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

ABA on Tap is proud to present Amanda Ralston (Part 2 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

SPEAKER_02 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. Welcome back to yet another installment of ABA on tap. I am your ever-grateful co-host, Mike Rubio. And we're back for part two with Mandy Ralston. Enjoy.

SPEAKER_00 0:45

I love that. Now there's an opportunity for specialty clinics. Because yes, very, very aggressive large individuals should not be in the same clinics as small little people getting early intervention.

SPEAKER_03 0:58

I love that. And and Kerry was talking about that too earlier.

SPEAKER_00 1:03

Let me qualify that too. It's not just the pe it's not just the large people around the little people. It's also the setting itself, the furniture. I don't need teenagers around a bunch of tiny desks, right?

SPEAKER_01 1:14

Yep.

SPEAKER_00 1:14

And it's also a completely different skill set for the RBTs and the BCBAs to be able to treat those types of different people, right?

SPEAKER_03 1:22

Absolutely. Okay.

SPEAKER_00 1:23

All right. Didn't want to I didn't want to house it all on the shoulders of the kids.

SPEAKER_03 1:26

No, no, absolutely. That makes a lot of sense. And and what Carrie talked about this is what you're talking about. It's just fresh on my mind, is she talked about kind of trying to create some roads. Like right now, because ABA is a single subject, every person is individualized. So there's not like, you know, and again, we don't want to standardize it, but there's not like a, hey, so your child has this comorbidity and this level of parent involvement and these additional things. This is the tract that has shown to work the best. You don't need to go down this, but now it's all just kind of, well, I might have had somebody that had something similar to that. Well, I've worked with some three-year-olds, so so it's just kind of like spinning your wheels, where like some roads is what she was talking about. And it sounds like what that's what you're talking about as well, which is amazing. And that that data lak would data lake would give you that almost between subjects, like you can get all of the different people, and you can see the ones that got you know 40 hours versus 30 hours versus two hours, the ones that had parent involvement. You know, I think that that's on the ethics code about you know, like parent parents being involved. Well, let's look at the data. If parents are not involved, are they making progress to the point where we can still justify it? Maybe it's not as if much as if they were being involved, or are they just flat out not making progress? You can take all of these unique profiles and give like a roadmap.

SPEAKER_00 2:42

That's so cool. Yeah, it's it's patient profiles, behavioral phenotypes, treatment pathways, right?

SPEAKER_03 2:48

That's so cool.

SPEAKER_00 2:49

And then be if you are able to say, generally speaking, with this behavioral phenotype under these kinds of settings and these kinds of intensities with these types of supports, we tend to see the data trend this way for this amount of time. When the data deviates from that pathway, that's a signal that your clinician needs to go in and figure out what's going on, right?

unknown 3:11

Yeah.

SPEAKER_00 3:11

The variance in the data and the in the treatment pathway that we usually see with this type of behavioral phenotype. And now, because they're strength or either under or over that trajectory, what's going on is different with this person. That's that's another clinical decision prompt to me as a user to understand what's what's different about this patient and their data trajectory. Why are they differing?

SPEAKER_03 3:31

I love that. Because, like with a single subject, you don't you never have the control to go against. It's just always that person's behavior. And there's so many variables there. I mean that allows people to ask for indefinite levels of service because there's no control to go against, which is awesome. You were talking earlier about kind of getting the providers and the payers linked up. I think that's what payers are looking for as well. Looking for some level of prognostication there.

SPEAKER_00 3:54

Oh, they they're desperate to understand. And uh so it is supposed to be, supposed to be, in the best interest of all three parties in this nice little three-legged stool. It's the patient, the provider, and the payer that you have the best possible outcome for the smallest amount of time in treatment at the best rate. That's value-based reimbursement. That's how it's supposed to go. But in order to do that, you have to have a transparent process that's structured so that you can compare apples to apples and patient data, right? But if everybody's doing it their way, you can't compare a patient to patient. It makes it very, very difficult to determine what is a good outcome. Was this treatment, you know, time and treatment short enough? And if the answer is for both of these, yes, that was a good outcome and yes, that was short enough time and treatment, then that is an argument for a better reimbursement rate for that provider. Right. I've been able to reliably demonstrate that given a certain type of profile, I can reach these types of outcomes in a short amount of time. That's value-based reimbursement. You can't get there unless you start standardizing all of your clinical decision making and being transparent about how you came up with your recommendations. Again, the they want to know why this kid gets 40 hours a week and this kid only gets 10, right?

SPEAKER_01 5:06

Yeah.

SPEAKER_03 5:07

Yeah. Honestly, what it is seems like a lot of times is because 40 hours a week makes the company more money.

SPEAKER_00 5:14

That's what I'm saying. That's a that's an operational decision, not universal like that, right? Yep. And and I'm here to say they're very well, there are kids that will need 30 hours a week of intensive early intervention in order to make the type of progress that we expect them to make in whatever amount of period of time. But there are also kids that don't need that level of intensity. And they're sitting on a waiting list and they could be getting 15, 10 hours, five hours per week and benefiting from that service. So don't hold up the pipeline because you're waiting to give everybody the same intensity of services, right? Just find out who's going to do well with less and get them the services they need now.

SPEAKER_03 5:52

Love it. I have a few more questions, but let me Okay, what a super. So you said earlier when you were talking about the payer part, and it's something that we've run into as we've started our own company of the medical necessity piece. And certain insurances are a little more stringent than others, and tying it into the diagnosis of autism. And I I think we did one with like Cigna, or we did like a peer-to-peer reviewer, they were like very stringent. Like these are the the core symptoms of autism. If it doesn't like directly tie in, then we're not gonna fund that. Where you mentioned that if I could show them that toileting was part of the diagnosis, it would be there for medically necess meet medical necessity, I guess would be the correct way to say it. Can you talk a little bit about how you've gone about with payers? Maybe there was an area that they initially said wasn't medically necessary and how you've gone about showing that it did meet that criterion of medical necessity.

SPEAKER_00 6:45

Well, that's that's the algorithms that I've tried to design within the the goal development module of no edic. And so I haven't talked to any of the payers directly myself here recently, but I'm sure I'm about to now with my new role of kids' choice. But you know, the the the algorithm that I tried to develop to simplify the medical necessity, I call it the M and C sandwich, right? So imagine you've got two pieces of bread, right? Sandwich is two pieces of bread. The first piece of bread on top says that it has to be tied to an assessment. That's one part of medical necessity. And the bottom piece of bread is that the outcome needs to be socially significant, right?

SPEAKER_01 7:22

Okay.

SPEAKER_00 7:23

Now, between those two slices of bread, it has to have at least one of these qualities. It's not a combination of two, if not all three. One, it prevents further regression. Two, it ensures health safety or functioning. Or three, it allows for further integration. As long as it has one of those things and it's tied to an assessment and it's socially significant, that meets the standard of medical necessity by definition, right? It's much simpler as an algorithm than a big long definition that you have to sort of interrogate to figure out where you are in it, right? So that's that's how I'm trying to help people think about medical necessity is you got to show me what symptom of autism is being directly impacted, and how are you going to ameliorate or mitigate that symptom or that impact with that symptom under this area quality life using these tools, right? So it's gonna take a lot of education, right? Because again, it our field has not done an excellent job on agreeing or getting to consensus on a lot of things, including the definition of medical necessity. I mean, including what's an outcome, right? The fact that we're still having a conversation about what an outcome is is wild. And then, you know, we've got multiple frameworks for outcome tools, but an outcome tool is not an outcome. Like having a certain score on the violin is not an outcome. Being toilet trained is an outcome, right?

SPEAKER_02 8:53

That's such an interesting premise there. The idea that, you know, we're not gonna move those scores a whole lot, but we're basing these treatment recommendations based on those particular metrics. And I I love the example you just gave in terms of things that may not ever hit those line items on a vineland, which uh you know, no, no not being critical of the vinyl at all. It's an amazing tool and its history is fantastic. And then it just may not be very well suited for what we're actually trying to get done.

SPEAKER_00 9:25

Well, it just may not be very it may not be sensitive.

SPEAKER_02 9:28

Sensitivity is a great way to put it, yeah.

SPEAKER_00 9:31

Right? To to really show where the moodle the the needle is moved for the families on terms of their stress. All right.

SPEAKER_02 9:40

Well, and then having to then you know, it's like manually try then tying goals to those line items in a straight line, which is I think another challenge that we face as clinicians. The logic is very strong there, but it doesn't necessarily hit the whole picture. So now you're teaching these isolated, maybe decontextualized skills under certain behavior developmental domains, and whether or not those actually come together to be something meaningful or socially significant is a separate question. I love the way you you conceptualize and describe that model. That's going to be super helpful for me moving forward.

SPEAKER_03 10:13

What are your thoughts on the outcomes slash the values piece? Because that's always been the million-dollar question, right? It's like, what is success in ABA? And it's like, well, the person can develop skills and function in a way that brings their life more fulfillment. Okay, cool. How do we measure that? Do we measure that on violence scores? Do we measure that on mastered goals? Like how, because we can always write more goals for somebody. Take the autism diagnosis out of it, right? Like anybody could have goals in their life, but somebody could write goals for me on my life, I could write my own goals, which is where probably the medical necessity piece came in. How would you define like a successful outcome or a valuable service?

SPEAKER_00 10:52

I mean, in terms of I've worked myself out of a job types of outcomes. Like this person has quote unquote graduated from the organization or from his treatment. I mean, I think my short version of best possible outcomes is maximum happiness and freedom at an individual level, whatever that looks like from person to person, right? Maximum happiness and freedom at an individual level. I want to know that this person is able to access as much reinforcement as they possibly can and to avoid as much punishment as they possibly can, whether that's restrictiveness or yeah, being able to live and recreate with whom they please, so on and so forth. So that's that's sort of the the long arch of what a best possible outcome might look like. But again, having a more granular understanding of these people beyond just their diagnosis, right? Because autism is a very heterogeneous group of people, and what it looks like and how it impacts each individual is very, very different. And so it can't just be a matter of you know, being non-differential or differentiated from their peers. Like that was a goal 50, 60 years ago, right? Nobody could tell that you had autism at one point that that was a legitimate goal. Well, we don't do that anymore. At least I hope we don't. But what we do want, you know, with this concept of neurodiversity, we understand that different people's brains work differently, and that's a good thing. But again, if if something about your medical condition or your mental health condition is impacting your quality of life, then that's where we start, right? If it's not bothering you, we're not touching it. Right.

SPEAKER_03 12:34

Right.

SPEAKER_00 12:34

But if it's bothering you, let's talk about it. Let's see, let's come up with a plan, right?

SPEAKER_03 12:38

Yeah, yeah. Yeah, which is a great use of those Likert scales that you had the parents, because a lot of times the parents are the kid's voice for lack of a better term, until they can communicate it in a way that other people can understand. Which is a great, I mean, that's a really easily, you know, judged metric as that goes through, oh, look, it was a five, it was impacting your life at a level five, and now it's down to level three. Look, that's meaningful and socially significant into your life too, not just into our life.

SPEAKER_02 13:07

Are you working any sort of an I for lack of better phrasing, sort of like, is it like a curriculum or an inventory of stimuli and activities? Does does your system also lend uh suggestions to clinicians as to, okay, so we've got this issue, what are you going to be doing directly? Uh, what does that look like?

SPEAKER_00 13:28

Yeah, the the goal development module does make recommendations regarding what assessment tools to use based off of the kid's age, the area of quality of life that's being impacted, possibly the payer. You know, so it says based on all the goals that you're going to want to address, we think these three are the most relevant assessment tools for you. So it makes those kind of recommendations. But again, they're only just recommendations. It's not making decisions for the user.

SPEAKER_01 13:54

Right.

SPEAKER_00 13:54

Right. Again, ultimately we want the user to say, you know what, that's a great idea, or nope, I didn't like that answer at all. And then tell us why and expand our sort of knowledge about what else is being used out there at this point. Uh I again I am a dinosaur. Um it was 26 years ago that I started this, so I might have some new tricks to learn still.

SPEAKER_02 14:13

So just out of curiosity, uh just hearing you explain this, what did your graphical organizer sort of conceptual framework look like? What does your whiteboard look like as you plan something like this out? It's all both of your back walls.

SPEAKER_00 14:28

Yeah, well, hang on. Let me see. I'm gonna have to take you outside. Let me turn off the board here.

SPEAKER_02 14:34

I had a feeling, just based on the way you describe things, I'm like, oh man, I I'd love to see her lists, her notebook, you know. What are your what are your doodles look like?

SPEAKER_00 14:44

This side isn't that exciting, but if I take you to the outside, you'll be able to see this is this is kind of how it goes in my brain.

SPEAKER_02 14:51

That's awesome. Thank you for sharing that with us. And just for the listener, it's it's exactly what I I described and we're envisioning here. It's a a lot of different uh pieces, notes, prints outs, pictures. It's almost like uh you're solving a a crime uh a murder. It's like a murder scene investigation. You just need yarn, you just need uh the the strings between your your attacks there.

SPEAKER_00 15:13

Yeah, I I think that definitely gives some Charlie Day energy from that name.

SPEAKER_02 15:18

So that thank you for sharing that with us. That's super cool.

SPEAKER_00 15:22

Really, it's I always like to say it's a jungle in here on the top of my brain. It's just like, you know, so much going on all the time.

SPEAKER_02 15:29

I think it really highlights, you know, for whatever it's worth, it just it just highlights the the diversity of skills that that somebody like yourself really puts forward on a given day, or you know, anybody who who's stuck it out this long in terms of what we do and balancing all the different variables, you know, the family factors, the how the child's behavior or the the patient's behavior impacts their environment based on any you know a slew of quality of life features that you've discussed. That's a lot. That's a lot to figure out, and then to then come up with all these goals that are gonna be approved by the scrutiny of this funding source, that then actually have to translate in, you know, what the hell are we gonna do? Right? You can do uh you can train an RBT and do their 40-hour competency, and they've gone through that test, they still have no clue how to run a session from that particular training, right? If it what you teach them to pass that test doesn't teach them anything about what you're actually gonna do with the with the child once they're in front of you. So it's you know, again, it's really neat to have you walk us through that process and all the other things that you're considering that are what I envision is, and hopefully this is the way we utilize it, is it's going to open up the time for the quality of interaction from clinician to patient and without having to think about so actively all these other things, but still having the flexibility of monitoring those variables so that you don't have the tech driving your service, but it's the other way around. So, yeah, thanks for sharing all that. I think it's really cool the way you you explain that.

SPEAKER_00 16:59

Thank you. I really appreciate the reinforcement.

SPEAKER_03 17:02

So you mentioned that you're working, you're just started working with a company called Kids Choice. Is that correct? Yeah, that's correct. But just reflecting on you know 20 years in the field, there would never have been a company 20 years ago called Kids Choice. It would have been kids listen, kids comply. Kids comply, right? Kids comply. Compliance incorporated, is that compliance incorporated. There you go.

SPEAKER_01 17:25

Kids compliant.

SPEAKER_03 17:26

Yeah. Our company is called Ascend Behavioral Solution, which is based on Ascent, which is a word I had not heard of when I first started. I hadn't even heard that word like five years ago. And now it's a huge, you know, premise in our field as is kids' choice. And you mentioned that you went there because that company really resonated with you. Can you talk about that? I know you keep saying that you're a dinosaur in the field, but clearly if you're working at a company called Kids' Choice, like that's that's not archaic. So what uh what are your thoughts there on kind of ABA choice? The evolution.

SPEAKER_02 17:59

There's plenty of criticisms out there about what we do and and they're valid. Yeah. I mean, you've seen it all, you've lived it all, and now he you're pushing the envelope a little further. Yeah. Talk to us about that.

SPEAKER_00 18:10

Yeah, well, again, it's not binary, right? There is no one system or parts and pieces of art science and literature that are appropriate for everyone, right? And so I applaud uh the Hanley's approach and HRE and uh the ascent-based teaching, et cetera. And I also say there is still room for individuals that may respond faster and more efficiently and more efficaciously to some of the old school methods, quote unquote, including extinction, right?

SPEAKER_03 18:41

Of course.

SPEAKER_00 18:41

So I don't want to paint paint my number with applied behavior analysis, right? Like we're gonna do the analysis part of applied behavior analysis and figure out what actually is the most appropriate intervention for these individuals. Now, that's me talking off the top of my head as Mandy Ralston, 26-year practitioner. Now, if I put on my CEO hat for kids' choice, you know, we've got clinical people that are making those kinds of frameworks and decisions, and I'm I'm there to say, yes, I like this and encourage them and reinforce them or shape them where it needs to happen. Um, so I'm not necessarily wearing a chief clinical officer hat at kids' choice. I'm I'm doing more of the culture and guiding the North Star role at this point, which I'm really happy to do. That's that's something I always been most proud of with my career, is that I've had people that have asked to come work with me that have nothing to do with applied behavior analysis because they see the culture in the offices that I've built. Can you speak to that?

SPEAKER_03 19:36

Can you speak to like, so if you're if your goal is to develop the culture and kind of what what does that mean to you? Or like what are the the pillars of your culture? What what will you look back if five, 10, 20 years, however long you're at uh this company, what will you look back on and be like, yeah, that was successful if XYZ is part of the culture?

SPEAKER_00 19:56

That's a great question. It's it's actually on my agenda this week uh to have a leadership meeting and talk about our vision, mission, strategies, and values, right? And and having a collective conversation. Like, I'm not gonna come in and just impose my values onto the whole group. I want to be part of the group's alignment and what we all agree on. Again, it's uh it's a diverse work group. This is the first time in in history that we've had five generations in a workforce at the same time, right? Anywhere from the the boomers who generally have made most of the systems that we've been operating under for the last 40 years, down to Gen Z, right? And so you've got the folks that have made some of these systems and continue to benefit from how they run. And then you've got individuals that have never not answered a phone call that wasn't already for them, right? They have no concept of what it's like, right? They have no concept of the landline, right? And so I've got to I've got to think about what works for everybody, right? But in general, one of the things I try to bring my own personal brand into culture is transparency, vulnerability, integrity. And I want to talk a lot about integrity with with with folks and you know, just understanding that integrity means doing the right thing even when nobody's looking, right? Because we work with a vulnerable population and we want to do right by them, even if they wouldn't be able to give a review, right? I want to talk about the fact that we can be authentic in ourselves and be professional at the same time. Like I show up as myself, and I think that's important because it was important for me. I would have liked to have seen somebody like me when I was younger, right? That was not afraid of not sitting neatly into a box of you know, tattoos around professional or having your head shaved a certain way is unprofessional. Like you can be professional and also look a little different, right? I also like to say there's no reason this can't also be fun, right? That's very serious work, right? It's serious work, but we can still have fun doing it, right? Just don't get HR involved in the case. Yeah. So just, you know, those types of things of sort of balancing the fact that this is heavy, mission-centered work that is difficult and cerebral, but there is plenty of opportunity also to live right alongside sort of a a lightness, right? You can have both. Hashtag is not binary.

SPEAKER_03 22:19

I love that. Yeah, I mean, I would always say that kids have two jobs. It's to learn about the world and to have fun. And the way they learn about the world is having fun. So that's so cool that you talk about the lightness and in in a in a thing that it can have a lot of weight. The diagnosis can have a lot of weight, and the parents take that on, and now they're feeling a certain way. There's the relationship stress, there's a financial stress, emotional stress. A way to find the lightness. And I used to remember I've been a trainer in my company for the last 15 years throughout the various companies. And I remember I used to kind of say it dismissively back in the day that there was a I don't know how long ago it was, but there was a survey done, and it was one of my trainings at a previous company about different therapies for individuals with autism. And occupational therapy was parents at that time favorite, you know. They they asked a bunch of parents, and that was the highest on the list. The most it was like 55% of parents listed that as their favorite, much higher than ABA. And I would kind of poo-poo it, like that's just like swinging and stuff like that. It's because they're not dealing with the hard stuff. But I think a lot of it was what you're saying is the lightness and and the fun and the yeah, that if we can bring that to the field, then the parents, like you've talked about, their Likert scale will go up because they'll be happier and the people will be more receptive of the services that they're given. So I I don't think it's this or that, like you said, or like you like to say it's this and that. How do we have lightness and the seriousness of the field? I I love that you said that. Thank you.

SPEAKER_00 23:49

No, yeah, for sure.

SPEAKER_02 23:50

Yeah, especially some of our younger patients, right? Like to kid it, like I get paid to play all day when I'm doing direct stuff. I mean, that's mostly what it looks like, right? And it's one of my favorite criticisms from from parents or the feedback. Well, it just looks like you're playing. Okay, it's a five-year-old kid. I mean, yeah, we there was some work that was happening in there too. I mean, if you want to call it that, there was some there were responses based on you know my SD and my instructional control. But yeah, I think it that it it should look fun, it should look at ease, and that can be difficult to achieve given all the other things that we're balancing, all the other things you're talking about, the data tracking, understanding what you're gonna do next. As a young clinician, knowing that you had the greatest plan that you came up with, and you brought this beautiful bag of stimuli, and then the first five minutes you realize that's not gonna work today. So, so what am I doing next? And that's where your stuff comes in, right? Quick pick up the tablet, the phone, hey, what happens next? Yeah, hopefully one day we'll get there, right?

SPEAKER_03 24:48

Yeah, yeah, there you go. That's awesome that you can develop that culture. I was that was uh one of the really fun parts of our job was sitting down and figuring out the mission statement and the vision statement. And it's so much aligned in what you're saying. We had we had spoken recently with um oh, why am I Maggie? Maggie Harabuda, who's an autistic BCBA, and she was talking about strengths-based versus deficit-based goal writing. So kind of incorporated that, the funness, you know, taking care of the RBTs. And I'm sure you'll have a blast being able to figure out and and have an influence on the culture. Because like you you said you've been trying to get down to the you know 30 foot from the 35,000 foot, but then when you get to go back up and you see the whole company like embodying your culture, that's so cool.

SPEAKER_00 25:30

Yeah, I mean, right now, I I again I just got started January 6th and we had uh Snow Mageddon like the third weekend. Um I couldn't even get back to Oklahoma for a week at one point. But I really have just been on the listening tour of you know, making sure that I understand, you know, what all the technicians and the BCBAs, the people that make the organization run, what they like about their job, what they think needs improving, what is a sacred cow, what I what should I never ever touch, you know? Yeah. Um, and you know, really just having discussions with everybody and and learning about the current culture, right? Because there's plenty that already is working. We just wanna we wanna improve the areas that maybe could be a little bit better, right? So that's I'm not gonna come in and you know start laying people off. That's that's that that's been a fear, I think, of of private equity acquisitions. Is that when you see private equity come in, it means oh my gosh, and they're gonna come in and you know do all this crazy stuff. Well, that's again, that's a binary, and that's not correct. It's not pro not all private equity is the same. I like to brag on this particular private equity group that has acquired kids' choice and brought me in that their aquitaine capital and they are out of New York, but it's an all-women group, which I think is a particular sensibility that is very rare within private equity. Uh and I think that's going to, yeah, it's gonna bring a different edge to it for sure, a different type of brain capital. And I'm super excited about that.

SPEAKER_03 26:54

Well, what you're doing is the same thing you would do with a clinical assessment. You're doing the, you know, the Likert scale with the parents. What's what it what's most important for you? And it sounds like you're doing that with the company, not just going in on off a vineland score and saying, well, you scored low on the vinyl and this is what you need to do. It's what do you want to work on first or what's working well, what's not working well. So and uh that would always blow my mind when uh I'd work for ABA companies and they would do ABA with the kids, but not with the OBM side of things. It would blow, it's like, you know, you can reinforce employees too. It's not just one of the last kind of uh, I guess more salient examples, one of the last companies that we worked for. They had a RBT that was calling out a lot. So their decision on what they were gonna do for this person was they were gonna punish them. They were gonna call them in and punish them and like I maybe suspend them for a couple of days or something like that. And it was like, okay, so you have somebody who clearly isn't enjoying their job, and the way that you're gonna help them by doing that is punish them into enjoying their job. It's like, okay, this is coming from an ABA company. You gotta play.

SPEAKER_00 27:59

Gen Xer probably came up with that idea, I'm pretty sure. You gotta write people up. It's like if if I had to go through that, you do too.

SPEAKER_02 28:04

So you gotta write people up. You gotta write people up.

SPEAKER_03 28:08

You gotta write them up. Just like the goals. If you if you write the goal, the skill will happen. It just magically doesn't matter what you do, you just gotta write the goal together. If they just write, employee will show up on 100% of opportunities across eight consecutive weeks. It just happens. I have a question kind of switching gears for you to something that Mike has piloted or is thinking about piloting that might be an interesting use of the AI. You made me think about it when you were talking about kind of the sitting down and talking about all of the variables that come into the ignoral diagnosis, and that's behavioral pediatrics. So I'll I guess I can kind of pass it to you, Mike, to explain what it's like. But I was thinking about her tool of that clinical profiling and how that could help pediatricians get us involved kind of to what you're talking about. I don't know if you want to speak to the behavioral pediatrics.

SPEAKER_02 28:54

I'm sure you're familiar with with the whole effort and movement, but yeah, that's been something that uh from a more developmental perspective, I like to I like the gray area. I I obviously we rely on a certain diagnostic code with which to disseminate our services under some authorization, medically speaking. And then one of the things that I enjoy as a clinician, especially because I I do really enjoy early intervention or early childhood intervention, is where there's less of a distinction and more of a gray area. So the idea that sure your child demonstrate or shows demonstrates these deficits, but at the end of the day, there's so much more about them that is just a four-year-old. And how do we, you know, how to reconcile that? So this idea of behavioral pediatrics, this notion that anywhere between 30 and 50 percent of people sitting in a pediatric waiting room are actually not there for a medical reason. They're there for a behavioral reason that the pediatrician is likely not gonna have the time nor the content expertise to address. They're gonna wait, they're gonna use phrases, and I'm not being, I'm not trying to be overly critical, but the idea that they're gonna say, well, let's wait and see what happens. Let's wait and see what happens. So your child is seven, they're still wetting their pants during the day for whatever reasons. Well, let's see if they outgrow it, try this and this. I've got 16 minutes to speak with you during my consultation because this is the way we run our logistic, and I may not have the training. And any of those kids asks you were talking about waiting for services, for example. Well, as you wait for the specialty service, folks like us could be providing some level of assistance to see if that problem differentiates. And now we might even be able to go back and tell the pediatrician, hey, we tried this and this stuff. We think there's something bigger happening here, or you know, or whatever the case may be. But yeah, that's that's something that I've been very interested in from Pat Freiman's dissemination of similar work and his literature. And it's every pediatrician I talk to loves the idea, and then getting the systems and pairs and pieces in place becomes a it's a different story, as you might know. So I don't know if you've got any comments on that.

SPEAKER_00 31:01

Yeah, I'm I'm trying to work out a deal with an organization here in Kentucky that has identified just that issue. They've got a wait list of 600 individuals trying to get a diagnosis through their behavioral pediatrics or developmental pediatrics. Yeah. Yeah. Right. And those people are looking at a year, 18 months before they'll ever see somebody that could possibly give that. So at least if they do this care navigation module, right, and they have this behavioral profile and those recommendations or those recommended action steps are there. Parents just want to feel like they're doing something for their kids. Right. And what's more is if those 600 people are in there and we start to understand before this is even appropriate, we need to do blah, blah, blah, blah, blah. Then it opens up the pipe, you know, the bottleneck again to get the other people that need that service faster. Right. And so it's, yeah, we we need to do a better job of sorting out our access to care so that the right people are getting to the right groups at the right time.

SPEAKER_02 32:01

Well, and the other piece there is it changes our service model, right? So now the idea that we're there for six months at a time turns more into six to eight sessions in which we have this effort, which we put forth this effort to see whether this is some bigger problem and that's why your child can hold their urine during the day, or no, this was just something that behaviorally we could address. So uh good for you for doing that work. I'm really glad to hear somebody talk about that moving forward. I think there is a a disconnect there. Maybe we're still, well, we're still very new at the medical table, I would say. And we haven't maybe done quite nearly enough to, for lack of better phrasing, prove ourselves in terms of standardized uh treatment protocols, things that the medical field really wants from us that for whatever reasons, and there's a numerous, there's a number of reasons that we haven't been able to deliver that, but now you're talking about the systems that will actually address that in some way, shape, or form here toward the future. So that's exciting.

SPEAKER_00 32:58

Well, I mean, I always like to joke. I mean, the behavior analysts, we are a conceited bunch too, right?

SPEAKER_02 33:05

Like it's good, it's good to admit that once in a while.

SPEAKER_00 33:09

Yeah, yeah. We we are really good at letting people know we know everything. So we've we kind of dug our own grave on that one in certain circles. But now also, again, we've had a 500% increase in BCBAs in the last 10 years, and over half of the field has less than three years of experience, right?

SPEAKER_03 33:26

And no one knows more than a new BCBA. They know the most.

SPEAKER_00 33:30

Well, because there's the fear of being wrong, right? Like you're getting paid a very nice salary to be right.

SPEAKER_02 33:35

Oh, the salary.

SPEAKER_00 33:36

Um yeah, I mean, now you a year and a day after you become certified yourself, you're allowed to start supervising the next cohort to sit for their exam. Well, what kind of experience and decision-making skills do you think they're passing down? I and you know, and again, that's that's a broad generalization, but it's mostly true. Yeah, right. So so yeah, we've we've got some catching up to do uh to have a right full seat at that medical table.

SPEAKER_03 34:02

Yeah, I would agree. No, that's that's so true. I work for a company called Proact as well. Have you heard of Proacting? I don't think so. Have you heard of CPI? Crisis Prevention. So it's a similar, I think better, but like it's a crisis prevention de-escalation into restraint methodology. And we train all sorts of individuals, group homes, schools, uh corrections officers, and BCBAs. And like you said, BCBAs are a conceited bunch. There's a interesting, you know, because I can step back to as a BCBA, but that's not the the hat that I'm wearing at that time. It's it's interesting. You you definitely see um compared to other groups, even educators, even administrative educators, BCBAs are definitely an interesting, definitely interesting individual. So when you said that, I was like, yep. Especially that's because most BCBAs can't see how they're observed outside the field because they're inside the field. Yeah, that's super super true.

SPEAKER_00 34:58

Yeah, I mean, at some point, and I I was guilty of this at one point in my career. I mean, at some point we convinced ourselves that because we're behavior analysts, that anything that is behavior is within our purview.

SPEAKER_03 35:07

Yes. Yes, right. And everything at the end of the day is behavior. So that's we we've done a few episodes on that about collaboration of care. And yeah, it's like eating, eating's behavior, sleeping, all of it's behavior, so but yet there's you know, speech pathologists or eating experts or things like that. So it's like where do we fit in? How do we collaborate? Yeah.

SPEAKER_00 35:28

Yeah. What is what is our lane exactly? And a lot of that isn't just particular to our role, it's also particular to our skill set and our competency.

SPEAKER_02 35:36

Yeah. I mean, you think it would make it easy given how much we deal with to be able to say, hey, I don't know enough about that. I'm gonna go back and look some things up, I'm gonna seek some consultation or some help. Um, I'm in a situation like that recently where I'm collaborating a lot with a school for a visually impaired child. It's not congenital blindness, but it was it occurred over sudden onset almost. Yeah, sudden onset. And it's been fascinating to be completely out of my scope, to be able to sit at those meetings and go, I don't know what you just said or what you're talking about. Will you show me what that means? And then be able to arrive at across the board for the other providers this idea that as as as far as your work is concerned, as long as I can just get the child to respond continuously, then that's enough practice to make your job a little easier. And it's been it's been nice, it was very daunting at first, but it's also been nice to go, hey, I was overthinking my job. I was trying to do too much. All I had to do for this kid is get him comfortable responding and now uh touching things, you know, in terms uh uh in order to identify them. Hey, it made sense that if we're doing hands, we should probably try the feet a little bit, you know. So just and talking to other people and and more than anything, talking to the VI people, the mobility people, and learning about what it is their greater goals are and saying, hey, I can probably get them practicing that initial step of that greater piece you're trying to teach. And it's it's been super successful. But again, it really took me, you know, not adopting my greater tendency as a behavior analyst to say, hey, I know all about this. It's it's like, no, wait a minute, the kid can't see. Like that, how what does that mean? That changes everything, right? Well, not everything necessarily, but now how do I explore it?

SPEAKER_03 37:20

Well, that means you're not gonna use a visual schedule, and if you don't use a visual schedule, you can't do ABA without a visual schedule.

SPEAKER_02 37:27

Well, again, we talk so much about visual structure, and for once here, this was not gonna be uh yeah, a non-element in the way we think about it.

SPEAKER_00 37:36

So I I learned some my most important lessons with working with the Kentucky School for the Deaf and like all the students and autism, you know, learning about joint attention ovation, you know, in order to give clear directions, like master class and really understanding how that free-term contingency actually has to work.

SPEAKER_03 37:58

Can you speak to that? That's that's fascinating.

SPEAKER_00 38:01

I mean, it's just we take for advantage as vocal people and hearing people that when we give a direction verbally that there should be an automatic correlation in terms of joint attention that that person heard me, and therefore whatever I'm prompting them them to do is actually going to get attached to whatever reinforcer consequence I attach to the response, right? When in fact a lot of times, even with hearing individuals, they have attention elsewhere. And so they may not actually hear the verbal stimulus that you are then trying to prompt the response to and then attaching a consequence to it. So having that joint attention prior to even giving a verbal stimulus or any kind of stimulus for that matter matters in terms of correlating stimulus response, and then ultimately the consequence that follows. Yeah. That is it never made it more clear than seeing it for somebody that had to be touched, or there had to be some kind of you know, physical prompt of some sort to make sure that you'd established attention prior to giving a direction.

SPEAKER_02 39:10

That's awesome.

SPEAKER_03 39:10

That's his train he's been on the last probably seven years, the joint attention train. So you are speaking his language now.

SPEAKER_02 39:16

And certainly moving away from this idea of direct eye contact, especially with somebody who's not sighted, but the idea that we're also using the auditory piece, that a tactile piece does become relevant. The notion that, you know, we've been doing this a long time. So the idea that of a response to name program or goal in your treatment was always very common. And looking at you in attention, it's like, well, name is a very important auditory stimulus, but it's one of many that I would expect a child to orient over to and look at if I made it. So yeah, everything you said speaks to me a ton in terms of how am I how are you actually attending? Knowing that even in saying response to name programs, we had this ideal envisionment of the child's gonna stop what they're doing, look over at our faces, and respond. And you know, I've got teenagers, they half the time they don't look at me at all. They're talking to me facing forward. But the idea is I know that they're jointly attending because I put out a cue and they responded to it. So again, I think there's so much to learn between those two extremes of this ideal. And it's something I even tell parents now, especially of young children, well, hey, they don't respond, they don't listen. Okay, as often as you can, within reason, I want you to go get at their level, make sure they can see you as you call their name. And if you do that, you know, about a thousand times, at some point you'll notice that they're gonna respond to their to your name by looking over at you because that's what they're expecting to come together in terms of the stimuli. So it is. I mean, again, we could talk about this all day, and and yet it's such such a foundational, such a basic concept of what we do, and we could explore it, you know, ad nauseum here as to how it applies with any given patient during an interaction of quality, right? And then how do you generalize that? That's a whole separate other uh semester. So we won't get into that.

SPEAKER_03 41:05

So you a question kind of for you more personally. So there's a couple of times where it sounds like you've had some pretty big transitions in your career. One was when Blue Sprig bought you out where you had the your own company, and then you went kind of more into the corporate side, then you took a little time off of the direct side while you're working on the software, and now you're getting back into the direct side of things. Is that fairly accurate?

SPEAKER_00 41:27

Yeah, that's the short version.

SPEAKER_03 41:30

So, yeah, the the TLDR, I think they say. So let me ask you first on the Blue Sprig side. So when you you said that was really eye-opening for you, and I imagine it was. And you mentioned it was the first time you'd been in a room where there was a hundred people with a hundred different ways of doing things. What were some other really kind of eye-opening things that you could share that you were rem remember or resonated with you going from the mom and pop shop to the the big corporate ABA?

SPEAKER_00 41:56

Yeah, I mean when you're doing the mom and pop shop thing, like you're you're constantly building the plane as it flies, right? Like you're you're thinking of terms of getting solutions in place quickly. And a lot of times that is about people and not necessary roles, right? So it's like, oh, Jack over here has this skill set, so I'll give him this thing to do, right? And then the next thing you know, Jack has about five different hats that he's wearing, and none of them are particularly clear. And, you know, I I I think that happens a lot in small ABA clinics as they can, as they start to grow or start to scale, because the demand is there, right? Like you want to serve families. And so you're you're getting in the habit of saying, yes, we'll try to serve everybody. And ultimately that that means that there are individuals within these clinical locations across the country that maybe are not appropriate for that particular location, right? So that was one thing that I saw. And again, that's where this sort of care navigation module started to come to come into mind for me is how can we assure that we're bringing patients into care that actually have a goodness of fit for the clinic that they're going into? Like, is there a clinician at this location that actually knows, has the skill set to work with this individual? So matching matching those people up. Yeah, I don't know if that answered your question the best. That was the first one that came to mind.

SPEAKER_03 43:18

No, that that meant I didn't know if there were any other big realizations that you had. And I guess that goes to my next question. Now that you've been back in the direct side of things for I think you said only like three weeks or something like that. Have there been some realizations, some surprises, some like, whoa, this is going on, or this is cool, or that what is this? Uh like what what's going on now? Uh three weeks back into the direct side of things.

SPEAKER_00 43:42

I mean, uh the the biggest thing for me, and this is not particular to kids' choice. This is just in general, because I'm in touch with the people here in my local community as well. The questions that parents were calling and asking me 25 years ago, they're still asking the same questions. They're still having the same bottleneck issues. Today.

SPEAKER_01 44:00

Wow. Right.

SPEAKER_00 44:01

And it doesn't matter if it's Kentucky or Oklahoma or California. Like the parents are still having the same exact issues. And that's that's a bummer. Like we should be doing better about trying to solve some of that for them. There are places in the more rural areas in Oklahoma that don't know what ABA is, might not even know much about autism. So I'm gonna go back to my tried and true playbook, which is going out and doing free workshops to families and schools just to try to educate them on what it is, what it isn't, give them a sort of a ABA 101 so that they understand. What's really interesting about kids' choice is that they've made a real mission out of building clinics in locations where there are no other services. They really have gone out to the rural areas and access to care has been very near and dear to their hearts for all these families.

SPEAKER_03 44:54

I guess it comes on a lot. Jennifer Stevens, who works in lives in Kentucky, and she's talked about the same thing about how it's very rural and it might be an hour and a half to get to like one client and how challenging that is, obviously, from the business. But sounds like kids' choice is both having to deal with that and finding solutions to that as well.

SPEAKER_00 45:11

Yeah, yeah. It's it's great. And it's creating jobs in those areas as well, right? And creating people that are very interested in supporting their community and the people that live in it. And then people learn there's a whole career involved with going into a blind behavior analysis. So it's super cool. And yeah, I mean, I I worked out in eastern Kentucky for years as well. That's a two and a half hour drive. You know, I'll get a Hazard, Kentucky, which is literally what the Dukes of Hazzard is based off of. Um, that's two and a half hours out there. And and I remember, you know, when I was first starting out doing this, printing out my map quest directions on paper and driving and trying to follow the directions at the same time and calling my office and say, okay, I'm gonna lose cell phone service when I go into this holler. If you don't hear from me in two hours, send help. You know?

SPEAKER_03 45:56

Wow. Yeah, wow, yeah. Yeah, I I've seen uh some cool documentaries about the hollers in like the Appalachia and stuff like that.

SPEAKER_00 46:08

That's a choice. Unique, maybe? Unique for sure. Unique. Yeah.

unknown 46:13

Wow.

SPEAKER_00 46:13

I I grew up in a no shade. I grew up in a town of 3,000 people in West Virginia, so I'm as Appalachian as it gets.

SPEAKER_03 46:20

So for you, yeah. I'm sure you've it's built a lot of character, and that's that's awesome.

SPEAKER_00 46:27

Still my mom.

SPEAKER_02 46:28

The relatability, right? I mean, and you get to just really see that for us as somebody's you know living life just a little bit differently with different factors involved. And I think there's a lot to learn from that. There's a lot of a lot to take in, a lot of uh new perspectives to go, oh wow, people get the same thing done in this particular way, not the way I would think. And uh certainly in sunny San Diego, we've got a lot to learn about those things. We're spoiled here. We've covered a lot of ground. Mandy Ralston, thank you so much. I guess sort of in in in closing, we've talked a little bit about tech, we've talked you know, a little bit about being in the field for a long time. If there's there's other things or one other thing that you think toward our our future and our prospects that you really want to see uh ABA evolve beyond, what might that be?

SPEAKER_00 47:19

Jeez. I've got a place to be. We've got to go.

SPEAKER_02 47:24

Well, that's why I said one, because I know that uh we could probably we didn't circle back to this in terms of or too much. We alluded to the notions of neurodiversity. We kind of talked in or around that, but we didn't, you know, take too much time to get into the the real criticisms that are out there. So, you know, let's take a few minutes now to see like again, you've seen a lot of evolution, I would hope, in terms of practice. So, you know, given your current role over the last three weeks, have you seen anything harken back in terms of protocol and procedure and go, yikes, we're still doing that? Or, you know, yeah, what's what's the next step for us in terms of really evolving past some of the criticisms that we're we're facing?

SPEAKER_00 48:00

Yeah, I mean, I think we can acknowledge the criticisms and again talk about hindsight bias and that hopefully as we're learning new and better ways to do things, we're adopting those new protocols and certainly being accountable for uh any uh harms that we've caused in the past. I think it's important for us to realize that we can both embrace a social model of disability and still have to operate in the constraints of a medical model of disability because that's how we get paid. Both can be true at the same time. Again, this is non-binary thinking, right? That you don't have to have one over the other. I know there are lots and lots of people out there that have very strong opinions about ABA and that it shouldn't be used and that it's quote unquote conversion therapy or it's quote unquote bog training or whatever. And those individuals that have those feelings and thoughts and opinions about ABA are perfectly within their right to have them. But what I would say is just because you share a diagnosis with a group of people doesn't mean you get to speak for the whole group, right? Yeah. So, you know, if you want to advocate for yourself, then please do that. I absolutely support that. But for every person that says ABA is torture or whatever words they want to use, I have plenty of other families that say this is the only thing that ever worked for my child, right? So it doesn't have to be a dichotomy, it doesn't have to be a binary. More than one thing can exist in the world at the same time and be valid and true. People are not black and white or ones and zeros, they're shades of gray. And so offer yourself and others a little bit of grace to let them make their own decisions and their own advocates.

SPEAKER_03 49:40

Wow. We have covered a lot of ground. That was wow, that was very, very well said. Is there anything that we didn't get to cover that you wanted that you wanted to speak on, or anything like just open it up, open floor to you if you're anywhere you want people to find you, anything you want to promote, or as we close here, you kind of point people in a certain direction?

SPEAKER_00 50:01

I mean, I'm not hard to find on the internet. I always like to say uh vaguely professional on LinkedIn, mostly authentic on Instagram, and I am completely unhinged on Facebook. So buyer beware, choose your own adventure.

SPEAKER_02 50:16

Nice.

SPEAKER_00 50:16

But yeah, I mean, if you if you want to keep up with the professional comings and goings, you can go to nonbinarysolution.com. I'll probably be out talking a good bit again this year. You'll probably see me at a couple conferences, and yeah, happy to take questions, dedications, requests.

SPEAKER_02 50:34

Nice, very well. Well, I'd like to highlight a couple closing points. Mr. Dan, I'm gonna ask for your help on this one.

SPEAKER_03 50:40

So we're we're gonna say not this or that because consider the non-binary solutions. Absolutely.

SPEAKER_02 50:45

Remember that people are not black and white and always analyze responsibly. Thank you, Mandy Ralston. It's been a pleasure speaking with you. Thank you so much for your time. Cheers.

SPEAKER_00 50:55

Thank you, guys. Always analyze responsibly.

SPEAKER_02 50:59

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.