Learning from the Czech Republic’s experiences with growing applied behavior analysis services for children with autism

ABSTRACT

Prior to 2016 applied behavior analysis (ABA) was relatively unknown in the Czech Republic. However, the region’s ABA community has grown exponentially over the last six years. This growth may be attributed to the work of families and professionals linked to the region’s autistic community. This progress has not been without challenges. Along the way, there have been numerous vocal opponents across various fields. Despite pushback, the headstrong ABA community has managed to: establish ABA professional organizations, hold ABA conferences, train various professionals in ABA, and pass laws surrounding the profession and its practice. Through efforts such as holding free community-based workshops, creating ABA-centric continuing education trainings for other helping professions, recruiting local media coverage, collaborating with other organizations, presenting multiple exemplars of case studies using ABA-based methods across disciplines, and lobbying the government for change, ABA is on its way to becoming a more available option for supporting those with autism in the area. This paper shares the trials and tribulations of the region, hoping that the experiences and actionable points here can help move similar nations towards ABA dissemination and professional establishment.

KEYWORDS:

• Autism
• applied behavior analysis
• European union
• dissemination
• licensure

Applied behavior analysis (ABA) is not a science whose usage benefits only those with autism. In fact, ABA has been validated in countless fields outside that of with individuals with autism and their families (Heward et al., 2022). Its applications to psychological and emotional disorders have been proposed (Ross, 2007), it has been used to treat mental health conditions (Harvey et al., 2009), and it has countless applications for the regular education classroom (e.g., Gentilini & Greer, 2021). However, in the Czech Republic and surrounding regions, the birth of ABA as a profession has most closely correlated with the work of families and professionals linked to the autistic community. These individuals are responsible for developing professional organizations, initiating the creation of university coursework, and sparking legislative changes. While attaining these milestones has been challenging, and there is still plenty of room to grow, these humble beginnings can help guide those looking to disseminate behavior analysis in areas where it is under-recognized or misunderstood.

An overview of the evolution of behavior analysis in the Czech Republic

A growing awareness of autism in the Czech Republic could be seen as the catalyst for changing outdated services. During the 2020/2021 school year, the Czech Republic’s Institute for Information in Education, reported that 114,108 pupils with disabilities were educated in the primary schools, with 4,216 of them having a diagnosis of autism (NAUTIS, 2022). However, increasing numbers in diagnoses became noticeable about a decade earlier, which is when the need for evidence-based practices in special education in the Czech Republic started gaining more attention (Carter et al., 2012). Additionally, research by Vitásková and Říhová in (2012), Salomone and colleagues in (2016), and Hrdlicka and colleagues in (2016) all looked specifically at the Czech Republic to investigate available services, family situation, access to information, and the age of diagnosis for children with autism. More recent research by Kingsdorf, Pancocha, and colleagues (e.g., 2020a, 2022b), continued to support the investigation of evidence-based practices in the field of autism by looking at the situation of behavior analysts in the region, the availability of services for caregivers, and solutions for supporting the developing field of ABA.

The work of researchers (e.g., Hrdlicka et al., 2016), in addition to the valiant efforts of families, sparked movement within the country’s government. In 2016 the Governmental Committee for Persons with Disabilities published the Incentive to Resolve the Adverse Life Situation of Persons with Autism Spectrum Disorder and their Families (Governmental Committee for Citizens with Disabilities/Vládní Výbor pro Zdravotně Postižené Občany, 2016). The document outlined 11 areas (e.g., public awareness, early screening, diagnostics, treatment and education) in need of immediate action. Subsequently, the Ministry of Health was appointed by the Czech government to develop and put into practice early childhood screening for autism. The ministry was further requested to develop standards for compulsory education and supervised practice, develop the scope of professional practice in the field of ABA, support the development of an ABA study program and licensure within the healthcare system, and negotiate the coverage of ABA as well as cognitive behavioral therapy (CBT) with the health insurance providers. This governmental initiative in 2016 was followed by best practices being published in 2018 by the Czech Psychiatric Association listing ABA as a recommended service for autism. Despite these steps in the right direction, the expansion of ABA as a field of practice has been an uphill battle. Dissemination has struggled in the face of other service options. Specifically, in contrast to other countries in Europe, the Czech Republic previously reported much higher rates of service delivery of speech-language and occupational therapy approaches, as opposed to behavioral treatments (Salomone et al., 2016). Furthermore, eclectic treatment options that do not include speech, occupational therapy, parent training, behavioral approaches, or developmental approaches accounted for over one third of the overall practices being used with children with autism (Salomone et al., 2016). Unfortunately, even harmful services have been seen in the region; such as chelation therapy (A2C Anti Aging Clinic Prague, 2022), holding therapy (Tavris, 2014), and associated restraint or unvalidated psychoanalytic treatments (Mercer, 2013). The marginalized usage of ABA aligns with challenges in awareness, education, and translated materials. Even with the support of the government in these areas, the process of establishing ABA as a profession in the region has been complicated, and the process of moving it forward challenging.

Behavior analysis in the region Prior to 2016

Prior to 2016, behavior analysis was relatively unknown in the region. When ABA was an evolving field in the West, in the 1960s and 1970s, the scientific landscape of the Czech Republic looked much different. So, while ABA practices were coming to light in the United States and the UK, the Czech Republic was restrained by communist ideology that considered approaches based on behaviorism to be bourgeois or capitalist, and therefore undesirable (Pancocha & Vadurova, 2022). The fall of the Iron Curtain in the late 1990s allowed for the expansion of the science of behavior in the region. However, this was mostly seen in the work of CBT. The extension of behavioral services which focused on the use of applied practices in teaching and learning or even the development of strategies for children with autism remained absent. Essentially, ABA was still missing from the country. This remained the case for many years, with there being almost no ABA practitioners in the country in 2015 (Roll-Pettersson et al., 2020). Unsurprisingly, there were no education or training programs, or licensure or certification systems.

Education and training in behavior analysis in the region

Historically, when addressing the components of education and training in ABA, the first step within the field has been the establishment of a Verified Course Sequence (VCS) by the Behavior Analysis Certification Board (BACB), later taken over by the Association of Applied Behavior Analysis International (ABAI). Although numerous changes have been made regarding the scope of these organizations within the region, steps were initially taken to align ABA educational offerings with these organizations. A training program in ABA at Masaryk University and school and training centers focusing on the science of behavior were established within the region in 2016 (BACB, 2018). Most of the coursework was taught by local behavior analysts (who completed their coursework abroad) in the local language. However, visiting professors from other universities in Europe did teach courses at times in the English language. This, and the education of the initial local behavior analysts abroad, was funded by a grant from the Czech Republic’s Ministry of Education. The staff exchanges were also supported by the Erasmus+ program.

While the coursework aligned with the recognized standards of behavior analysis abroad (i.e., those outlined by the BACB and ABAI), it was imperative that it also meets local educational, practical, and assessment requirements. Therefore, additional content was added to the basic VCS, practicum, and testing requirements to align with the health care law and standards of other allied health professions. Figures 1 and 2 depict the requirements for behavior analysts in the Czech Republic. It can be noted that a degree in ABA is not required to become a behavior analyst in the region. In fact, there are no local university degrees in behavior analysis available, only the supplemental VCS.

Figure 1. Comparison of the BACB certification and Czech behavior analyst certification and licensure education requirements.

Figure 2. Comparison of the BACB certification and Czech behavior analyst certification and licensure practicum and assessment requirements.

In addition to establishing a Czech-language VCS with locally applicable coursework, the University has facilitated ABA education and training for students studying to be teachers (Kingsdorf & Pančocha, 2020b), expanded training programs which support established educators (Troshanska et al., 2022), and adapted coursework for caregivers (Kingsdorf et al., 2022b). Since 2016 the numbers of individuals within the region who have benefited from gaining education and training within the field of ABA has steadily increased. As one example, over 350 teachers and social workers have attended ABA training at Masaryk University (see Figure 3). The number of internationally certified behavior professionals in the region has also cumulatively risen. From 2016 to 2022 the numbers of Registered Behavior Technicians® (RBT®), Board Certified Assistant Behavior Analysts® (BCaBA®), and Board Certified Behavior Analysts® (BCBA®) certificants in the Czech Republic have gone from zero to over 30 (see Figure 4). Additionally, with the new regulations in place making behavior analysts allied health professionals in the region, 2020 to 2022 saw continuous growth in the development of a field that now has 47 behavior analysts (see Figure 5). Furthermore, several hundred parents have participated in workshops on ABA, specifically on topics such as problem behavior reduction, communication training, toilet training, sleep, and food selectivity. Trainings on the basics of ABA were also provided to speech-language therapists and clinical psychologists in an effort to further disseminate the science and build allies across fields. These training efforts have moved outside of the University, too, with organizations such as Uceni zABAvou (Learning with Joy) https://www.ucenizabavou.cz and Modry Kruh (Blue Circle) www.modry-kruh.cz providing formal and informal training on ABA to the local community. Since the Czech Republic’s recent improvement in ABA education and dissemination (Arntzen & Pellón, 2021), they have seemingly surpassed other countries in their availability of ABA services (Kingsdorf et al., 2022a). However, even these advances in education and training availability have not been without hurdles. For example, the University has been met with difficulties recruiting students into the ABA program, which is likely related to the uncertainty surrounding local ABA career opportunities beyond graduation.

Figure 3. Cumulative teachers and social workers receiving ABA training at Masaryk University.

Figure 4. Cumulative Czech professionals certified by the BACB.

Figure 5. Cumulative behavior professionals licensed by the Czech Government.

Certification and licensure in behavior analysis in the region

While education is vital to ensuring that correct knowledge and application exist in the field of ABA practice, supporting the development of legislation surrounding certification and licensure can further protect those receiving services. In the United States, where ABA is more established, a code for its usage emerged in the 1980s (Dorsey et al., 2009). Unfortunately, the development of these guidelines for practice was the result of ethical violations committed within the field (for a history of the ethical codes, see Bailey & Burch, 2011). The guidelines created in the 1980s have been revised over the years, and now take the form of a widely recognized Ethics Code for Behavior Analysts (BACB, 2020). Generally speaking, the aim of the code and the certification are to reduce the malpractice committed by individuals professing to be practicing ABA. However, the ability of this organization and accompanying code to govern ABA across such a wide base of practice has been brought into question, especially as it relates to the provision of ABA services by independent practitioners (Dorsey et al., 2009); yet, this is the model of practice most commonly used in developing regions like the Czech Republic. Resultantly, the BACB recognized the lack of funds, resources, and knowledge of all local laws or legal authority to protect those receiving independent ABA services around the world, putting the onus on non-English speaking countries to create systems of self-support.

Historically, credentialing has been considered voluntary, managed within the profession and without safeguards in place to inhibit unqualified practice. This is in contrast to the statutory basis of licensure. As a result, licensure may be considered more beneficial for a community than credentialing. Even in the United States, licensure has become more necessary, having favorable outcomes, such as allowing States to develop their own standards for practice, governing bodies, and consumer protections (Dorsey et al., 2009). The aim of these laws has been to both protect vulnerable populations and set the stage for insurance funding, since licensure has historically been required for insurance billing in the US.

In areas like the Czech Republic, the limited scale of the profession and the small span of the country has made informal regulation of the profession seem more manageable. However, even on a small scale, lack of awareness about the standards of practice as well as lack of formal regulation may give rise to events damaging the entire field of ABA. For example, in 2021 the Czech Television (https://www.ceskatelevize.cz/porady/1092813857-infiltrace/420235100201001/) ran an undercover expose on an in-home school that was claiming to provide behavioral services to children with autism. Resultantly, it was revealed that the safety of a vulnerable population may have been put in jeopardy and ersatz behavior analysis was publicly judged and condemned in the media based on applications by non-credentialed providers. Ultimately, the documentary did not run in its entirety, and there is litigation surrounding the journalistic methods used and the services filmed in the program (Irozhlas, 2021). Such an example demonstrates the need for regulations surrounding the use of ABA in the region. While it could be argued that establishing regulations on this micro-level creates boundaries for practice within the region of Europe, it would appear that the overall gains for those receiving ABA would mitigate these concerns. Meaning, licensure would allow local authorities to regulate the public advertisement of practitioners as behavior analysts, allow consumers to distinguish between licensed and unlicensed practitioners, establish regulations for procedures for local billing practices and funding source recruitment, appropriately position authorities with the knowledge of the local language and culture when addressing consumer complaints through investigations, raise awareness of treatment options locally, and develop standards for education and training to align with available resources. Therefore, although the need for licensure was apparent, getting there was complicated. The first step of creating a local license meant establishing behavior analysis as a profession within the Czech Republic.

Gaining professional recognition for behavior analysts

Historically, establishing a behavior analyst as a recognized professional has been complicated. As with establishing any profession there are typically large gaps between the linear stages of: (1) the profession establishing services that are valued by a community, (2) the development of professionals available to provide the services, and (3) the development of regulations and regulatory agencies (Carr & Nosik, 2017). For example, as further discussed by Carr and Nosik (2017), ABA practices began in the 1950s, with the development of training programs and practitioners in the 1960s, with that developmental period spanning many decades, before getting to a place of developing regulatory bodies in the 1990s. This specifically describes the movement of the profession in the United States, though. Abroad, as in Europe, it has been recently discussed that at least 21 countries are in various states of trying to find a legal basis for the profession in their regions (Keenan et al., 2022).

It could be hypothesized that some of the roadblocks met along the route to professional recognition are the result of the field being historically stuck within or perhaps between the established practices of psychology and education (Shook & Favell, 2008). However, with the reality that many practitioners within the psychology and education fields have had little to no training in behavior analysis, the field has needed to be claimed as its own discipline (Shook & Favell, 2008). Becoming its own discipline without upsetting those which it left behind remains another obstacle. While interprofessional collaboration is a known challenge for behavior analysts, embracing it during the field’s development, and continuing to do so, is important for progress. Slim and Reuter-Yuill (2021) recently discussed the importance of making professionals in varying fields, such as speech-language, occupational therapy, physicians, and teachers allies by building a climate of respect and shared values, acknowledging various roles and abilities, communicating in a responsible manner, and applying team-building strategies. Such interprofessionalism is not only likely to result in better outcomes for those receiving ABA services, but also establish the profession of behavior analysis as one that does not exist to usurp the positions of other services providers, but augment them.

Behavior analysis as a recognized profession in the region

Looking for a place for the profession of behavior analysis in the Czech Republic began with an analysis of qualification systems in the fields of education, social care, and healthcare, which have traditionally had independent professional regulations within the country. Typically, a profession can be regulated only within one of the three systems and therefore it was decided that behavior analysis best fell under the health care legislation. The Czech Republic, like many nations within Europe, uses a national qualification system for outlining the components of recognized professions and their scope of practice. This system clearly denotes education levels for a profession and how the profession aligns with larger qualification frameworks like that of the European Union, the European Qualification Framework (EQF; European Union, 2008; 2018). The presence of a profession within this national framework allows for more career, funding, and mobility opportunities. Without the profession of behavior analyst being recognized within the country it is unlikely that universities will offer terminal degree programs in that area, that organizations will advertise jobs, that professionals will be able to change jobs within the national and international fields, and that monetary sources will be allocated for related services (e.g., funding from health insurance).

In the Czech Republic, many of the aforementioned challenges in creating a recognized profession have been experienced, including building interprofessional collaboration which results in garnering support from non-behavioral colleagues. For example, at least six known letters exist from other Czech health professionals (i.e., psychologists, psychotherapists, psychiatrists, and speech-language therapists) that were written and sent to the government between 2017 and 2019 on why ABA should not be a recognized profession (letters available upon request from the authors). Some of their key arguments, many of which are unfounded, are that: (1) There is a lack of evidence of ABA’s effectiveness, (2) the field is missing a cost-benefit analysis, (3) the exorbitant cost of ABA services will drain resources for other mental health services, (4) ABA is just part of behavioral psychotherapy and should fall under education in psychotherapy (namely CBT), (5) the rigors of the proposed system of education and training in ABA are not in line with that of other health professions, (6) ABA is just part of CBT and therefore does not need a new profession, as it could be practiced by clinical psychologists with training in CBT, (7) the amendment and new profession were not thoroughly discussed with other professions that support people with autism spectrum disorder (ASD), namely clinical psychologists, psychiatrists, speech-language therapists, and their representative associations, (8) ABA is being pushed by lobbyists with unclear intentions, and (9) there is no medical academic institution which could provide education in ABA, since ABA is not a medical treatment, but a socialization technique, and therefore does not belong to health care. Additional public statements have been made by opponents of ABA ranging from highlighting the lack of professional training in ABA in the country to false proclamations about its adverse effects. In fact, such unsubstantiated claims about ABA were presented by some of the leading psychiatrists during the Senate Health Care Committee meeting, which was debating the bill on the new profession of behavior analyst in 2017. The second author was present at the meeting and observed outlandish statements on ABA-based interventions including claims that it can possibly lead to creating mass murderers similar to Anders Breivik (for information on Anders Breivik see Meloy et al., 2015). However, steps have been taken to mitigate this conflict by creating presentations for local medical professionals (e.g., https://iviv.ped.muni.cz/projekty/euroba) on the value of ABA using layman’s terms, culturally relevant case studies from the region and abroad, and the expertise of dually credentialed professionals (e.g., local psychologists and speech-language therapists who have become behavior analysts).

After a long and complicated legal as well as professional struggle, behavior professions, namely behavior analysts, assistant behavior analysts, and behavior technicians, were finally approved and enacted within the Czech allied health care professional legislation in 2017 (see Figure 6 for the timeline of the legislative processes involved). This was followed in 2018 and 2019 by the publication of several by-laws of the Ministry of Health, specifying the scope of practice, education and training requirements, and accreditation standards for professional training programs in behavior analysis. Finally, the first applicants for licensure were able to be approved in 2020.

Figure 6. Key events in establishing ABA in the Czech Republic.

Next steps for behavior analysis in the region

Despite this forward movement, more needs to be done to support the practices of behavior analysts in the region. Even with the exponential growth of the field since 2016, practitioners still find themselves over-worked and under-supported (Kingsdorf & Pančocha, 2020a) and caregivers still miss out on the services that they need (Kingsdorf et al., 2022a). This varying degree of available services and community needs being met is something that is currently seen throughout Europe (Keenan et al., 2022). In the Czech Republic specifically, the profession is currently listed in the law, but yet to be recognized by the general public. Health insurance is not providing reimbursement for ABA services. Professionals like psychologists and speech language pathologists, for example, remain free to use ABA tactics in their practices. However, insurance does not recognize ABA as a specific service type, regardless of the professional delivering them or with whom they are working, making ABA-specific reimbursement impossible (i.e., a billing code for ABA services does not exist in the Czech health insurance system). Therefore, having behavior analysts take alternate career routes to later practice and bill for ABA services is not currently feasible. Additionally, there are limited choices for behavior analysts to work within the healthcare or social services systems. Furthermore, there are minimal legal protections for clients and behavior analysts. Therefore, the battle for establishing behavior analysis in the region is far from done. Despite the fact that the profession has been included in the health care law, there were repeated attempts to disqualify and remove it. Therefore, constant effort from the behavior community is required to maintain the status of the profession, including diligent presentation of good practices to different stakeholders, and providing educational and awareness activities in order to make the profession, its ethics, and scope of practice known to the professional communities as well as the general public. Further, incorporating the activities of behavior analysts into complex multidisciplinary support systems for people with ASD is necessary. Repeated negotiations with health care insurance providers as well as the Ministry of Health are underway to root the profession within the allied health system and provide ABA intervention coverage from the public health insurance, and are likely to be ongoing. Spreading the knowledge and skills related to ABA to other fields of practice (e.g., education, counseling, and social work) has already been started, but requires continued efforts.

Expanding the process to similar regions

The trials and tribulations of the Czech Republic can help guide similar nations on their journeys of ABA dissemination and establishment, especially as it relates to the field of autism. While all nations will have slightly different steps to take surrounding the legislature and local requirements, there are some key actions that should be considered. Refer to the brief infographic in Figure 7 for some important “dos” and “don’ts” in dissemination. However, these and other points are expanded upon below.

Figure 7. Dos And don’ts for ABA dissemination in your region.

1. Program common stimuli, like continuing education trainings, for other helping professions (e.g., speech-language pathologists, occupational therapists, psychologists, teachers) to include workshops, seminars, and other activities that present multiple exemplars of ABA applications across fields.

2. Take steps to get media coverage of your ABA events by contacting local radio stations to advertise and inviting local papers to photograph/report on your events.

3. If you are looking to expand ASD services to include ABA, invite ASD parent organizations to attend practical workshops on ABA for them and other parents.

4. Connect on social media with the international behavior analytic community and organizations (e.g., BACB, ABAI, APBA, UK-SBA, etc.). When possible, especially with smaller organizations, extend invitations to connect in-person as tours of centers, classrooms, universities, etc.

5. Plan and host an ABA conference in your region, bringing in multiple stakeholders locally and from abroad.

6. Go to events held by other professional organizations concerned with the treatment of ASD or other developmental disabilities (e.g., psychologists, psychiatrists, speech-language therapists, and occupational therapists) to introduce yourself and your cause and learn about theirs.

7. Research the steps in your region for establishing non-government organizations (NGO) that support professional development (e.g., the Czech Society for Applied Behavior Analysis, CSABA). These organizations can be a starting point for later professional development.

8. Organize public hearings at the national government level together with parents and other stakeholders, bringing in international representatives of the science.

9. Seek legal advice and learn the system of establishing professional status within your system of government.

10. Find influential professionals (e.g., medical doctors) that have demonstrated an understanding of the complexity of ASD treatment and need for evidence-based treatments, provide them with information on ABA, if needed, later ask them for support (e.g., signatures on documents, written letters, appearances at your events), and reinforce their involvement with your cause (e.g., offering to provide free workshops or training to their staff).

11. Contact local political representatives (MPs) via letters, emails, or telephone calls, explain your cause, and ask if they would be willing to adopt the agenda of introducing the new profession to the system (in case changes in legislature are necessary).

12. Schedule meetings with government clerks and workers in charge of professional qualifications and standards to gather information about pieces like introducing a new profession.

13. Present on ABA at conferences and publish in journals outside of the field of ABA (e.g., medicine, social care, special education, psychology), but in your local language and using multiple exemplars of ABA case applications.

14. Connect with a local university program and offer elective or professional development courses on ABA (e.g., through departments of special education, pedagogy, or psychology).

15. Contact ABA supporters in other countries in your region that are working on the same issues, form an advisory board together, hold reoccurring meetings, and share materials.

16. Write down the steps needed for professional recognition (task analysis) specific to your national/state system.

17. Meet periodically with others striving for the same goal in your country, divide the work, take turns in the leadership, and reinforce each other’s efforts.

18. Identify local sites who are implementing best practices in ABA (e.g., an ABA classroom, ABA center, or ABA home program) and hold an “open house” where you invite other professionals, parents, and media to come observe.

19. Make videos, in the local language, with examples of validated ABA and parents’ testimonials describing the progress of their children.

20. Disseminate ABA to the general public yourself by speaking to journalists, writing articles about ABA and ASD for non-ABA social media sites, and speaking on the radio, television, and in podcasts.

Conclusion

The development of behavior analysis in the Czech Republic is a recent phenomenon. Prior to 2016 very little was known or implemented, in respect to ABA. As depicted in the infographic on the key events in establishing ABA in the region, Figure 6, it is evident that the country made great strides in the science through the active efforts of families and professionals. However, creating a profession involved a complex legislative process. The example provided here can hopefully serve as initial guidance and inspiration. However, this process is likely unique to each country. In the case of the Czech Republic specifically, it should be noted that it was required that a law be changed to recognize the profession. Taking on such a process is a big endeavor, one that was met by fierce resistance from many other Czech professional organizations as well as other parties with vested interests, including organizations providing outdated and empirically-lacking services to people with ASD. Regardless of the specific steps in your region, keep in mind that creating allies across fields along the way might be tantamount to success.

Ethical statement

No human subjects participated in this research. However, the work was approved by the Institution’s Review Board.

Data sharing statement

Data were not specifically collected for this manuscript. However, all data/sources mentioned in the manuscript are available from the authors upon request.

Disclosure statement

No potential conflict of interest was reported by the authors.