Ethical Implications of Hiring Parents as Practitioners

Over the past several years, with the influx of PE backed agencies, we’ve experienced changes in the industry as a whole; some positive and some not positive at all. The positive impact I’ve seen is the ability to scale up faster than a typical BCBA owner, with no backing, who has to grow slowly and organically while re-investing the profits into the business. Assuming a focus on providing high quality services, PE backed agencies can grow faster which allows for more clients to receive services which is great.

The not so positive impact includes companies only recommending and accepting 40 hour/week cases, self-diagnosing, waiving co-pays and deductibles for all clients even those for which there is no financial hardship, etc. etc. I know several large multi-state agencies who implement these policies which at the very least are unethical and make it very hard for smaller agencies to survive.

But, an agency hiring a parent, training them to be an RBT and paying them to provide services to their own child rises to a new level of unethical! I know many are talking about it all over social media and find this egregious as well.

When I was at AST many years ago, our goal was that family members would continue to implement therapeutic programs even when the therapist or BCBA was not on site. We required parents to participate in no less than 20% of the monthly services. That was the norm and we commended parents who went the distance of taking the coursework and were thrilled if a parent actually became a BCBA. But never in our wildest dreams would we consider hiring that parent and paying him/her to service their child.

It is frankly incomprehensible to me how paying a parent to provide services to their own child is ethical. I have consulted with several BCBAs who have started their agencies to ensure their child received quality care due to, in most cases, year plus waitlists in their local areas. The BACB was quick to respond that this was a “dual relationship” and the BCBA who was the agency owner (although not providing services to his/her child) was at risk of losing their credential on the basis of an ethical violation. Their alternative was to independently hire and pay out-of-pocket to have their child’s services be provided outside of their agency to avoid any conflict.

Parents being employed to provide services to their own child is clearly a dual relationship and a conflict of interest. This service delivery model has so many inherent issues it’s impossible to list them all. But to name a few:

• What happens when the parent (employee) must receive disciplinary action? How does one navigate that?
• Do insurance companies know that their members who are paying the premiums, deductibles, copays/co-insurance, etc are also being paid by the same funds which the insurance company is reimbursing to the company for which they work?
• Are the RBTs (parents) aware that they are in multiple relationships – parent + RBT to child receiving ABA and in violation of their ethical code?
• Are the BCBAs aware that they are involved in a dual relationship – employment supervisor (of an RBT) to a “secondary” client (parent of a child in their ABA program) and in violation of their code?
• Parents have a personal investment in their child’s success and although subconscious may skew the data.
• Parents who are financially challenged may manipulate their timesheets which would result in manipulated data and fraudulent billing.