al. 2008;
Tanaka-Matsumi et al. 1996). However, skilled, thorough, and
well-trained behavior analysts may not always consider client
culture. When assessing an individual’s or a group’s behavior,
behavior analysts often collect data about motivating opera-
tions, antecedents, behaviors, and consequences. However,
common functional assessment data collection strategies and
interview forms may not thoroughly explore cultural prefer-
ences and norms. Behavior analysts may consider the intersec-
tion of a cultural and linguistic context with the terms, concepts,
and science of behavior analysis (Jones and Hoerger 2009). It is
possible that, without information about cultural preferences
and norms, behavior analysts may unintentionally provide less
than optimal service delivery.

Consider an example of a behavior analyst who provided
in-home and community services to the family of a child with
severe autism. The family, to whom church is very important,
attended a weekly three hour church service. The behavior
analyst, who did not attend church and was not a religious
person, failed to inquire in detail about the family’s and child’s
experience at church. Eventually, the family specifically asked
the behavior analyst to teach the child the necessary skills to
participate in the church service. However, the behavior ana-
lyst still did not assign a high priority to teaching the child the
skills needed for successful church attendance. The behavior
analyst’s choices demonstrated a lack of understanding of the
client’s values, characteristics, preferences, and circum-
stances. In contrast, a culturally aware behavior analyst may
be aware that Bthe selection of target behaviors is an expres-
sion of values^ (Kauffman et al. 2008, p. 254) and that paren-
tal expectations of children are likely controlled by cultural
contingencies (Akcinar and Baydar 2014).

In addition to the previous two examples, being culturally
aware may also increase the probability that behavior analysts
will engage in behaviors that are socially acceptable to people
from diverse cultural backgrounds. These behaviors include
selecting culturally appropriate treatments (see Rispoli et al.
2011), recognizing that Bparenting styles that are culture spe-
cific could lead to distinct behavioral consequences for a
child^ (Akcinar and Baydar 2014, p. 119), and implementing
culturally appropriate language acquisition programs (see
Brodhead et al. 2014). Cultural awareness could also ensure
that behavior analysts treat service delivery as Balways a two-
way street^ (Bolling 2002), meaning that the relationship be-
tween the behavior analyst and the stakeholders should in-
clude input about what cultural contingencies and values
may contribute to an effective relationship and intervention.

Finally, increasing cultural awareness may also decrease
the probability of behavior analysts expecting the clients they
serve to conform to their own cultural and scientific values
and contingencies. The science of applied behavior analysis
(ABA) is a unique cultural system (see Glenn 1993). Given
that the science of ABA inherently embodies a certain set of
values such as a Westernized model of science and health care,
the cultural values and contingencies of ABA may not always
align with those of the client. As Bolling (2002) noted,

It is difficult for people in the US cultural mainstream,
including researchers, to believe that there are any assump-
tions other than their own about how the world works,
what a ‘person’ is, how we function, how time works, what
feelings are, how to use language, what the goal of life is,
how people interrelate, [and] how and where it is appro-
priate to show feelings or to seek help. (p. 22)

Awareness of cultural differences and similarities may al-
low for programmatic modifications that result in more

86 Behav Analysis Practice (2016) 9:84–94

culturally appropriate models of behavior analytic service
delivery.

In summary, there may be many important reasons for be-
havior analysts to develop cultural awareness skills.

Although there is a growing interest in conceptual (e.g.,
Brodhead et al. 2014; Fong and Tanaka 2013) and applied
strategies for administering behavioral interventions for cli-
ents from diverse cultural backgrounds (e.g., Padilla
Dalamau et al. 2011; Rispoli et al. 2011; Washio and
Houmanfar 2007), there is little guidance concerning how
practicing behavior analysts can become culturally aware or
further develop that awareness. Therefore, guidance on how to
become culturally aware may be an important resource for
behavior analysts.

The purpose of this paper is to offer suggestions that can
serve as a starting point for how behavior analysts may further
increase their cultural awareness. We believe that cultural
awareness, as described herein, reflect Baer et al. (1968) state-
ment that the Bbehavior, stimuli and/or organism under study
are chosen because of their importance to man and society^
(p. 92). Individuals participating in behavior change programs
and those who provide significant support for them should
determine what is important to them, to their society, and to
their culture. In this paper, we discuss strategies for under-
standing a client’s cultural values and contingencies, as well
as those of the behavior analyst. Then, we describe strategies
for embedding cultural awareness practices into behavior an-
alytic service delivery, supervision, and professional develop-
ment. Finally, we conclude with additional discussion and
considerations for becoming culturally aware in everyday
practice.

Strategies for Developing Cultural Awareness

The following two sections describe how behavior analysts
can become more aware of personal cultural values and con-
tingencies and how they can develop skills to learn about their
clients’ cultural identities. We will refer to cultural values and
contingencies as the cultural system, except where values or
contingencies play an independent role in our analysis of de-
veloping cultural awareness. We will refer to cultural identity
as characteristics that extend beyond individual differences to
those traits that members of a given culture share with one
another (Adler 1998). For example, an individual from Africa
may express their cultural identity through their belief struc-
ture, attire, foods eaten, or hair style. Even though this indi-
vidual might identify as African, there are subcultures to
which they might further identify with. Our suggestions are
meant to serve as a starting point for furthering a behavior
analytic understanding of cultural awareness and how that
awareness can be integrated and improved upon in everyday
practice. It is recommended that behavior analysts

concurrently engage in cultural awareness practices
concerning their own behavior as well as those of their clients.
It is important to be aware of one’s own biases or
preconceived notions as a behavior analyst, as well acknowl-
edging limitations in one’s cultural knowledge. Lastly, our
suggestions are not intended to result in a rigid set of rules
or practices. Rather, our hope is the suggestions will lead to
broad practices that develop and continually refine cultural
awareness, which will hopefully allow behavior analysts to
be more open and flexible to the various cultures that will be
experienced. Openness and flexibility in the presence of var-
ious cultures will hopefully result in better outcomes for those
we serve.

Developing Cultural Awareness of Self

From a behavior analytic perspective, self-awareness can be
defined as verbal discrimination of our own behavior (Barnes-
Holmes et al. 2001). Sugai et al. (2012) describe culture as
common behaviors related by comparable learning histories,
social and environmental contingencies, contexts and stimuli,
so self-awareness might also include verbal discrimination of
these aspects of personal experience. An understanding of our
own cultural system may be an important first step toward
correcting biases that affect our interactions with others
(Lillis and Hayes 2007). The American Psychological
Association’s (APA) (2003) multicultural guidelines encour-
age clinicians to Brecognize that, as cultural beings, they may
hold attitudes and beliefs that can detrimentally influence their
perceptions of and interactions with individuals who are eth-
nically and racially different from themselves^ (p. 382).
Developing self-awareness may prevent our biases from im-
peding how we serve culturally diverse clients.

One strategy to enhance cultural self-awareness is talking
about our diverse client interactions with a professional com-
munity in group discussions, written forums, journals, men-
torship meetings, verbal feedback sessions, or self-reflective
exercises (Tervalon and Murray-Garcia 1998). Skinner (1974)
emphasized the relationship between self-awareness and con-
trol over our own behavior,and proposed that talking about
our behavior is how we achieve self-awareness. Recent be-
havior analytic research indicates that when individuals ver-
bally describe their own behavior, the behavior may change
(Tourinho 2006). Discussion with mentors and colleagues
may help behavior analysts learn about themselves and also
change their cross-cultural interactions for the better.

Another suggestion is to be Bmindful^ by attending fully
and alertly, in the moment, to client interactions and our own
private events, without judging or evaluating the events as
they occur (Bishop et al. 2004; Hayes and Plumb 2007;
Vandenberghe 2008). We recommend practitioners hone their
ability to attend closely to clients and self, in context, for two
reasons related to self-awareness. First, such attention may

87 Behav Analysis Practice (2016) 9:84–94

help enhance skills of self-observation and self-description
regarding our overt and covert behavior. Also, while we can
remain committed to overtly behaving in ways consistent with
values of multiculturalism, even in the presence of values and
contingencies that create bias, mindfulness may reduce the
biases that produce thoughts, feelings, and reactions to cultur-
ally diverse people (Lillis and Hayes 2007). Attending closely
to our clients and being active and alert is good practice for
building rapport, too.

Clinicians can engage in more culturally aware practice by
assessing, collecting data, and testing hypotheses rather than
accepting their own experiences and biases as the norm (Sue
1998). Scientific mindedness is a characteristic of clinicians
and human service providers who develop theories about cli-
ent behaviors by analyzing data rather than by dependence on
their personal assumptions (Sue 1998), and may reduce bias
and foster better understanding of client behavior. A reliance
on scientific, behavior analytic knowledge when working with
clients is also required by the Professional and Ethical
Compliance Code for Behavior Analysts (BACB 2015).

While mindful attention focuses on the interaction between
the behavior analyst and the client/family, scientific minded-
ness is a focus on interpreting information from the client and
family; both characteristics facilitate culturally aware practice.
For example, a behavior analyst consults to a family of a child
with a sleep disorder, and learns that the mother sleeps in her
five-year-old child’s bed while the father sleeps in a larger
room, alone. The practitioner may notice, and be able to co-
vertly tact, that this is not the norm of the cultural majority nor
congruent with his personal experience or values. The analyst
may assume that the mother should not sleep in the child’s bed
or notice thoughts of judgment he feels. Lillis and Hayes
(2007) recommend practitioners accept that such reactions
may be normal, given our cultural systems and the human
tendency to evaluate, but remain committed to acting positive-
ly based on our values. Through a process of assessment and
covert verbal behavior, the practitioner might accept the co-
sleeping arrangement to be culturally appropriate for and pre-
ferred by the family, and choose to develop an intervention
that keeps the arrangement in place. A blend of both self-
awareness and reliance on scientific knowledge is likely to
produce the most culturally aware assessment and
intervention.

Finally, there are several self-assessment tools that behav-
ior analysts can use to become more aware of their own cul-
tural identity. We recommend the use of assessment tools for
measuring and reflecting on the clinician’s own cultural
biases, values, and understanding. One assessment tool, the
BDiversity Self-Assessment,^ that can be utilized during the
intake process allows team members to examine their under-
standing of diversity (Montgomery 2001); this tool asks users
to reflect on their own assumptions and biases by answering
11 questions. Another assessment tool that may be useful is

the self-test questionnaire entitled BHow Do You Relate to
Various Groups of People in Society?^ (Randall-David
1989). This questionnaire asks respondents how they might
respond to individuals of various cultural backgrounds—by
greeting, by accepting, by obtaining help from, by having
background knowledge about, and/or by advocating for the
individuals. The 30 types of individuals in these questions are
then organized into five categories: ethnic/racial, social issues/
problems, religious, physically/mentally handicapped, and
political, and a concentration of checks within a specific cat-
egory of individuals or at specific levels of response may then
indicate a conflict that could prevent the respondent from pro-
viding effective treatment. Behavior analysts can then consid-
er how their biases might affect treatment and may consider
other courses of action, such as making referrals to other be-
havior analysts. A final potentially useful measure is the
Multicultural Sensitivity Scale (Jibaja et al. 2000), a 21-item
self-assessment tool developed as a valid and reliable way to
measure multicultural sensitivity. This tool was originally
used to assess the multicultural sensitivity of teachers and
was later adapted to be used by physician assistant students
(Jibaja-Rusth et al. 1994). Altogether, the behavior analyst
may find these assessments helpful in further developing their
own cultural awareness in order to further develop culturally
competent methods of service delivery.

Developing Cultural Awareness of Clients

The above section describes strategies for how a behavior
analyst may learn about his or her own cultural system.
Below, we describe how behavior analysts may learn more
about their client’s cultural system through assessment prac-
tices. Culturally aware assessment practices may allow behav-
ior analysts to obtain important cultural information about
clients in order to understand their worldviews. Culturally
aware assessment may also allow behavior analysts to identify
any potential cultural barriers such as modalities of commu-
nication and expression of emotions (see Garcia et al. 2003).

To increase the probability that assessment will identify
cultural variables, Vandenberghe (2008) recommends focus-
ing on functional relations and behavioral principles rather
than topography. For example, Filipino families often live
with extended family members, and the household situation
can seem chaotic by Western living standards. If a child has
difficulty sleeping, a behavior analyst may advise the parents
that they should separate the sleeping room from the living
room. People of Filipino descent may be shy about responding
to someone in a position of authority, so they may say Byes^ to
the behavior analyst. However, during the following session,
it might be revealed that the parents did not change anything
and that the child is still sleep deprived. In this case, a natural
reaction may be to become frustrated with the lack of parental
follow through. However, lack of follow through may also be

88 Behav Analysis Practice (2016) 9:84–94

interpreted as an indicator that the intervention recommenda-
tion may not have been culturally appropriate.

Vandenberghe’s (2008) description of functional analytic
psychotherapy may also be a useful resource for determining
how to provide culturally aware behavior analytic practices.
Vandenberghe (2008) emphasizes the need for a behavior ana-
lyst to be aware of differences that may exist, including cultural
differences, between the behavior analyst, client, and their fam-
ilies. Specifically, behavior analysts should be knowledgeable
about the client’s culture, differentiate between an unfamiliar
cultural norm and a pathology, and take culture into
consideration during the therapeutic process. Finally, Hymes
(1962) noted that communicative competence is related to an
individual’s awareness of the laws of language structure and
language use within a given culture. Therefore, behavior ana-
lysts should be skilled in sending and receiving cultural com-
munications. Specific recommendations are described below.

Recommendations

Consider the Language of Assessment Our first recommen-
dation, which applies to all phases of assessment and treat-
ment, is that behavior analysts should reflect on the spoken
and written language he or she uses and how it will be per-
ceived by the client. We recommend behavior analysts avoid
the use of behavior analytic jargon, as it may confuse clients
and their families, and possibly lead to their failure to imple-
ment interventions. This recommendation is consistent with
the Professional and Ethical Compliance Code for Behavior
Analysts (2015). For example when the phrase Bfunctional
analysis^ is used, Japanese families assume that it is mathe-
matical jargon rather than a reference to a behavior analytic
assessment process. Avoidance of excessive or complex be-
havior analytic jargon may eliminate such problems.

It is important throughout assessment and treatment to
communicate in a manner easily understood, culturally aware,
and does not include terms that are culturally inappropriate or
confusing (Rolider and Axelrod 2005). Furthermore, it may be
important to consider who will be completing service related
forms (e.g., intake paperwork) and whether the level of liter-
acy and comprehension of the language used in the forms are
similar. If a person lacks adequate language comprehension,
completing paperwork may be difficult, embarrassing, or in-
timidating. In such a case, behavior analysts may consider
giving the person the opportunity to complete the forms orally
or have another person help with the form completion. They
may also consider using an interpreter or providing forms in
the person’s native language. Additionally, we agree with
Vandenberghe’s (2008) recommendation that the language
used to define problem behaviors should be carefully exam-
ined to ensure the behaviors are communicated in a positive
manner using multiple forms of communication that are sen-
sitive to potential cultural differences in eye contact, wait time,

meanings of words, non-vocal body language, personal space,
and quality of voice.

Understand Cultural Identity Our second recommendation
is to consider that the client, and the client’s family and com-
munity, are important sources for acquiring an understanding
the cultural identity of the individual. Therefore, we recom-
mend conducting an analysis of cultural identity with stake-
holders immediately after service initiation with the client and/
or family. The cultural identity analysis should inform the
assessment process and the designing of interventions.
During intake, the behavior analyst may, with proper consent,
gather input from key community members familiar with the
client, in addition to those whose feedback is typically sought
(e.g., teachers, professionals, administrators, and family).
Additionally, the behavior analyst should seek recommenda-
tions from the family regarding additional parties (e.g., other
community members) who should be involved. Family and
community members may be able to provide the most valu-
able information regarding the client’s culture, language, and
sociocultural framework (Salend and Taylor 2002). These dis-
cussions will allow members of the team to acquire a mutual
understanding of the client’s cultural system, which may result
in increased cultural awareness.

It is important to highlight that the client/family’s language
is an important cultural variable that should be understood in
addition to collaboration with stakeholders. For example, be-
havioral patterns may be similar across cultures, while
the language and concepts that are used can differ
(Vandenberghe 2008). In Japan, parents and teachers may
use the word Bpanic^ to describe a child’s behavior, and this
may imply a Btantrum^ or Bmeltdown.^ Because the word
Btantrum^ is often associated with baby colic behavior, par-
ents and teachers may prefer to use Bpanic^ to describe the
aggressive behavior of older children. Without knowing this, a
behavior analyst may initially misunderstand what the client’s
challenging behavior is. It is therefore important for behavior
analysts to clarify what the client or family actually mean by
the terms they use.

The behavior analyst should also consider accounting for
what treatments are appropriate, preferable, or considered
norms within a culture. As illustrated by the example of the
Filipino family at the beginning of this section, identifying
cultural norms may be important for successful assessment
and effective treatment. Information about what is acceptable
within a person’s culture is also ideally obtained beginning
with the intake process (and later during the assessment pro-
cess) by including stakeholders in the process and ensuring
that background information includes input from multiple
sources of information (assessments and interviews; Sugai
et al. 2012). For example, the grandparents rather than the
parents may be the primary caregivers in an Indian family.
Therefore, it would be important to include the grandparents

89 Behav Analysis Practice (2016) 9:84–94

during intake in order to obtain information. During later
phases of the intervention, it may also be beneficial to contin-
ue to involve the family in development of the data collection
and to make changes in the intervention based on the family’s
interactional style. In designing the intervention, the team will
then be able to include culturally appropriate reinforcers and
skill building, again taking into account strategies that are
appropriate to the client’s culture and belief system.

It may also be important to define a client’s behavior in
positive terms and in relation to cultural norms to help ensure
culturally aware behavioral definitions. For example, in exam-
ining table manners across cultures, French parents may be-
lieve that child table manners are the essence of their culture.
In Japan, in contrast, many children will leave the table during
a meal, and it is acceptable in certain settings for them to run
around, even in restaurants. More specifically, during lunch
with family friends, a Japanese child might imitate a peer and
leave the table during lunch with a smile on his or her face. For
Japanese parents, this is the cultural norm, but French parents
often consider this behavior is inappropriate.

Use Readily Available Resources Our third and final
recommendation for this section is for behavior analysts to
consider making use of the resources that are already available
to help make their practice more culturally aware. Salend and
Taylor (2002) describe guidelines for creating more culturally
aware functional behavior assessments. These guidelines suggest
behavior analysts should involve family, community members,
and professionals to learn about the client’s culture and examine
possible sociocultural explanations of behavior. They also sug-
gest behavior analysts attend trainings and engage in activities
that allow them to reflect on how their culture might impact their
belief system (Salend and Taylor 2002).

Another resource that can help behavior analysts en-
hance their culturally awareness is provided by Sugai
et al. (2012). The authors discuss how applied behavior
analytical terms can be understood within different cultural
contexts. For example, in some cultures, the concept of
reinforcement can be illustrated by describing the act of
bowing to greet one another. In this exchange, a bow is
more likely to be given if a person is first bowed to, thus
the initial bowing behavior is reinforced. Like Salend and
Taylor (2002), these authors describe how steps in inter-
ventions, such as school-wide positive behavior support,
can be made more culturally aware—for example, by using
activities that are considerate of learning histories and the
norms and values of the culture, family, school, and
community.

Tanaka-Matsumi et al. (1996) also provided another re-
source for increasing culturally aware behavior analytic ser-
vices. Specifically, the authors provide guidelines for
conducting a culturally informed functional assessment inter-
view, in which increases in accurate case formulation,

decreases in diagnostic errors, decreases in attrition, increases
in the credibility of the therapy, and increases in the expecta-
tion of positive change, client compliance, and active partici-
pation in treatment might be a result. The authors emphasize
the importance of examining the functional relationships be-
tween a client’s behavior and culture, which may increase
buy-in from all parties involved and help acquire an accurate
description of the client’s challenging behavior.

Moving from Assessment to Treatment Once information
has been obtained through reflection on and assessment of the
client’s culture as well as the behavior analyst’s own culture,
the behavior analyst can use the information to make informed
decisions about next courses of action, such as accepting the
client, referring the client elsewhere, seeking additional infor-
mation about the client’s culture, or securing supervision from
a more experienced behavior analyst as needed. It should be
noted that lack of a cultural match does not necessarily mean
that the behavior analyst cannot provide adequate services to
the client. A behavior analyst should rely on professional ex-
perience and knowledge to serve this client, given the behav-
ior analyst’s cultural context, but should also remember that
within-group differences are greater than between-group dif-
ferences (Sue 2003). For example, a client of the same race
and socioeconomic background may not have cultural norms
that are strongly similar to those of the behavior analyst. There
are various domains of culture (e.g., family, geography, sexual
orientation, and religion) that relate to the behavior of the
individual. A behavior analyst who lacks experience and
knowledge to serve a culturally different client should seek
additional information about the client’s cultural behaviors,
values, and norms and should also seek direct exposure to
culturally similar experiences and people, if possible (Sugai
et al. 2012; Vandenberghe 2008). Finally, even when behavior
analysts strive to be more culturally aware, provision of cul-
turally aware services may not always go smoothly
(Vandenberghe 2008), so behavior analysts should view skill
development in this domain as a process and engage in ongo-
ing assessment to continually improve their practice (see the
BCultural Awareness Training in Graduate and Professional
Development Programs^ section below).

Recommendations for Increasing Cultural
Awareness within Clinical Organizations
and Professional Development Programs

In order for behavior analysts to become aware of the cultural
values of their clients, as well as their own cultural values,
service delivery and training programs must also develop sys-
tems of support and encourage professional growth in this
area. The following recommendations concern how
cultural awareness training can be integrated into clinical

90 Behav Analysis Practice (2016) 9:84–94

organizations and graduate and professional development pro-
grams. These recommendations are not all inclusive; rather,
they highlight examples of how behavior analysts can institu-
tionalize cultural awareness within their professional and
training systems.

Increasing Cultural Awareness within a Clinical
Organization

One strategy to increase the likelihood of culturally aware
behavior is to embed cultural awareness training and supervi-
sion at the institutional level within an organization.
Implementing training and supervision systems may help an
organization achieve the goal of institutionalizing the skill of
cultural awareness (see Betancourt et al. 2003, for suggestions
on cultural competency training for health care workers). The
following three recommendations are based on Brodhead and
Higbee’s (2012) recommendations for using behavioral sys-
tems to teach and maintain ethical behavior in a human service
organization.

The first recommendation is to identify an individual with-
in the organization who can be charged with ensuring that
cultural awareness is addressed. Because it is likely not to be
reasonable or possible for all members of the organization to
focus solely on developing cultural competency, it may be
useful for an organization to identify one individual who can
help guide the development of cultural awareness in other
members of the organization. This individual’s role would
be similar to that of the ethics coordinator described by
Brodhead and Higbee (2012). The identified individual who
would focus on cultural competency would also be responsi-
ble for identifying points of discussion for individual and
group supervision and would also serve as a reference within
the organization to stay up-to-date on best practices for cul-
tural competency.

The second recommendation is to incorporate cultural
awareness training into individual supervision. During indi-
vidual supervision, the supervisor can ask the supervisee to
discuss any instances where conflicts between cultures might
result in barriers to effective service delivery. For example, a
supervisee may seek feedback on the appropriate way to re-
spond when offered food during in-home consultation. The
supervisee may also seek guidance on how the cultural values
and contingencies of a specific family should be considered
when designing a parent training, as parental values might
lead to parenting styles that are culture specific (Akcinar and
Baydar 2014). The purpose of discussing cultural awareness
during supervision meetings is to provide multiple, continu-
ous opportunities for feedback and discussion. It is recom-
mended that fidelity checklists be developed and used in su-
pervision include items that assess cultural awareness during
assessment, intervention, and ongoing consultation.

The third recommendation is to incorporate cultural aware-
ness training into group supervision and training. Similar to
company-wide trainings on ethics, functional assessment, and
skill acquisition, trainings on cultural competency can allow
for group discussion and feedback on best practices for the
cultures the organization is likely to serve. Difficult or impor-
tant questions that arise during individual supervision can be
addressed during group training, allowing for additional op-
portunities for discussion and feedback about the appropriate
service delivery under a given set of cultural variables.
Discussions can be facilitated by a company expert in cultural
competency to ensure that topics are adequately addressed
(see Wolfe and Durán 2013, for a review and suggestions for
a similar training in a public school setting).

One strategy for behavior analysts to document the efficacy
of their services may be to distribute social validity surveys to
the clients they serve. Social validity surveys can ask whether
clients are pleased with their interactions with the behavior
analyst, whether the behavior analyst is respectful of cultural
values, and whether the behavior analyst recommends cultur-
ally appropriate interventions. Such a survey could also be
useful for evaluating the effectiveness of supervision and pro-
fessional development programs in creating culturally aware
behavior analysts.

Cultural Awareness Training in Graduate
and Professional Development Programs

Developing training programs for behavior analysts that teach
cultural awareness could have a positive impact on the field of
behavior analysis. This is especially important given the re-
cent expansion of behavior analysis training programs as well
as the application of behavior analysis outside of the United
States. To address the need to develop cultural awareness
skills, behavior analysts will need to develop coursework spe-
cific to cultural awareness, develop standards for practice and
competency (Carey and Marques 2007; Diaz-Lazaro and
Cohen 2001; Fong and Tanaka 2013; Westefeld and
Rasmussen 2013), and develop continuing education oppor-
tunities to assure continued competency (Cross et al. 1989).

One strategy to ensure that the professional development of
behavior analysts addresses cultural awareness is to include
cultural awareness content in behavior analytic course se-
quences. The BACB Fourth Edition Task List does not explic-
itly cover cultural awareness or content related to cultural
systems. However, other comparable fields such as psycholo-
gy and medicine require specific training for cultural aware-
ness (American Psychological Association [APA], 2015;
Association of American Medical Colleges 2005).
Specifically, medical students are required to have cultural
competency training integrated into their curriculum in order
to assure that cultural competency is established as an impor-
tant and pervasive issue in the provision of care. Furthermore,

91 Behav Analysis Practice (2016) 9:84–94

there exist specific accreditation standards in psychology re-
lating to cultural competency in the practice of psychologists
that concern the various means by which cultural competency
can impact the conduct of the behavior analyst (APA 2015). In
addition to ethical standards regarding the practice of behavior
analysis, we recommend that the field adopt appropriate cul-
tural training standards. While it may be the case that effective
assessment and intervention will likely include an analysis of
relevant cultural variables, the absence of training standards
related to conducting and developing culturally aware practice
skills in our discipline’s task list (BACB 2015) may lead to a
failure to foster and develop the necessary skills. Specifically,
these training targets would be of the greatest importance in
BRecommendations for Increasing Culture of Awareness
within Clinical Organizations and Professional Development
Programs^ Section of the task list, which focuses on the de-
velopment of skills related to the client-centered responsibili-
ties of aspiring behavior analysts.

Another strategy to increase cultural awareness may be to
institutionalize standards of practice for serving clients from
diverse cultural backgrounds. Representing the Multicultural
Alliance of Behavior Analysis, a special interest group of the
Association for Behavior Analysis International, Fong and
Tanaka (2013) published a list of seven standards for cultural
competence in behavior analysis. These standards include un-
derstanding one’s own cultural biases and how these might
conflict with the biases of those they serve, using culturally
aware applications of behavior analysis, and advocating for
diversity in the workplace. Fong and Tanaka (2013) also sug-
gest that behavior analysts advocate for culturally appropriate
language interventions, participate in continuing education
and training related to cultural awareness, and make appropri-
ate referrals if they are not qualified to work with diverse
clients. We encourage organizations and training programs
to review Fong and Tanaka’s (2013) recommendations and
consider integrating them into supervision and coursework.

Researchers, creators of training materials, and administra-
tors of university programs can all contribute to developing
cultural awareness skills in the field. We encourage more re-
search on topics of diversity, cross-cultural implementation,
and international dissemination of ABA. It has been recom-
mended that when behaviorally oriented researchers publish
articles, the BParticipant^ section include more information
about cultural variables (Brodhead et al. 2014; Kaufman
et al. 2008). We further suggest that authors of textbooks
and training manuals, and designers of continuing education
and online trainings increase the number and variety of topics
related to culture and diversity. By adding more examples of
scenarios involving issues of diversity, cultural awareness, and
culturally aware assessment and intervention, behavior ana-
lysts may continue to lay the groundwork for pre-service be-
havior analysts to practice more effectively with a broader
range of populations. Administrators and faculty in

universities can set specific learning outcomes for teaching
about diversity and cross-cultural implementation skills.
Such initiatives can be adopted at the level of the university
or within an academic department. Behavior analytic training
programs can also develop student abroad experiences to in-
troduce students to different cultures or program experiences
involving different local cultures. Effectiveness with diverse
populations can be specified as both a value and a learning
outcome for students in our programs.

A final strategy for integrating cultural awareness into pro-
fessional development is to encourage continuing education
requirements for cultural awareness. In the field of behavior
analysis, professional development with respect to cultural
awareness receives no special attention. As a result, if behav-
ior analysts in the field come into contact with issues related to
culture in continuing education, they are likely to do so in the
general category of ethics. Even if standards for cultural
awareness are not established, we recommend that qualified
behavior analysts consider conducting continuing education
trainings on cultural awareness in order to increase the prob-
ability of behavior analysts coming into contact with impor-
tant information related to cultural systems.

Discussion

Two decades ago, Hayes and Toarmino (1995) asked, Bif be-
havioral principles are generally applicable, why is it neces-
sary to understand cultural diversity?^ Today, behavior ana-
lysts may remain unconvinced that specific training in cultural
awareness is required. The BACB Fourth Edition Task List
does not directly address cultural awareness in its own titled
guideline, and most behavior analytic graduate and certificate
programs are based in large part on the Task List (BACB
2012). We argue that few specific practice guidelines are
available to behavior analysts. However, the Professional
and Ethical Compliance Code for Behavior Analysts (BACB
2015) does touch on this topic, with the requirement that

Where differences of age, gender, race, culture, ethnic-
ity, national origin, religion, sexual orientation, disabil-
ity, language, or socioeconomic status significantly af-
fect behavior analysts’ work concerning particular indi-
viduals or groups, behavior analysts obtain the training,
experience, consultation, and/or supervision necessary
to ensure the competence of their services, or they make
appropriate referrals. (p.5)

However, we suggest that such cultural differences always
affect our work with individuals or groups. Therefore, it may
be important for behavior analysts to continue to develop their
cultural awareness skills by systematically ensuring ongoing

92 Behav Analysis Practice (2016) 9:84–94

training, experience, and supervision for cultural competence
and awareness.

The above recommendations are meant to serve as a starting
point for considering strategies to increase cultural awareness
among behavior analysts. Although the recommendations may
very well improve a behavior analyst’s cultural awareness, there
are several additional considerations and limitations to our rec-
ommendations. First, it is important for behavior analysts to not
make gross generalizations about clients or their families based
on the culture(s) they represent. Specifically, if an individual lives
in the United States of America, is light skinned, attends a
Christian denomination church and speaks English fluently,
one should not assume that the individual is of European
American descent. In fact, that individual might be of Hispanic
descent, speak Portuguese fluently, come from Guatemala, and
reside in the United States temporarily while competing higher
education requirements. It is very possible that avoiding such
generalization or stereotyping can be difficult when learning or
teaching about cultural practices as part of a cultural awareness
system. However, collecting information about different cultural
systems should place behavior analysts in a better position to
Binfer the possible effects of the environment^ in order to make
effective treatment recommendations (Brodhead et al. 2014,
p. 81). Therefore, we encourage behavior analysts consider our
recommendations for increasing culturally awareness prior to the
intake process.

Another limitation of this paper is that it does not provide
systematic guidelines for how behavior analysts should work
with culturally diverse clients. However, because there is a
lack of resources in the area of cultural awareness and behav-
ior analysis, we hope this paper serves as a starting point for
future discussions and analyses. Systematic guidelines for
practicing behavior analysts have been published in other
areas, such as guidelines for identifying an appropriate
function-based treatment for escape-maintained problem be-
havior (Geiger et al. 2010) and for maintaining professional
relationships (Brodhead 2015). Therefore, it may be useful for
future researchers or behavior analysts to develop systematic
guidelines for working with culturally diverse clients in order
to provide practicing behavior analysts with a systematic
framework for their work.

Finally, it is important to note that the fidelity of the behav-
ior analytic intervention should not be compromised in order
to incorporate culturally aware practices. It is very possible
that a culturally informed assessment may lead to a culturally
informed intervention that may ultimately lead to implemen-
tation with high fidelity. Whereas, an assessment that is not
culturally informed may lead to an intervention not matched to
client culture which then can’t implemented with fidelity. In
some cases, however, multiple courses of treatment may be
available to deliver the same treatment outcome. If this occurs,
we recommend that behavior analysts consider identifying the
most culturally appropriate treatment whenever possible. See

Padilla Dalamau et al. (2011) for an example of identifying
client preferences for functional communication training
interventions.

In summary, cultural variables matter even when
implementing practices supported by research and based on
the science of behavior analysis (Sugai et al. 2012). No be-
havior analyst can learn everything about every culture.
However, we can develop skills to collect the right data and
to understand ways in which culture may affect reinforcers,
goals, teams, and interventions in general. We can cultivate
awareness of diversity and willingness to honor what is right
for our clients. Behavior analysts may not be even aware of
how much our personal learning histories differ from the con-
tingencies related to our clients’ behaviors, their reinforcers,
their behavioral patterns, and the effect of the societal systems
in which they live. Continuing to cultivate openness to learn-
ing about these variables, along with an awareness of the
limitations created by our personal learning histories, may
lead us in new directions that will benefit diverse populations
with behavior analysis. The growing diversity of our popula-
tion expands the complexity and variety we can expect to
encounter, and so we must continue to develop cultural com-
petence skills through behaviors of awareness, collecting the
right data, and honoring what is important to our clients.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no competing
interests.

Ethical Approval This article does not contain any studies with human
participants or animals performed by any of the authors.

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  • Developing the Cultural Awareness Skills of Behavior Analysts
    • Abstract
    • Strategies for Developing Cultural Awareness
      • Developing Cultural Awareness of Self
      • Developing Cultural Awareness of Clients
      • Recommendations
    • Recommendations for Increasing Cultural Awareness within Clinical Organizations and Professional Development Programs
      • Increasing Cultural Awareness within a Clinical Organization
      • Cultural Awareness Training in Graduate and Professional Development Programs
    • Discussion
    • References
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