A Pour of the New Brew: Clinical Decision Support & Non-Binary Thinking with Amanda Ralston (Part I)

ABA on Tap is proud to present Amanda Ralston (Part 1 of 2):

Grab a stool and a cold one because this week on ABA on Tap, we’re joined by an ABA powerhouse,  now tech-innovator, Amanda "Mandy" Ralston, M.Ed., BCBA, LBA. With over 25 years in the field and a "serial entrepreneur" badge of honor, Mandy is here to help us move past the rigid, binary thinking that often limits our profession.

In this episode, we’re serving up:

• The "Medical Necessity Sandwich": Mandy breaks down her viral concept for navigating documentation and clinical decision-making.
• NonBinary Solutions: Why she pivoted from clinic owner to tech founder to build NonBinary Solutions, a data analytics firm creating Clinical Decision Support Systems (CDSS).
• Standardizing the Wild West: A candid look at the lack of standardization in ABA—from terminology to outcomes—and how technology can bridge the gap without replacing clinical intuition.
• Digital Mentorship: How emerging AI and software tools can act as "mycorrhizal influencers" to guide the next generation of BCBAs.
• The Future of ABA: Why value-based care and clinical intelligence are the next "taps" we need to open for better quality of life outcomes.

Whether you’re a seasoned BCBA or an RBT just starting your fieldwork, Mandy’s authentic and transparent take on the industry is exactly what you need to level up your practice.

Tune in, drink up , and always analyze responsibly. Cheers!

Transcript

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SPEAKER_04 0:01

Welcome to ABA on tap. I'm Mike Ribio with Dan Lowry. So without further ado, sit back, relax, and always analyze responsibly. All right, all right. And welcome back to yet again another installment of ABA on tap. I am your ever-grateful co-host, Mike Rubio, alongside Mr. Dan Lowry. Dan, how you doing?

SPEAKER_05 0:44

Doing great, doing great. How are you doing? I know we had an exciting day today. We have two top echelon guests here. Professionals, yeah. Got us really excited today.

SPEAKER_04 0:53

Quintessential professionals. And I guess I'll share this uh since we've got our our guests waiting here and listening. Feel very blessed to be in our seventh season. Over the past couple seasons, we've really gained a lot of momentum and especially last season with all the guests that agreed to come in. And I gotta tell you, today I, you know, earlier in the week I looked at our our calendar and I saw the guests, and I I got a little nervous. You know, I'm I'm very grateful to be able to take the time. Very we're very grateful for the time that they give to come and uh spend chatting with us. And yeah, you you sometimes see certain names, and these are people who you've read about, people whose work and diversity of work you very much respect. And yeah, it you know, throws you off a little bit. So feeling grateful. Had a great first run today with one of those individuals. Here we've got another heavy hitter, somebody who's you know me, Dan. I've I've I shy away from words like innovation and I don't know, things that that people maybe overuse and it doesn't matter.

SPEAKER_05 1:50

Not that you don't believe in it because it's you feel like it's gonna pass.

SPEAKER_04 1:53

It's just sort of a buzzword, right? And then again, you come across people who are really pushing the the you know at the front line, really pushing the envelope, really doing new things that are gonna be exciting. And and more importantly, something that maybe we didn't highlight so much earlier today, but these are all things that I really think bring the focus, a laser focus now on the service delivery, on the interaction with the patient or client. So that's that's really exciting. All right. So yeah, well, without further ado, our guest today is Mandy Ralson. Mandy, how are you doing? Good afternoon.

SPEAKER_00 2:35

Hey guys, I'm doing well, thank you. How are you?

SPEAKER_04 2:38

Uh we're we're doing great, excited to have you on the podcast. Thank you so much for spending some time with us on a Sunday afternoon. How's how's the weather? Are you you guys been getting hit with storms in there?

SPEAKER_02 2:49

I am looking out the office window and there is snow that is floating up at the moment. So we've got some flories gone.

SPEAKER_05 2:55

Snow that's floating up, okay.

SPEAKER_04 2:58

Well, just just by contrast, we're in uh you know very, very balmy, very rough San Diego. It's uh it's a tough 68 degrees here.

SPEAKER_05 3:06

So I'll hate that for you guys. It's 74 now.

SPEAKER_04 3:10

Oh, geez, it's 74. Well, just rub it in, huh? Right. What was me? I earlier I almost had to put a a sweater on. It was it was 64, yeah.

SPEAKER_01 3:20

You poor, poor thing.

SPEAKER_04 3:23

So again, we can't thank you enough for for spending some time with us. We really like to highlight the origin story for our guests, especially for somebody like yourself doing very interesting things now. How it all culminated, where it all started, if you don't mind taking us back as far back as you want to go. And I guess the important part here is how you know how it all relates to what you're moving forward these days.

SPEAKER_02 3:46

Yeah, so I got started in this field around 1999. I've read in my last semester of my psychology undergrad program, my textbook at the time told me that autism was one in every 10,000 individuals.

SPEAKER_04 4:02

I remember that.

SPEAKER_02 4:03

Right. And the gold standard for treatment was something called applied behavior analysis. So I decided to write a research paper based off of these two paragraphs in this book.

SPEAKER_03 4:12

Oh, wow.

SPEAKER_02 4:13

And yeah, I met seven families here in Lexington, Kentucky that were flying a consultant out from California once a quarter to, you know, assess one day, train day two, and then fly back, you know, by using family members, high school students, college students, independent contractors as quote-unquote therapists to cobble together 30 to 40 hour a week programs for these kids. Yeah. It was brutal. I mean, people were emptying their savings accounts, using their other child's college fund, you know, to pay for all this out of pocket. And yeah, I just I got really curious and ended up working with those same seven families after I graduated. And yeah, it was one girl and six boys, so very on point in terms of statistics, uh, statistics, excuse me. And, you know, all levels of you know, degrees of impact with their awesome as as well. You know, one of them would have been considered Asperger syndrome at the time, and a couple of individuals were profound autism. But then after I started doing that work, we heard about this guy named Dr. Vincent Carbone, who was traveling all over the country to talk about why some of the old DTT methods were outdated and we needed to start looking into the literature that Skinner wrote with verbal behavior. And so I basically started stalking him, um, light stalking. And he he took a shine to me. And we ended up going down to Jacksonsville, Florida to do a boot camp of 90 hours of intensive training under Carbone to grandfather and individuals that were sort of already in the field but didn't have master's degrees. And so that's how I got to my DCABA. Carbone was my mentor and supervisor for a year after that 90-hour programming. And so he and I would send VHS tapes back and forth in the mail and talk on a landline phone about my competencies, right? And then I sat for my exam in 2001 in Nashville, Tennessee, with a number two pencil and a Scantron. So that's how long I've been in this industry.

SPEAKER_04 6:20

What are the what are the last four uh digits of your BACB number?

SPEAKER_02 6:25

Well, now I'm a B C B A. So I went ahead and got my master's degree in 2014. And so B C B A is a little bit further along.

SPEAKER_04 6:34

I see. Okay. That that's just based on the timeline. I'm like, that's sometimes when people see that, they'll ask me, Wow, so you've been this a while, you know, you've been at this for a while. And it's like, yeah, that the number's gotten bigger. I haven't been at it that way.

SPEAKER_05 6:46

We're only four. Your yours only has four, mine has five.

SPEAKER_04 6:49

Yeah, yeah, that's the difference there. Uh interesting. So, so Dr. Whenever I hear Dr. Carbone's name, it's always CMOR, C M O T stuff. I I love his breakdown in that and how much sense it makes with just little simple things that happen to, you know, uh some of our RBTs, people that are like, yeah, you know, whenever I ring the doorbell, the child starts crying. And then you find out that, well, that's because when they asked, that's when they're asked to put their iPad away. It's like, oh, okay. That makes total sense. It was totally doc listening to, I think it was a CE or something with him. What a what a great experience to be able to have such a heavy hitter, such a prominent name as as your mentor, or talk a little bit more about that, if you don't mind.

SPEAKER_02 7:28

Yeah, I mean, again, it was the early, early days, and he had his clinic in Jacksonsville at that time. And then later he moved up to NIAC, New York, and opened a cargoing clinic there. And so, you know, I would basically go to his clinic and just sit for three days and and listen and watch and pill for everything I possibly could, copy everything I possibly could that he was doing, which is, you know, I wouldn't say I did it to the near quality that, of course, that group did, but at least I had a North Star that I was trying to emulate, right?

SPEAKER_05 7:59

What were the things that you would uh copy from or that you took back from you from those original days?

SPEAKER_02 8:05

Oh my gosh. I mean, so much. I mean, we at my my second clinic was so okay, let me rewind. So I built two different clinics here in Kentucky. The first one was started in 1999, and it was me and three other women, uh women, and that was before there was any funding, uh, barely enough any certification, no licensure, nothing, right? And so we none of us were business majors, and so I became CEO at age 25 of an organization that had 120 clients and 85 employees in three locations. Right. And because none of us were business majors, we made, well, I always like to say I got a real life MBA for the cost of you know a hard business education. So I learned some hard lessons the first go-round. And then I spent about four years driving 40,000 miles a year anywhere from Kentucky, Indiana, and Ohio for people that could pay out of pocket for my services as a consultant, right? And so sort of went back to the model that I was raised under of me not being the consultant and going and teaching other independent contractors how to cobble together these ABA programs because again, there's there's no funding. And there were 18 behavior analysts in the state of Kentucky at that time, right?

SPEAKER_03 9:21

Yikes.

SPEAKER_02 9:22

So I got tired of not being able to control quality with those types of programs. You know, they're independent contractors, they come and go, they don't really have to listen to you. And so begudgingly, after I swore off building another clinic, I ended up building another clinic. And so I started verbal behavior consulting in 2007 and grew that much more slowly, made new and different, more exciting mistakes, but again, took what I learned from the first one and didn't repeat those. And so, yeah, a lot of what I did with verbal behavior consulting was based off of Carbones Clinic, right down to, you know, the teaching procedures, the materials, the binders, the data collection sheets, you know, the the behavioral protocols that we used, all of that. I mean, we literally I copied as much as I possibly could.

SPEAKER_05 10:10

So it's interesting that you bring up the like consulting and having people come for like a group of families. We worked with an individual, she actually was in the presentation, and we worked with her son who's now in his 30s. She lived in San Diego, and they did a similar thing with the Lovas people from LA. They would have a group of people in San Diego. I think there was like three to five families that they would I don't think they would have to fly the but the people from UCLA would drive down for a little bit, train, and then drive back up. So it seems like kind of a similar modality. So that's like the early, early, early days of ABA. Like what did what did that look like? Because I I came into the field about like 2007 and it was a lot of DTT and and that kind of was very structured versus now it's kind of very different. Can can you speak to like what that looked like back in those days?

SPEAKER_02 11:03

Well, I mean first of all, I'd like to say that you know things that we did 25 years ago we would not be doing today, right? Because with new information, new data, new variable, new plan, right? And so I I have this whole presentation that I've done talking about hindsight bias, right? And that it's easy to criticize what we were doing 20 years ago, 26 years ago, but everybody was doing exactly what we're doing today, which is trying to help, right? And using what was state of the art at the time, right?

SPEAKER_03 11:38

Yeah.

SPEAKER_02 11:39

But definitely teaching procedures were outdated at that point. So, you know, I was the classic person that, you know, Carbone would talk about coming into the child's house and saying, okay, gonna turn off the TV, get off your chair up lane, let's go downstairs into the therapy room, take away all your reinforcer, put shit on your desk, and then think you're gonna work with me for two hours without a tantrum. Well, guess what? It only takes about three trips to the house before I'm greeted with bye Mandy. Right. So I'd make myself a worsening of conditions. And so they're manding though. That's great. Yeah, bye Mandy. Yeah, yeah. Got a lot of good mans that way. Um but yeah, I mean, learned so much through that process about what good motivation actually looks like, what good teaching procedures actually look like, and when when learners want to come to the table because they want more of what you're offering, right? Yeah, I mean, it's it was flashcards, it was making your own materials, it was, you know, pencil and paper data collection, it was trial by trial data collection. Yep. The no-no prompt was an art kick. Yep.

SPEAKER_05 12:43

Oh, I taught them for many years. No no show. No show. Then you uh ask again, then you can change the order. Yeah, yeah.

SPEAKER_02 12:51

Man, yeah. I mean, it's like, do you ever go into McDonald's and be like, you know, burger, no, burger, no. You know, and then they finally tell you what it is that you're gonna order, right? It's like that's not how life works. Or like go into your first day at your job, like, where's your mailbox? Nope, try again. Where's your mailbox? Try again. Here's your mailbox, where's your mailbox? Like it was a careboy to try to do it.

SPEAKER_04 13:13

Could you have shown me the mailbox first before asking me, please?

SPEAKER_02 13:17

Right, right. So those those are the types of things that it's like I I really have seen an evolution and attitude and teaching procedure and motivating operations and what good looks like, right?

SPEAKER_04 13:30

Yeah. So we we kind of cut you short there. We we stopped you at your origin story at Carbone, and then we got into some really interesting stuff I want to come back to. Tell us a little bit more about the origin and your progression, and then I think we're gonna be able to spend a lot of time talking about the evolution of teaching procedures, because that's exactly where we kind of come in in terms of what we do and the things we like to talk about. So you you mentioned you started verbal behavior, you know, the verbal behavior consulting. Anything anything beyond that?

SPEAKER_02 13:59

Yeah, so VBC started in 2007, and like I said, I grew up much more slowly. And then we had an exit in 2019 to Blue Sprig, which was the fourth largest provider at the time. So I got to hang out inside that larger organization for about three years. And what I saw once I was inside was eye-opening. You know, you when you're in your echo chamber at your clinic, you think that this is how other people do things. And it was a revelation to realize that basically I could get a hundred providers in a room and put one kid in front of them and say, How are you gonna approach support or treatment for this person? And they will all have completely different approaches. And most of the reason they do it that way is because that's how they've always done it. It's not necessarily based on data or science or the most recent literature, it's literally what they learn to do from their supervisor and it's rinse and repeat, right?

SPEAKER_03 14:49

Yeah.

SPEAKER_02 14:50

Which is suboptimal, right? Like you would want to think that if you went to a hundred different oncologists with certain symptoms or quality of life issues, that you would reasonably arrive at about the same recommendation from all those people. But that's not how things work in our field right now, and and that could be a problem. It is a problem, right?

SPEAKER_04 15:13

Where so we we were actually just talking about this with our last guest, Carrie Milico, and she had something interesting, Dan, that you'd captured on. I hope I'm not gonna butcher it, but the idea that that our individualization in terms of processes is sort of our worst enemy in a sense. And that's kind of what you're hitting on. On the other end, d did you see where too much then standardization uh then affects individualization? Where's the sweet spot? Where's the middle ground? I know technology comes into play there. Give us your insight on that.

SPEAKER_02 15:51

I mean, people want to have this conversation with science versus art, right, within the field, like how much is science and how much is art. And you know, there's soft skills, sure, all that is true. So I guess part of the question that I want to answer here is when I saw that variation in clinical decision making amongst our provider groups that got me interested in technology called clinical decision support systems. Right. And so one of the acquisitions that the Blue Sprig had made uh shortly after I'd gotten there was a group called the Cedar Group. And the Cedar group was making clinical decision support systems for the payer side. So reviewing medical necessary and excuse me, necessity, understanding intensity, treatment plan reviews, et cetera, et cetera. So the the nurse practitioners, the other BCBAs on the payer side could review things in a standardized fashion and reasonably arrive at about the same conclusion about whether this was a good plan or a needed review, so on and so forth. So I learned about that technology and I started thinking about what does that look like if we made that for the provider side, right? And so that's what I ended up doing afterward, and after I left Blue Sprig, right? So non-binary solutions is the name of the tech company that I started in 2022. And we built a system called Noetics. That's K-N-O-W-E-T-I-C dot AI. And don't let the AI scare you. It's a very small portion of what the software actually does, but it was definitely the the trendy thing to do when you're grabbing the website URL right off the bat.

SPEAKER_03 17:22

Right.

SPEAKER_02 17:23

But basically, what we've built through Noetic is a set of modules. The first module is called care navigation. And essentially what that is, is a robust and structured clinical interview to help users understand who are these very, very different people coming into their care. So I did every clinical intake, like the initial intake uh for every one of the kids that came through my clinic. And so it's based off of basically everything I learned the hard way, I should have asked before day one. Right. Like if I just would have asked, and has this person had a sleep study, I would have known that you know they should they should have had a seizure rule out at some point. Or if I just would have asked, does this teenager tend to target smaller children? I never would have put that person in the same clinic as these smaller children, right? So it's knowing all the things that you need to learn the hard way, essentially, and and giving people a digital mentor, right? That now you have something that actually does guide your thinking about how to approach intake. And so that that clinical interview that you go through no edic and you punch in answers as you're doing it live with the family, their face-to-face or through telehealth, and it builds a profile of that individual. It writes the report for you and says, here's everything we know about this individual, here's their medical background, here's their behavioral background, educational, here's their preferences, here's what they're good at. And based off of the algorithms in the background, which are based off of a knowledge set for me, the algorithms then say, based on these combinations, we're recommending these action steps for this person. Like you need a sleep study, or this family needs, you know, marriage and family counseling in order to get on the same page about behavioral issues first, or this kid has a history of elopement and is attracted to water, and therefore a water safety class would be pertinent for this individual, right? So just coming up with a list of recommendations for that for a kid, which is something that is then able, you can hand that to the parents and they can go ahead and be doing that if they're sitting on a wait list, like so many of them are, right? Or these are things that the clinical director now knows need to sort of happen either currently or prior to intake with that individual. So then you have a pipeline and a dashboard of all the folks that are on your waiting list, understanding what their different profiles look like. And most importantly, because all these individuals are being brought into a data set in the same fashion with the same questions given the opportunity and the appropriateness of the questions, we now have a uh structured data set of patient profiles, which is necessary in order to be able to compare patients to patients. If you dump all the patient information into a data lake and it's fragmented in terms of what information is there and what information isn't there, or everybody's been doing it their way, and then they dump all their patient data into a data lake, then you're gonna have chaos. And AI, machine learning, cannot make sense of chaos, which is why you get hallucinations from the internet, right? I haven't heard of that. Right. So so yeah, there's lots of different facets in there, and so I'll stop talking for a second because we can go any particular direction you want to based off all that.

SPEAKER_04 20:36

Man, well, Dan, I I saw you writing some things down. I've got a million things I can ask about. Go ahead. Could you let's see? So are you you you you certainly understand a lot about the I guess training or coding side of these engines, or at least it it that's the way you you're speaking to it. Well, and I think that's important in just the sense that you know, in my limited experience, I've got a concept or an idea, and then I get somebody now coding it, and there there can be a lot lost in translation. So, based on your experience versus, say, diagnostic correlates, can you talk to us a little bit about how your particular engine makes those correlations based on responses? So the idea that it might come up with, hey, marriage family therapy might be very good. Oddly enough, that's something that we've talked about in terms of say even just divorce rates for for kids with exceptional needs. I mean, divorce rates are already pretty high. You you take into account that particular variable, it goes up to like near 80% or something. So clearly there's things that can be helped there. What kinds of responses or what triggers that particular recommendation? How much can you tell us about that given the system you're building?

SPEAKER_02 21:45

Well, I looked into a lot of quality of life metrics and assessment tools, and I sort of came up with uh a proprietary version for NoEdic that is really trying to understand what is actually impacting. The family and the kids' quality of life, and how does that relate to their autism, right? Because if it's a quality of life issue but it doesn't relate to their autism, then it's not medically necessary. But if it is the quality of life issue and I can show how symptom impact is related to it, then it is medically necessary, which is an important conversation to be having and an important algorithm to have because a lot of payers have started saying we won't work on that because that's custodial, right?

SPEAKER_03 22:26

Yep.

SPEAKER_02 22:26

Well, if I can if I can show you that the child's inability to learn how to brush their teeth actually is directly related to their autism, then it's medically necessary, right? And therefore it should go on a three-point plan. And so one of the questions to your thing about the family counseling, cohesive parenting is one of the questions on on the noetic goal development module, right? So and basically it's designed as a liker scale. So the the various areas of quality life, basically, you go through them with the family and you say, how much has this issue been an issue for your family in the last one month? Like very common, not so much, or rare or never, right? And so based on how you answer all the quality life areas, it will use again an algorithm in the background to float the ones that should have the most priority to the top. So that if you only have a limited amount of time to work with this person, you understand what should be first on the trade planning list, right? So spoiler alert, you know, the the big seven, I call them, um, are the ones that are most weighted most heavily within the system. And those are eating, sleeping, toileting, safety, communication, emergency preparedness, and access to care. Right. So if any of those seven areas are pinged as yes, this has been an issue for my family or my my kid or me in the last uh one month, then they automatically float to the top. Because what I'm trying to solve for there is what I've seen historically be a problem for patients and families. Patients and families come into a provider's office and they say, Hey, my eight-year-old son still isn't toilet trained all the way. He only eats five things, and we can't go to the grocery store anymore because he runs into the parking lot. And the therapist hears that and goes, Great, we're gonna do the Abels or the VB map, and then maybe also the vinylin, right? And then they start plucking goals out of obscurity and to say, This kid reminds me of this other kid I worked with, so I'll copy and paste some goals from that treatment plan over to this one. And I mean guess what? The three things, right? Yeah, the three things that the family just told you were really impacting their quality of life are on that list, right? And so I don't mind you guys do the ables and the VB map and all those things, but show me how your objectives or whatever, you know, D1 correlates to how we're going to get to toilet training, right? Show me how that those those things actually impact quality of life. That's that's one of my soapbox issues.

SPEAKER_04 24:55

That that's incredible. I think that's incredibly important, whether we label it social significance or how the developmental piece comes in. Yeah, I mean, I agree, especially when you think about things like eating and sleeping, which are very common with the population we work with. I mean, yes, it's you might be able to take of some greater behavioral concern without addressing those pieces, but by addressing those pieces, I think you would agree, uh, you know, the the the landscape's very different. So you're actually getting at the root of a problem versus just kind of addressing a symptom in a manner of speaking.

SPEAKER_02 25:28

And it's it's not an accident either that those seven areas generally correspond well to caregiver education or training or support, right? Whatever whatever phrase you want to use for 156. So again, so again, if you've got a waiting list of individuals, maybe you have BCBAs in your organization that are able to do just some caregiver training while you're getting queued up for some other services to help address some of these really urgent issues. And yes, I mean, this is also a conversation towards value-based reimbursement, right? Uh eating, sleeping, toileting not only impacts access to care, et cetera, it also directly impacts the family. So and sleep is a great example. Like if the kid's not sleeping, nobody's sleeping, right? And sleep deprivation is directly correlated with all kinds of health concerns, right? And so if you are not getting adequate sleep as an adult or child, you tend to have a laundry list of other medical issues. So this is a way of driving down costs over a lifetime for people on a payer platform, right? Same thing with like, can your child get their teeth clean without general anesthesia? Right. Guess what? Right. If you can't go to a regular dentist appointment on a regular basis and get your teeth clean, oral health is directly correlated with all kinds of negative health impacts. So again, reducing the cost of care over a lifetime by addressing these things early on.

SPEAKER_05 27:03

That's why I don't have kids because I enjoy my sleeping, and I know there's a lot of negative sleep at well.

SPEAKER_04 27:10

No, no, go ahead. But to the greater point, though, I think that it's important uh to really highlight that eating and sleeping as a first-time parent, now as a first-time parent who might have concerns, developmental concerns, man, those weigh heavy. So, you know, you're not sleeping. It means you might be, you know, playing short-order cook to try and get your kid to eat something. You might be feeding them things you don't feel comfortable with, but at least they're eating something. So it they're just such foundational, i i they're so foundational, these pieces, right? And yet if they're out of order or out of whack and we're not addressing those, that's an uphill battle to take care of anything else, you know. But again, they're they're super basic.

SPEAKER_05 27:50

What I really like too about the quality of life, and it's interesting because on our podcast we recorded a little earlier, we were talking about curriculum and assessments and things like that. I really like the the generalization and the applied aspect of that. You know, the what the first and seventh dimension are what I guess there's not necessarily numbers, but the implied and the generality piece. Because I've at our company we've done parent groups for a long period of time. And I think it's like in ABA, right? Where it's all so empirical and so like, well, we can't use a rate yourself scale because you know that's that could be biased and stuff like that. But I I feel like there's so much value into that because at the end of the day, if the parents are finding value in the results, then they're gonna be so much more likely to buy in. I can think of so many parent groups that I've run, and we've run parent groups over 10 years, and it's been a really good learning experience both for us and the parents, then maybe the the child wouldn't like you mentioned toileting and eating, those two specific things, sleeping as well, but toileting and eating, that might only be a little part of the programming, but it's a big part of the parents' concern. So, like when we would talk about things in parent groups and we could look at the dad and like, oh, look at your kids playing games and your kid has these fine motor skills, they're like, Yeah, that's cool, but they still won't eat, or yeah, that's cool, but I I'm just they won't go to the bathroom and it's like, yeah, but look at all these other things. I don't care, they won't go to the bathroom. I mean, they literally don't say I don't care, but like that's what they're saying without saying it. And it's because we're not prioritizing things that they care about, whether that's to meet, like you said, payer profile, whether that's to hit a score on a vineland or or knock off a level on the vinyland. I do think there's oftentimes a disconnect between what parents want to work on or the consumer wants to work on, what we're working on, which then leads to kind of a disconnect in the progression of that individual from the parents' perspective.

SPEAKER_02 29:39

Absolutely. I mean, again, with the the sleep issue and and the rate of divorce amongst individuals with autism. How many families have I seen have their eight, nine, ten-year-old child still sleeping in a marital bed? Right? Won't sleep in their own bed. And and if if that's okay with the family, that's fine. Again, that's uh why all those questions are posed. How much has this been an issue for you? Because culturally, if you're cool with that, I'm cool with that, right? Yeah, but if it's a problem for you, then let's talk about it. Let's like approach what how we can do some problem solving around it. What's what's going to be feasible, right?

SPEAKER_04 30:17

And developmentally, again, just so much value with that in terms of, say, like something like co-sleeping. Culturally, it could be very relevant. From a socioeconomic perspective, it could be very relevant. And then there's how do you solve those particular get over those obstacles knowing that having the child sleep independently may in and of itself be the biggest need here. How do we simulate that in some way? How are we moving toward that now from a developmental perspective, knowing that this may by and large be the problem with your with the sleeping concern, right?

SPEAKER_05 30:49

And that that's one of the things too that I look back on. We talked about things that we look back on, the hindsight bias back in the day. And my answer to you know, sleep training back in the day would have been just you know, blanket extinction. Ignore your kid. Your kids, I mean, clearly, you know, that was 20 years ago. Things have changed. I have some buddies that have one-year-olds, and they're like, Yeah, we don't ignore our kid. We we go and give in, you know, and and maybe over a long period of time that that could be detrimental. But also, there's a lot more nuance than than I would have said back 20 years ago, just ignore and well, you're gonna have this extinction burst. It's I don't know how long it's gonna last. It might last a long time, and it might result in you getting divorced because now your kid's keeping you up the whole night, and now you're at your significant other's throat, and now you've got a whole list of collateral damage things from some ABA practitioner's advice that you know there's a lot of definitely like you would say multivariate there that can univariate solution to a multivariate problem.

SPEAKER_04 31:43

Yeah, I mean, there yeah, there's just so much nuance there. So, in terms of now having this information, what's the next step for you? Are you you're certainly addressing these things behaviorally, but say for eating or sleeping concerns, what else comes up as useful correlates to say to a family, hey, you may want to go see this professional, you may want to ask your pediatrician such and such. Tell us a little bit more about how those things come in.

SPEAKER_02 32:09

Yeah, I mean, part of the questions are, you know, has this been an issue for you in the last one month and eating or sleeping or what thing comes up, then have you had a medical evaluation regarding this is the very next question every time, right? Because you have to rule out any kind of physiological medical issues prior to actually making any kind of a address met versus a behavioral stance. So, so yeah, it does it does populate additional questions based on how you answer certain ones to again sort of prompt you through a decision-making matrix that's on the back end, like you wouldn't see it unless it was relevant, right? So jumping around here, I guess I should I should jump to the the punchline here lately. So I've had non-binary solutions since May of 22. Um, and then just recently, January 6th, I started in my new role as CEO of kids' choice therapy in Oklahoma. So it's kind of a full circle circle moment, right? That I'm thank you. Appreciate it. Then I'm sort of back in the saddle at a clinic again. You know, I've been away from clinics for several years, and this opportunity came my way, and I was very excited to to jump back in and and really start to work with a growing group. So that's that's where we are today.

SPEAKER_04 33:33

Clearly, you and I'm drawing a lot of inspiration from this. I mean, clearly you've been in and out of the direct intervention model, and I'm not sure how much of that uh you might be doing now, but you're certainly clearly you've got your hands on that. You're you're conceptualizing and programming and building, and then it sounds like you're actively going back into the actual service delivery to see how that's all working. And I think that's super valuable, just like you having the technical skills you have with now the behavioral understanding, you're able to span both sides of that in a way that maybe you know it looks like has a positive effect now on your product. Talk to us a little bit about that. How, you know, how do you how do you keep your chops up? What do you do to make sure that you're still seeing how these systems now get implemented, whether it's working with younger professionals or uh even hands-on directly with with patients?

SPEAKER_02 34:25

Oh, give me a minute. It's only been a couple of weeks, but uh no, yeah. I mean, most of it is yeah, I I've kept my my clinical chops, I think, most active just by having conversations with other clinicians that are still actually working with the caseload and following them and going to observe some of their work, et cetera. I am excited to be back in physical clinics at this point and see children. It's it's exciting to be around kids again. It's fun again. But yeah, I mean, I've had a lot of feedback from clinicians over the last three or four years about the software that we were building. So we had a lot of beta users, we had 28 different organizations on the software at one point. And so we had a lot of feedback on what they liked, what they didn't like, so on and so forth. So we really, I think we were on version 8.0 of the care navigation software before I took this most recent role and handed everything over to my my gaggle of white men at non-binary solutions. So yeah, you know, we got a lot of feedback. Like, can you add this question? Can you add this? Can you also consider this? And it was never a matter of taking things out of the software, it was always a matter of adding additional things based on their experience too. So it really is, it has been shaped by clinical minds, which I really appreciate. That's not an engineer sitting somewhere in a black box trying to come up with a software about how to guide clinicians that actually is built by clinicians for clinicians.

SPEAKER_04 35:50

Yeah, that's I mean, I think that's super important. Again, however, it is that you draw back that information. Just, you know, in our experience, again, the technology is great, these systems are fantastic, and then you do start hitting that limit where you see that you you run that you're running that risk of now the technology defining your service delivery and not the other way around. So really cool to hear you explain that process of advising or informing the technology based on what's happening in real time.

SPEAKER_05 36:16

Let's kind of expand on that because Carrie, the person that we had on just before you, she had some background in Central Reach. Are you familiar with Central Reach?

SPEAKER_01 36:25

Oh no, I never heard of them.

SPEAKER_04 36:28

They're a smaller outfit. Yeah, I we understand why. We get it. It's okay. Dan will tell you all about it. Go ahead, Dan.

SPEAKER_01 36:36

Say more, Dan.

SPEAKER_05 36:37

Say more. Yes. Okay, so uh there's a lot of reaches there, the one in the middle. No, so she worked there for a little while, and and we kind of explored the idea about sessions built around systems versus systems built built around sessions. And we we talked a little bit about the idea of even with focus groups and things like that, at least in my experience, and maybe you dealt with this at like Blue Sprig or maybe some of the bigger entities I've worked at, bigger companies and then smaller companies, and I know Mike and I have our own company. The bigger companies, it was all pretty much about efficiency, just be more efficient, build more hours, efficiency, efficiency, efficiency. So, from my understanding, like when a lot of these things are piloted, now while they are consulting with the companies, the people they're consulting with are probably the higher level people in the company. So the suggestions that they're giving are based around efficiency, like how can we progress through this, or how can we take time off of supervisors' hands, which is great. Anytime we can be more efficient, that's that's great. Are there ways that you have like got down to the clinician level or somehow solicited the actual like clinician level feedback on like the clinical side of things that's really gotten into the software to enhance it?

SPEAKER_02 37:49

That's exactly who's been giving giving us the feedback, the actual users, the VCBAs who are going to be the providers of record, right? And even still, I mean it's never built, like it's not finished, it's constantly being shaped by the users. So every time you know there's a recommendation made through that care to get navigation protocol, or if you're asking the uh AI chatbot to search through the records and find something, I'll go back to that in a second. But anytime you get an answer from the software, it has a feedback button. Do you do you like this or do you not like this? Yes or no? And if you say no, then we're gonna ask you what didn't you like about it? What did you expect differently? So we're still getting that human in the loop understanding of what's working and what's not working. So to jump to the AI side of things, I'm gonna jump around. There's a little Sasquatch-looking character called No Yeti who uh hangs out. Nice, hangs out in the corner, and he's an AI chat bot. What's different about him is he is HIPAA compliant. Um so you can upload all the patient records into their file. And using NoITIC, you can then chat with all those records. So summarize all the patient data in November and it would do that for you, right? Or does this kid have a peanut allergy? And it would quickly read through all the records and then tell you yes or no, this kid does or does not have a peanut allergy, right? So being able to quickly sift through lots of information in a HIPAA compliant place, which is what you cannot do with any of these other large chatbots, right? And spoiler alert, everybody don't upload patient records onto the internet.

unknown 39:29

Yikes.

SPEAKER_02 39:30

So so yeah, we are still getting feedback and having that thing trained on a regular basis through the users telling us that it tell you what you expected to hear about that person's medical records. And we've also found a use case for this with families that if they do these care navigation modules, then they are asking for access to that module themselves so that they can then go through and actually chat with their child's records as well. Because they get tired of hauling their three-ring binders of all their medical records from appointment to appointment. And so having it all uploaded and stored in one place is hugely useful for them. What was I gonna say about the operational efficiency? Oh, yeah. I mean, this is one of the various reasons I named the company non-binary solutions. So there's a laundry list at this point. But one of them is it's not a binary. You can have both operational efficiency and clinical excellence at the same time, and you should, right? Yeah.

SPEAKER_05 40:26

What was the and that you heard on the um oh what was the it was on a podcast that was like the single metric. Oh, do you remember?

SPEAKER_04 40:36

Let's say again. Oh, I'm sorry, I interrupt going.

SPEAKER_05 40:39

It was uh it was a quote along those lines. It was about like making all of decisions based on one metric. I'm sorry, go ahead. I think I interrupted you there.

SPEAKER_02 40:46

Oh no, it's fine. No, no, no, that's totally fine. I don't I don't mind. But yeah, I mean you can and you should have both. And that's really something that I'm I'm hoping that I can help instill in kids' choice as we move forward. I mean, the there's a great organization. Right now, what I'm interested in finding out is what's working, what's not working, where can we be more efficient? How can we basically standardize the clinical process such that families can have the same experience in one clinic that they would have in another clinic, right? Sort of like a Starbucks, right? Like you can more or less guarantee when you go into a Starbucks in Seattle or one year in licensed in Kentucky that you're gonna have about the same service experience. And that's what we're really gonna try to lock up with kids' choice.

SPEAKER_05 41:30

I love that. Thank you. On the software side of things, I I do have some questions about kids' choice. I'll get to those in a second. For the software side, thank you for taking such consideration, careful consideration into the clinical side of things. I I do think, you know, like you've you've used the the phrasing that innovation is bastardized. And I think a lot of people say they're being innovative, but not. And it seems like a lot of times with the the software, once things can become efficient, there's actually uh reverse incentives to become in innovative at that point. Because why innovate when I'm now efficient and my service is now just nicely matched with the software, and we're we're vibing in that situation. So thank you for taking that feedback, but also like consistently updating and and integrating and kind of getting on that next level. Because, like Carrie talked about, it's really easy on the software side of things too, once you have something to keep it the same for 20 years, and because it's working, now you're doing stuff that was great 20 years ago that time has kind of passed it by.

SPEAKER_02 42:31

Yeah, I I think with the rate of rate of change with technology, I I don't know that we're gonna see a lot of that moving forward. It could be very much the opposite problem. We could be moving too fast with technology and racing to have all the answers and not being intentional or ethical or careful or thoughtful about how we're developing those systems and who they're impacting and what what we're not talking about in those rooms. You know, there's there's all kinds of problems with technology and big data and AI. There's lots of good things about it too. I think we're just gonna have to have our eyes wide open about balancing all the things.

SPEAKER_05 43:08

That makes sense. And I think this it's one of your uh gripes for lack of a better term, kind of with just the general idea of AI or the more of the execution of there's a lot of great benefits to it, and then sometimes people just put all of their eggs in that basket, and they're like, oh well, AI can just do everything, and then you lose the personal touch behind it, and it can become too mechanized at some point. And actually, there's plenty of examples of, and again, I'm not knocking AI, it's great. There's some examples of AI being used that even in our lives that like make things way more challenging. So I I can totally see what you're saying about the exponential growth and people's excitement over it. Like you're saying, do it kind of in a stepwise fashion rather than just throwing all of your eggs into that basket, because that could probably also be counterproductive.

SPEAKER_04 43:54

What what are the guardrails? I mean, I mean you know, I don't want to get too far ahead of ourselves, but maybe you've anticipated. Those already in terms of I think what we're all getting at is almost younger clinicians having maybe the danger of having too much information at their disposal or decision making becoming a little harder because we've got all these options. Any ideas about how we might learn to prioritize that? Again, going back to your example of uh eating and sleeping is sort of these you know foundational pieces. Any other examples of that or any other guardrails that you've anticipated based on that?

SPEAKER_02 44:29

Well, yeah, I mean, decision making uh is something again that I've studied for the last few years. And on one end of the spectrum, you've got this binary thinking, the dichotomous thinking, right? Everything's everything now only has two sides and you have to pick one. Yeah, right. So that's one problem, and that's a whole set of problems of its own. And then on the other end of the spectrum, you've got the paradox of choice, which is what I think you're talking about with the the younger clinicians are having to deal with now. It's like when you go into the grocery store now, there's the yogurt yogurt aisle. It's not like I just went to get yogurt, there's a yogurt aisle. Now I am faced with hundreds of choices for yogurt, and it makes deciding what yogurt to pick exponentially more difficult, right? And so, you know, we make about 35,000 decisions per day, right? Just average decisions. And when you go into a restaurant and you sit down with some friends, what do you generally say? What are you going to get? Right. And so it's like if we need that level of support to decide what we're going to eat, it seems reasonable that we might want some support in clinical decision making. Yeah. Just thinking, yeah, maybe, right? Like somebody else to check my math, even if even me, you know, with 25 years of practitioner experience, it's nice to have somebody else to go, do you see what I'm seeing? Right? This is what you would do too. And and so that's the kind of supportive technology I want to offer folks. Not the things that are doing the math for you, but the things that are checking your math.

SPEAKER_03 45:56

Right.

SPEAKER_02 45:57

Right. So yeah, I'm I'm not interested in taking the analysis out of applied behavior analysis. Like I think that's a skill set that you actually have to have in order to be a good practitioner.

SPEAKER_04 46:08

And the really good thoughts that you're lending there. I think that that all of us keeping those active, whether we're users or creators like yourself, I think that's going to be the active question is what am I doing as part of this? So these are all my options that were spit out. Now, which ones actually pertain or are relevant to right now, right here in this living room with this family? Uh I think that's a really good explanation. I don't know that there's any hard set of guardrails we can create for ourselves other than that active impetus to keep thinking about that so that we don't, you know, whether it's goal banks or to anything that's templated, it's very easy for us as humans to just up let it be, and now it looks good and it's passing the sniff test because you've got enough goals, but at the end of the day, you know, it does this have any meaning or any real-time relevance.

SPEAKER_05 46:52

So you know what would be really cool, and it might be something that you uh you're exploring with your the software, is because most of the clinical suggestions, like you said, are based on that clinician's personal experience. Whereas you mentioned in the medical field, you'd hope that you go to an oncologist and they give similar prognostications and similar treatment regimens, like on the software side of things, so it goes through all the clinical questionnaires and everything like that. And then the clinician puts like kind of what they would recommend, and then that's then cross-checked by what the software through the AI would recommend. And like now they, like you said, now it can be somebody to ask, oh, do you also see it the way that I see it? It sounds like maybe you're kind of going along those lines.

SPEAKER_02 47:40

I I don't think that I've gone quite that far down the rabbit hole yet, but that's something definitely that I can see somebody developing at some point in the future. I think I am more trying to give people uh uh digital bumper rails so that they can narrow the scope of thinking such that they might reasonably land in about the same spot as their neighbor, right? So coming from a 35,000 foot view down to a parking lot, right? Like you can get into the weeds after that, but let me put you at least in the parking lot of what's going to be a meaningful, socially valid outcome for this family and how is it tied to medical necessity? Let me start you there first, right? Love it.

SPEAKER_05 48:19

Is there oh good question? Is now taking the other side, the the devil's advocate side of that, because I do hear about a lot of well, maybe not a lot, some uh ABA outfits, you know, they have their their ideal client, whether it's maybe their clinic-based outfit, so it's a client that's you know four-year-old, four years old with moderate level of behaviors and 30 hours of availability or whatever depends on the clientele. Are you at all worried that so because you said it'll basically create a profile of this client, that companies will use that to almost filter out and be like, well, we can have we can do all these intakes and then we get this nicely created profile, and then we can basically look at these profiles and find the ones that fit what we're looking for the most?

SPEAKER_02 49:05

Well, that that would be a business decision and not a clinical decision, right? And so when you see people blanketly saying all the kids always get 30 hours a week, that's not a clinical decision, that's an operational decision, right? And I think a lot of people are questioning how did you come up with that number of hours? And that's a valid question in those sort of circumstances with the patient profiles. What I'm really, really hoping comes of the use of the software and that data lake of all those different patient profiles is having a more granular understanding of these very, very different people with quote unquote autism, right? Because I think we have a multitude of behavioral phenotypes that we should be looking at and not just housing everybody under autism or even level one, two, and three autism, right? And most of these folks don't just have autism. They also have ADHD, they also have a history of trauma, they also have gastrointestinal issues, right? And so really understanding which types of people do well in what types of clinical settings, with what intensity and what supports for how long, that's how we get to real individualized patient data programs, right? And for the kids that are not getting served, now I have demographic information about who is not getting served and why.

SPEAKER_04 50:22

And we can be certain that Mandy Ralston is gonna do amazing things with that information. This does conclude part one of our interview with Amanda Ralston. Make sure you come back for part two and always analyze responsibly. ABA on tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.