When it comes to a wealth of experience, subject matter expertise, and an interest in solving a complex problem, entrepreneur Amanda "Mandy" Ralston fits the bill. Her work offers a unique solution with the potential to improve people's lives.
"I don't take myself that seriously, but I do take my ideas very seriously, and most of the work that I do every day is in service of getting those ideas out into the world," said Ralston during an in-person interview with the Bay Area Reporter.
Ralston, queer and neurodivergent, is the founder and CEO of NonBinary Solutions, a technology and consulting firm, and she's on a mission to improve the quality and efficiency of autism diagnoses.
"Some of the work that I do may look different than how other people do it, but you can't get something different unless you behave differently. The outcome can't be different if you're doing the same thing everybody else is doing," she explained.
Cue a discernible problem in the field of applied behavior analysis — how to provide mentorship to less experienced autism service providers while also creating a standardized approach to treatment planning for autistic individuals — and follow it with a (sensory considerate) drum roll for Ralston's clinical decision support systems-based solution, NBS, founded in May 2022.
"Now that there's mandated insurance coverage in all 50 states, and we've got more [autism service] providers, people are willing to give that autism diagnosis in order to access care," she said. "It doesn't mean that that's necessarily the care that they need, but that's what's available. So the whole thing is really a big mess, which in the entrepreneurial world, is an opportunity. You see a problem, you try to go solve it, and that's what I'm trying to do."
The serial entrepreneur
Ralston, 47, is a board certified behavior analyst (BCBA) based in Kentucky with over 25 years of experience in the field of applied behavior analysis (ABA). She's also the founder and former CEO of two ABA clinics, Verbal Behavior Consulting Inc. and Behavioral Intervention for Autistic Children (BIFAC) Inc., and was the director of clinical intelligence and design at the Cedar Group.
She calls herself a "serial entrepreneur."
"Other workplaces — the rules and the structure — didn't make sense to me," Ralston said. "And so I think I've been in the habit of making my own spaces because I don't understand how other people arrive at some of the decisions that they come to."
In creating her own spaces, she's also demonstrated certain leadership qualities to which people respond well.
"I'm very authentic and transparent in how I operate, and I think that comes through," she said. "The greatest reinforcer and compliment of my career is that people that I have had work for me repeatedly want to come back and work for me again, and that people that barely know me want to come work for me."
David Beatty, whom Ralston described as a friend and adviser, referred to Ralston as a "true mission driven entrepreneur" and championed her founding of NBS.
"She identified a strong need in a market she knows deeply and went about finding a solution that not only promises to be highly profitable, it greatly improves the lives of an entire community," wrote Beatty, a gay man, in an email to the B.A.R.
Beatty is the founder and CEO of New York City-based funder Gaingels, an LGBTQ+ angel investor group that supports the diversity, inclusivity, and equity of the LGBTQ+ community and allies in the venture capital space.
"I am delighted and honored to have been asked to be her adviser. ... It is people like Mandy who continue to inspire me every day," he commented.
Steven Lamont, MBA, who lives in the Bay Area, also praised Ralston's entrepreneurial skills.
"She has a vision, has transferred her experience into an impressive first release of the product, and has great ideas for moving forward. She surrounds herself with supportive people and advisers who believe in her vision and her ability to succeed," wrote Lamont, an ally, in an email to the B.A.R.
Lamont is an entrepreneur and angel investor who primarily invests through the Sand Hill Angels. The investor group supports DEI initiatives and is allied with Gaingels, Techstars Rising Stars, and others.
Not binary
Ralston's been touring throughout the United States these past many months, giving audiences insight into the relevant statistics and findings that prompted the development of NonBinary Solutions, as well as details about its CDSS software, Knowetic.ai, which uses artificial intelligence.
She talks about the current 60,000+ autism service providers, the majority of whom have only a few years of experience in the field; their varied treatment plans; and the nonbinary nature of neurodivergences, i.e. neurological differences related to thinking and behavior.
One such speaking gig was the 20th annual Transformational Collaborative Outcomes Management (TCOM) conference, held October 2-4 at Hotel Nikko in San Francisco. In her presentation, "The Role of NonBinary Thinking and Neurodiversity in Life and Work," she emphasized the limitations of black-and-white thinking when it comes to autism and other neurodivergences.
"People are not binary. They're not black and white; there are shades of gray. ... People are not just one thing. They're a mix of a whole bunch of things at the same time, and so not pigeonholing people is really, really important. [For instance], you're neurodivergent and I'm neurodivergent, and our experiences may have lots in common, but they're completely different," she said.
The name of her firm, NonBinary Solutions, stems from her pursuit in getting that across to people — that they exist in a world ripe with nuances, complexities, overlaps, and intersectionalities.
Her Instagram posts often feature the hashtag "#ItsNotBinary," in line with that perspective.
The firm's name is also a means to talk about the connection between nonbinary, gender-nonconforming, and transgender individuals and neurodivergences, which scholars and news outlets such as NPR have reported on in recent years.
"I get to tell people, 'Did you know that individuals on the neurodivergence spectrum are six times more likely to not identify with the gender they were assigned at birth? ... So if you care about people with autism or neurodivergence, you also now have to care about people that are gender fluid or trans, because there's an overlap there,'" Ralston said.
"I like pointing out those types of nonlinear, nonbinary things for folks to help create empathy in a world that is increasingly binary in its thinking," she added.
A nonbinary solution
Ralston's early findings about autism were eye-opening in terms of what a diagnosis did — and mostly did not — entail.
"Back when I got started with this, in 1999, there was no insurance coverage," said Ralston. "Certification for behavior analysis had only just started in 1998. The CDC [U.S. Centers for Disease Control and Prevention] data for the rate of diagnosis of autism was one in every 1,000 at that point, and it's because there were no services. There were no providers. There was no funding for any of it."
Fast-forward 20-some years after Ralston's entrance into the field as a BCBA and initial autism research, when now one in 36 people are diagnosed as autistic — the equivalent to a 250% increase in the prevalence of autism since 2000, according to the NonBinary Solutions website.
In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a guide created by the American Psychiatric Association, the diagnostic criteria for autism spectrum disorder (i.e. code F84.0) includes "persistent deficits in social communication and social interaction across multiple contexts" and "restricted, repetitive patterns of behavior, interests, or activities."
The DSM continues to use the one code — F84.0 — for a very wide range of people, though no two autistic people are the same.
"There's the very articulate, exceptional individuals with autism on one end of the spectrum, or whatever you want to say about the [autism] infinity symbol, and then there's the profoundly autistic individuals that can't speak for themselves, that will need lifelong support, 24/7. And so the folks that are able to advocate for themselves should advocate for themselves, but not necessarily advocate for the whole group just because they share a diagnosis," Ralston said.
According to Ralston, the increased number of autism diagnoses has coincided with a 500% increase in ABA therapy providers in the last 10 years. Over half of those individuals are new to the field.
"Those are the folks that are out there making these treatment decisions. And it takes a lot of mistakes to have good experience, and I'm trying to prevent a lot of mistakes from being made in order to get that experience," she said.
This is where NonBinary Solutions' Knowetic.ai comes into play, as it acts as a mentor to these new-to-the-ABA-field professionals.
"The software is sort of like a digital bumper rail for people to narrow the amount of information they need to focus on in order to make these treatment pathways for people," she said.
The software, launched in July 2024, is also in line with the adage, "If you've met one autistic person, then you've met one autistic person," as it provides comprehensive data about autistic traits, symptoms, and behaviors, she noted.
"It creates a data set of all these very, very different people with autism to try to get a more granular understanding of what the different behavioral phenotypes of all those people with autism are," said Ralston.
Knowetic.ai's care navigation module not only helps the software's users bring people into care but also obtain a holistic understanding of them.
"It's not just, 'Oh, you have autism,' but [also] 'Do you have other medical diagnoses on top of that? Who did you get your autistic diagnosis from? Was it a primary care physician, or did you get a multidisciplinary evaluation from a group of professionals? Because that's a very different thing," Ralston said.
To get NBS off the ground and its software into the hands of clients, Ralston and the NBS team — Tim Guthrie, CFO and co-founder; Robert Beer, chief technology officer and co-founder; Jeff Ochall, chief data officer, business development; and Volo Dudas, programmer partner — used existing capital and raised $800,000 for pre-seed funding. Their anticipated gross profit for 2025 is near $5,000,000, with a projected increase to over $10,000,000 in 2026 and over $20,000,000 in 2027.
Lamont stated that Ralston's company is making a difference.
"NBS is addressing a real and growing problem," he stated. "I see it everywhere around me. I know some research points to a higher incidence of autism among LGBTQ+ individuals, which makes it all the more important to address. NBS brings objective analysis to assess and track progress in autism treatment. That makes it an essential tool for therapists trying to do their best to support their patients, and it will be more reassuring to the family members who want more information."
NBS currently has a contract with a multi-state managed care organization; partnerships with Arizona State University, the University of Kentucky, and the University of Georgia, The Center for Autism and Behavioral Education Research; and multiple active customers, such as independently owned clinics, Ralston said.
Meg Solomon, M.S.Ed., BCBA, who Ralston described as "vital to our (i.e. NBS's) success and understanding of user-needs for the Knowetic.ai software," is one of them.
Solomon, an ally, is the owner and CEO of ABA Across Environments, a private practice based in Colorado Springs, Colorado that provides ABA services to children and young adults and centers on acceptance and commitment therapy.
"NonBinary Solutions and Knowetic have enabled us to focus on therapeutic relationships by saving us time during onboarding. That time has not only helped the learners by allowing us to provide a more trusting foundation as a trauma-informed provider, but it has also saved the company money during the onboarding process. What we see happening with Goal Development and Knowyeti [i.e. components of the software] have been exciting, and we can trust that those services will provide time to our clinical team while continuing to pass cost savings onto the company," wrote Solomon in an email to the B.A.R.
The nonlinear path forward
Post-TCOM conference, Ralston shared news via Instagram of her two-and-a-half hour talk having gone well — so well, in fact, that she was invited on the spot to speak at a Bancroft Autism Services center in Philadelphia in the coming weeks.
Ralston will also be the keynote speaker at the 2024 Colorado ABA conference, which will be held November 7-9 in Denver.
She'll be continuing to get the word out about NBS and the message of "it's not binary."
This story is part of the Digital Equity Local Voices Fellowship lab through News is Out. The lab initiative is made possible with support from Comcast NBCUniversal.
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