March 20, 2020 Update: We have updated the following information to provide a revised description of individuals who may be at increased risk of becoming very ill during the pandemic. The revised statement also clarifies the guidance provided to support certificants in making decisions around service provision. It is important to remember that the BACB cannot issue a blanket directive to continue or discontinue services due to the complexity of each individual situation and client.
March 19, 2020 (Modified March 20, 2020)
Because the COVID-19 pandemic is particularly impactful on vulnerable populations and their service providers, we offer the following information to our certificants as they make critical decisions about service delivery during this difficult time. Please keep in mind that this information does not constitute legal or medical advice.
First, we extend our gratitude to the many BACB certificants who had contingency plans in place to address service interruptions. We also want to serve as a resource for the many certificants who have contacted us for ethics guidance as they seek to develop and modify contingency plans consistent with the Professional and Ethical Compliance Code for Behavior Analysts (Code) during the pandemic. The Code is primarily focused on ensuring that high-quality services are delivered in a safe manner. Throughout the Code, it is clear that the primary directive is to do no harm to clients. Section 2.0, Behavior Analysts’ Responsibility to Clients, states “Behavior analysts have a responsibility to operate in the best interest of clients.” Section 2.04(d) states: “Behavior analysts put the client’s care above all others…”
Section 1.04(d) of the Code makes it clear that certificants must comply with legal requirements, including those related to social distancing and service provision. Recent directives regarding social distancing may create scenarios that are not easily addressed under 4.07(b) of the Code. Essentially, the social distancing requirements could be deemed “environmental conditions [that] hinder implementation of the behavior-change program.” Accordingly, certificants must “seek to eliminate the environmental constraints, or identify in writing the obstacles to doing so.” 4.07(b). This means that if there are barriers to service provision in a particular region or context (e.g., a mandate to engage social distancing, high-risk clients) that cannot be removed or adequately addressed, certificants must document in writing the barriers and steps taken for each client.
As BACB certificants endeavor to uphold the Code and protect clients, we provide the following considerations:
Health and Safety
- The Centers for Disease Control and Prevention (CDC) currently list the following as groups who may be at increased risk for getting “very sick” during the pandemic: older adults; people of any age who have asthma, COVID-19, or serious underlying medical conditions (blood disorders; chronic kidney and liver diseases; compromised immune systems; current or recent pregnancies; diabetes heart disease; lung disease; metabolic disorders; and neurological, neurologic, and neurodevelopmental conditions). For more information on these categories, please see the following resources: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html and Appendix A in https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf. Each certificant is responsible for verifying whether a client falls into one or more of these groups to assist in fully determining the risks associated with continuing to provide services in their current form.
- The World Health Organization and the CDC recommend social distancing to slow the spread of the infection, minimize the risk of infection to those considered high-risk, and reduce the strain on health services and resources. In the United States, the federal and state governments have directed the public to engage in social distancing, schools have closed or moved to online instruction, and many other public services have been limited or temporarily stopped. Similar practices have been enacted in many other countries.
- The CDC indicates that individuals who are asymptomatic or have yet to display symptoms may expose others to the virus, and because testing is limited, most individuals are unable to verify that they are not infected. This means that service providers or clients who do not appear ill could be spreading the virus.
- To minimize risk, service providers should consider developing a COVID-19 pandemic risk mitigation plan and implementation policies. The risk mitigation plan may include some of the following elements: regular communication with staff and clients about how to stay safe, telecommuting/telehealth, limits on air travel, attestations about symptoms and exposure, encouraging social distancing, considerations for determining whether to continue/augment/suspend client services, and cancelling services/sessions if clients or service providers are symptomatic or if deemed necessary to comply with social distancing recommendations.
Continuity of Care and Appropriate Transition of Services
- Section 2.15, Interrupting or Discontinuing Services, indicates that certificants must work in the best interest of clients to avoid interrupting or disrupting services. This code element must be balanced with the overall requirement to not harm clients. Therefore, certificants providing services to vulnerable individuals must first comply with all government mandates (1.04(d) of the Code). Assuming there are no mandates to the contrary, the service provider must determine if the risk of suspending services (e.g., substantial risk of injury to the client) is greater than the risk of continuing to provide services.
- If continuing services is deemed appropriate, the certificant must then determine if services can be delivered in a manner that does not unduly increase the risk of exposure to COVID-19 (e.g., enhanced disinfecting protocols, minimizing numbers and points of contact, using protective gear).
- In the event that services should be suspended in their current form, the next step is to determine if services can be augmented (e.g., provide telehealth services, develop maintenance and generalization programming, create home-based program materials, move to parent consultation via telehealth) to minimize disruptions (i.e., minimize loss of critical skills).
- If it is determined that services must be stopped, as opposed to augmented, providers should engage in appropriate steps to ensure continuity of care and appropriate transition (e.g., update reports and data, make relevant documents and materials available to caregivers, provide caregivers with a list of other relevant providers).
- In summary, certificants must systematically and carefully consider the risks of stopping, continuing as-is, or augmenting services, and then take steps to carry out the decision in a way that minimizes risks to clients, caregivers, and staff and maximizes therapeutic benefits to clients.
As certificants make these difficult decisions, we urge you to follow all laws and public health recommendations from your local health authority and respective governmental agencies. We have compiled a list of resources relevant to the COVID-19 pandemic below. Note that including a resource is not an endorsement of the agency or organization, or the guidance provided by said agency or organization.
The BACB will continue to monitor the evolution and impact of COVID-19 and work to continue supporting the profession during this difficult time. If you have questions, please visit the Contact Us page.
- ASHA: Protecting Those You Serve, Co-Workers, and Yourself From COVID-19
- BHCOE: COVID-19 FAQs for ABA Providers
- CDC: Coronavirus Info
- CDC: Prevention
- CDC: Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission (PDF Download)
- CDC: Preventing the Spread of Coronavirus Disease 2019 in Homes and Residential Communities
- President’s Coronavirus Guidelines for America03/16/20120 (PDF Download)
- WHO: Key Messages and Actions for COVID-19 Prevention and Control in Schools (PDF Download)
- WHO: Mental Health and Psychosocial Considerations During COVID-19 Outbreak (PDF Download)