In February, on orders from the U.S. Department of Government Efficiency, Medicaid officials created a first-of-its-kind online portal containing hundreds of millions of billing records that supposedly would allow everyday people to crowdsource investigations into healthcare fraud.

“DOGE is not a department,鈥� Elon Musk . 鈥淚t’s a state of mind.”

At the time, thousands of heavily armed federal agents were smashing into cars and battering their way into homes throughout Minnesota鈥檚 Twin Cities, under the guise of investigating what the Trump administration insisted was unchecked fraud in autism therapy committed by Somali immigrants.

There was a grain of truth: Fraud is indeed widespread in autism therapy, something a series of federal audits begun during the Biden administration found in red states and blue. In the wake of the audits鈥� release, the Trump administration raided autism centers, blaming lawless immigrants, welfare cheats and 鈥渨oke ideology鈥� for the scandals unfolding nationwide. 

But a 74 investigation found another problem entirely: a massive influx of private equity players capitalizing on the autism therapy industry to the tune of $7 billion in taxpayer-funded Medicaid payments over the course of six years. And much of this explosive growth has come at the expense of children.

The explosive growth of applied behavior analysis

社区黑料 downloaded the 275 million-record DOGE dataset and analyzed Medicaid claims for autism therapy from 2019 to 2024. Our analysis reveals how an unproven, even harmful, behavior modification system called applied behavior analysis, or ABA, is crowding out more effective 鈥� and humane 鈥� treatments for children with autism.

And it shows how a well-intentioned campaign by parents desperate to find a “cure” for their autistic kids has mushroomed into a poorly implemented but extremely lucrative mechanism for providing ABA 鈥� a system of rewards and punishments designed to eliminate certain behaviors 鈥� to as many autistic children as possible, regardless of their age or actual needs. 

Pediatricians, psychologists and other professionals who diagnose autism reflexively prescribe ABA to parents, typically unaware that there is mounting disagreement about the therapy鈥檚 effectiveness and the associated trauma that can follow an autistic individual into adulthood. Told this is the child鈥檚 best chance at a decent life, few caregivers question the guidance until harmful effects start to show.

Experts consulted by 社区黑料 weren鈥檛 surprised by our findings. Health officials turned on the fiscal taps before instituting meaningful legal oversight 鈥� creating the exact kind of loosely regulated environment that draws the opaque investment strategy employed by private equity. 

A secretive corner of the financial sector not held to the same standards as exchange-traded stocks, bank loans and other publicly monitored investments, private equity has acquired businesses in numerous industries over the last decade, hoovering up billions of dollars. 

Private equity typically acquires privately held companies that have access to steady streams of revenue, extracting as much cash as possible in the short term and leaving debt when investors move on. To maximize profits, they often deliver the easiest, most lucrative services, rather than the personalized treatments Medicaid and other public funds were supposed to pay for.

From 2019 to 2024, 社区黑料 found, Medicaid claims for the six most common autism therapy billing codes shot up some 381%, from $400 million a year to nearly $2 billion 鈥� with private equity-backed providers leading the billing pack.

Indeed, federal begun in 2022 鈥� two of them in blue states and two in red 鈥� reveal a very purple problem. They detail how bad actors in the for-profit business sector, whether greedy or merely inept, push autistic children toward ABA therapy at the expense of other, more effective supports at school that students with disabilities are guaranteed by law. 

Families whose children are referred to ABA by pediatricians and other providers are typically urged by private therapy centers to sign them up for as many hours as possible 鈥� up to 40 hours a week 鈥� and to keep them there for years. That is a prescription ripe for exploitation, says Ari Ne鈥橢man, an assistant professor of health policy and management at Harvard’s T.H. Chan School of Public Health and former director of the Autistic Self-Advocacy Network.  

鈥淧rivate equity was attracted to ABA because the industry as a whole had set up a very tidy financial arrangement for itself,鈥� says Ne鈥橢man. 鈥淚t鈥檚 not that private equity is corrupting a previously fine field. Private equity entered the field because of the flaws that were already there.鈥� 

For fiscal year 2026, federal spending on special education . If the $2 billion now being spent every year on ABA for children with publicly subsidized health insurance were added to schools鈥� annual budgets, every district in the country could add one full-time and one half-time occupational therapist 鈥� specialists in desperate short supply who have proven success in addressing many issues facing autistic children.

DOGE鈥檚 intentions notwithstanding, many in the autism community have hoped the crisis posed by runaway Medicaid spending might present an opportunity to take a hard look at how ABA has grown into an industry with the fiscal might to stave off even basic state and federal oversight. And how it is crowding out more effective, humane alternatives, and even preventing children from going to school.

Instead, now they fear that politics will further overshadow needed autism therapy reforms. The second Trump administration has withheld some $3 billion in Medicaid funding from California and Minnesota, insisting that their governors 鈥� whom the president views as foes 鈥� are not attending to fraud. As a consequence, people with disabilities have already lost services. 

As the Medicaid cuts in Trump鈥檚 One Big Beautiful Bill go into effect, and as he and Health and Human Services Secretary Robert F. Kennedy Jr. continue to promote disproven and dangerous 鈥�cures鈥� for autism 鈥� at the cost of research into better treatments 鈥� disability advocates fear the future will look a lot like a dark past.   

ABA claims vastly outpace spending on autistic people鈥檚 quality of life

In addition to the financial boondoggles, there鈥檚 a human cost. 

During the six years of records we analyzed, Medicaid billing for ABA therapy totaled nearly $7 billion. That鈥檚 $1 billion more than the United States has spent in 20 years on research and programs under the Autism CARES Act, which pays for services to better autistic people鈥檚 lives.   

As disproportionately small as the CARES Act funding is, even after two decades of lobbying by autists and advocates, very little of it is spent on . Of the $2 billion appropriated last year, to be spent over five years, $30 million will go to creating support for caregivers, $13 million to job training and $19 million to safety and well-being.    

Now, even that modest pot of funding is imperiled, as Kennedy is redirecting federal resources toward new research on vaccines and other long-discredited 鈥渃auses鈥� of autism and dangerous, ineffective treatment strategies. 

Meanwhile, is that the most widely used therapy, ABA, is frequently ineffective and . The therapy was pioneered in the 1960s by Norwegian-born UCLA researcher Ole Ivar Lovaas, who used the same regime of rewards and punishments to develop LGBTQ conversion therapy 鈥� now widely acknowledged as abusive.

Independent researchers and autistic adults who went through ABA say its focus on 鈥渆xtinguishing鈥� natural and frequently beneficial autistic traits and in their place demanding compliance with 鈥渘ormal鈥� behaviors is traumatizing. Much as conversion therapy can鈥檛 change a person鈥檚 identity but can instead instill shame, behavior conditioning will not make autists nondisabled and sends the message their strengths are unimportant.

Lovaas is one of two early autism researchers whose histories are now known to include ties to Nazi Germany. In interviews, Lovaas said that during the five-year German occupation of Norway, he and his family were forced to labor on farms. But a 2025 report in the journal History of the Human Sciences documents his role as a local of Norway鈥檚 Nazi youth movement. The Third Reich sought to 鈥�euthanize鈥� autistic people, who were seen as a financial and genetic burden to society.  

The other autism researcher who played a role in the Nazis’ eugenics campaigns was Dr. Hans Asperger, who reported of 鈥渕alformed children鈥� to be targeted for sterilization or death. 

Proponents are quick to assert that today鈥檚 ABA is a far cry from the slaps and electric shocks of what was known as the Lovaas Method early on. Yet the goal 鈥� to 鈥渆xtinguish鈥� autistic traits in children鈥� typically remains. Kids as young as 2 are routinely subjected to as many as 40 hours a week of repetitive behavior modification drills.   

A past 74 investigation found that for years, the evidence used to legitimize ABA was produced by the industry itself, was rife with undisclosed conflicts of interest and neglected basic guardrails such as documentation of harmful 鈥渁dverse events.鈥� By contrast, independent research into ABA by the and academic scholars found little to no evidence of effectiveness.

A of 460 autistic adults and caregivers of autistic children found that nearly half of those who went through ABA showed symptoms of post-traumatic stress, while 72% of those who did not participate in the therapy were asymptomatic.   

, researchers at the University of Wisconsin-Madison, Ohio State University and the University of Texas at Austin found that people who had participated in ABA before age 18 were 30% more likely to experience a mental health hospitalization than autistic people who had not. Autistic people who had been treated with ABA and hospitalized were also admitted with 32% greater frequency than those who had not.   

Again, says Ne鈥橢man, the industry is predicated on a flawed, but very profitable, model. ABA industry recommendations call for every child, regardless of how young they are or what their needs are, to receive the same intensity of treatment.     

鈥淚 would argue that ABA is potentially harmful in any situation because we haven鈥檛 really addressed the ethical concerns of the potential mental health consequences,鈥� says Ne鈥橢man. 鈥淏ut even if we were to set that aside, the idea that there is an evidence base for applying ABA in all instances without regard to any consideration for age or the types of challenges that someone has, it鈥檚 just ludicrous.鈥�

鈥淔orty hours a week of therapy is a full-time job for a 3-year-old,鈥� says Ne鈥橢man. 鈥淚t鈥檚 harmful for kids and families first and foremost, but I also think it鈥檚 a poor use of public funds.鈥� 

When therapy supplants school

The four federal audits of state Medicaid spending show what advocates have long decried: ABA service providers are allowed to keep children in lucrative standalone treatment centers where they are barred by Medicaid law from receiving academic instruction 鈥� often for years after they should begin attending school.

Auditors raised similar concerns in Indiana, flagging the case of a child who was referred to ABA in January 2014 at the age of 2 and was still receiving more than seven hours of therapy a day, five days a week, at age 8 鈥� years after they should have been in school. Medicaid payments for this child increased from $52,000 a year in 2017 to more than $185,000 in 2022, when the child was 11, for a total of $677,448. 

(For perspective, state spending on school-based special education services varies wildly and is poorly reported. One often-used estimate is that an average of $26,000 is spent annually on each student with a disability, versus $9,000 per non-disabled pupil.)     

Special education teachers say that when these students show up in a classroom, it鈥檚 after years of lost academic instruction. In practice, often this means they will be denied the chance to learn alongside their typically developing peers 鈥� a right enshrined in federal law. 

Advocates say the exact number of children in this position is probably unknowable. As a youngster approaches kindergarten age, families are often warned by their ABA provider that taking their child out of private therapy and enrolling them in school will cause regression. Much as homeschoolers often do, these families can sign official documents saying they are taking responsibility for their child鈥檚 education.    

In the case of the Indiana youngster, now 11, auditors noted that the treatment plan did not say whether the child attended school, 鈥渂ut had a standardized statement: 鈥楾he patient鈥檚 family [has] taken on responsibility for meeting the educational needs of this patient.鈥� 鈥� 

After the audit, Indiana lawmakers on how much therapy centers could bill per child, and for how much time. Many children have reached or are near reaching the cap.  

A state task force appointed to address issues likely to follow the changes repeatedly heard from parents and advocates concerned about older children who, no longer eligible for Medicaid-funded ABA, would attend school for the first time. As a result, a new law allows private ABA therapists to accompany children to class for a transition period. 

How did the ABA industry get so big?

For the first 20 years after Lovaas announced he had 鈥渞ecovered鈥� 鈥� his term for cured 鈥� nine of 19 autistic children on whom he had developed ABA, the supposed miracle cure was inaccessible to almost all families. Insurers were not required to cover the diagnosis or treatment of autism.

Then, in 2005, the mother of a 4-year-old autistic boy sat down at her kitchen table and drafted a bill to require health insurers in South Carolina to cover the 鈥済old standard鈥� therapy being touted as a child鈥檚 best shot at a 鈥渘ormal鈥� life. Then she enlisted hundreds of parents of autistic children to lobby state lawmakers to pass it. 

was compelling. To afford ABA, then costing $70,000 a year, she and her husband had downsized their house and spent their home equity 鈥� plus her entire salary as a law professor 鈥� on therapy for their son, Ryan. 

The grassroots push paid off. In 2007, despite ferocious insurance industry opposition, the South Carolina legislature approved the bill 鈥� only to have the governor veto it, with just one day left in the session. 

Unumb put out another call. Accompanied by a CNN camera crew, an army of parents flooded the statehouse, demanding a veto override. 

When the vote was cast, Unumb , the lawmakers on the floor turned toward the families in the gallery and gave them a standing ovation.    

Weeks later, Unumb held a summit to teach other parents, who flew in from around the country, how she had succeeded in getting what鈥檚 known as Ryan鈥檚 Law passed. She spent the next decade working with Autism Speaks, helping to organize families in other states.

The parents had potent lobbying partners. To convince insurers that ABA was not experimental, a growing community of practitioners created an organization, the Behavior Analyst Certification Board, that set standards, bestowed credentials and promoted research. 

The board did not respond to a request for comment.  

Few questioned whether there was an inherent conflict of interest in an industry creating its own proof points. Most people were more focused on the plight of families 鈥� and the promise heralded by a miraculous, if frightfully expensive, cure. By 2019, every state required most private insurers to pay for autism services, though with wildly differing benefit levels. 

The bigger turning point occurred in 2014, when the Obama administration clarified that the Affordable Care Act required publicly subsidized care plans, including Medicaid, to pay for autism treatment. 

At the same time, the rate at which children were identified as autistic began rising dramatically. The ACA for the first time required insurers to pay for autism assessments, and improvements to diagnostic criteria helped to identify autistic children whose traits were previously missed. 

An analysis of special education Child Count data shows that between 2011 and 2022, autism鈥檚 prevalence rose from 2.3 to 6.3 per 1,000 children, with the greatest increases among those aged 5 to 8 years.

Today, Unumb is the CEO of the Council of Autism Service Providers. The organization, she wrote in an email to 社区黑料, 鈥渂elieves ABA providers must continuously earn the public鈥檚 trust in caring for children with autism. Genuine fraud, waste and abuse must be called out and punished to uphold accountability and patient safety.鈥�

鈥淏ad actors exist in every healthcare profession, including ABA, but that doesn鈥檛 mean they are prevalent,鈥� she added. 鈥淭housands of qualified, ethical ABA providers are at work every day, doing the right thing and making a difference in children鈥檚 lives.鈥�

Private equity enters the picture 

Private equity funds are groups of investors who pool their money to buy ownership stakes in privately held companies or real estate. These firms and their deals are subject to far less government oversight than public companies that trade on the stock market. They rarely disclose information about their activity. 

They typically have managers, who make decisions about the businesses they acquire but don鈥檛 put much of their own money into the investments. Frequently, the goal is to simultaneously cut costs and increase revenue to create a cash flow for the investors. The businesses are usually resold within three to five years. 

Over the last two decades, private equity has become increasingly common in healthcare, even though the acquisition of doctor鈥檚 practices, hospitals, medical equipment manufacturers and nursing homes can . In terms of public oversight, though, all those industries are tightly regulated compared to ABA. 

The mandates for insurance coverage of autism were instituted with very little initial oversight of the quality of services being provided. States that did require providers to be licensed often simply decided to recognize the ABA industry鈥檚 internal credentials.

While these standards are often stricter than a provider鈥檚 hiring requirements, the practice of adopting industry credentials leaves behavior analysts in charge of overseeing their own members. When, in the wake of a scathing federal audit of its Medicaid billing practices, Colorado recently moved to license therapists, it rejected a suggestion that a newly created oversight board contain outside professionals such as psychologists. Instead, the board will be composed of four therapists and one public member, who can also have industry ties. 

The combination of lax standards and ready cash proved irresistible to private equity firms, which began buying ABA practices and consolidating them into large, multi-state chains. From 2015 to 2024, private equity firms acquired 574 sites run by 147 providers, according to researchers from the Brown University School of Public Health.

Of the 50 largest providers by Medicaid billing in 社区黑料鈥檚 dataset, 23 are (or, in two cases, were) owned by private equity. From 2019 to 2024, their claims totaled $2 billion. 

Private equity firms own 11 of the top 15, with claims totaling more than $1.5 billion between 2019 and 2024. 

The process has dramatically reshaped an industry already in need of reform 鈥� in the wrong direction. 

鈥淭hey have created massive national chains with the primary purpose of extracting high returns in a short period of time,鈥� write the authors of 鈥�,鈥� a report from the Center for Economic and Policy Research. 鈥淐onsolidation gives private equity-owned provider organizations a large competitive advantage over other for-profit and nonprofit providers, as well those offering other approaches to [autism] services.鈥�

鈥淚t also gives them more bargaining power to negotiate higher rates for themselves vis-脿-vis state agencies, regulators and insurance payers. Some PE firms have used this leverage to extract higher reimbursements under threat of closing down sites in states in which they do not get the rates they prefer.鈥�

Many of the large networks also advertise immediate openings for autism assessments, which they tout as a quick path to enrolling in therapy. Otherwise, according to the National Institutes for Health, the median time a family spends on a wait list for an independent evaluation is a year and a half. 

How private equity works

Some private equity funds take a partial ownership stake in a business that needs cash to expand or improve. But most of those investing in autism therapy are typically buyout funds, which acquire and consolidate existing businesses.

These funds’ managers invest very little of their own money, maybe 1% or 2% of the total. Investors, which often include pension funds and other institutions, put in another 30% to 50%. The rest of the cost of the acquisition is borrowed 鈥� what鈥檚 referred to as a leveraged buyout.

To make these transactions, a fund sets up a series of companies. Responsibility for the debt is transferred to the company being acquired. 

As the purchased company struggles to make the loan payments, a share of the cash coming in is returned to the investors. Sometimes, the fund managers take out loans on the already indebted business and give the cash to their investors as a dividend.   

Meanwhile, the leaders of the investment fund 鈥� whose expertise is typically in maximizing profits 鈥� are allowed to make decisions about staffing, levels of patient care, who they will serve and where. 

ABA is supposed to be highly individualized, with therapists continually collecting data on children鈥檚 responses to repeated efforts to get them to stop behaviors deemed undesirable, such as hand-flapping or rocking, or to perform actions the therapist wants, like making eye contact. 

This information, gathered by the lowest-rung member of the ABA team, a behavior technician, is supposed to be reviewed by a credentialed provider known as a board-certified behavior analyst, who uses it to modify the child鈥檚 treatment plan on a regular basis.       

But in state audits, federal investigators found repeated instances where the therapists鈥� notes submitted as claims documentation had been copied and pasted, often day after day, bearing the names of numerous different children working with different therapists.

Notes were often signed off by therapists before they had finished the session in question, and Medicaid was frequently billed for unallowable activities, such as naps and lunch.   

For their 2023 report on private equity鈥檚 influence on ABA, investigators at the Center for Economic and Policy Research interviewed former employees of one of the oldest therapy center networks, the Centers for Autism and Related Disorders, or CARD. Founded by one of Lovaas鈥� graduate students, the chain was sold to the private equity group Blackstone in 2018 for a reported $700 million.  

The former employees said that under Blackstone鈥檚 management, they were told to prioritize younger children. Not only can smaller kids remain enrolled for several years before reaching school age, they are most likely to be referred for additional hours of therapy per week under the guise of early intervention. 

鈥淭hey would literally terminate patients in our programs who required lower hours and replace them with those requiring at least 30 to 40,鈥� the researchers quoted one former employee as saying.

CARD did not respond to requests for comment. In a statement to 社区黑料, Blackstone said the network of centers was hit by a 鈥減erfect storm鈥� of COVID-19-era lockdowns, labor shortages and low insurance reimbursement rates that led to a Chapter 11 restructuring. 

鈥淲hen it became clear that a restructuring was necessary to put the company on the best long-term path to deliver on its mission, we worked day and night 鈥� to keep its existing facilities open so the company could continue serving patients,鈥� the statement says.

The statement adds that Blackstone was never involved in specific clinical treatment decisions and had sought to increase pay, reduce caseloads and improve training and operations. 

If an individual center or an entire network is accused of fraud or found to have abused patients, the investment managers who made decisions to maximize profit can鈥檛 be held accountable. Just like the debt, liability accrues to the 鈥減ortfolio company鈥� that owns the actual centers.  

By 2022, CARD had in states with lower Medicaid reimbursement rates and made that put others out of business, shrinking from 250 centers to 100. In June 2023, it filed for bankruptcy and was bought by a group of private investors recruited by its founder.

According to 社区黑料鈥檚 dataset, in 2019, CARD billed Medicaid more than $13 million. In 2024, its Medicaid receipts were slightly less than $2 million.

Private equity鈥檚 structure shields investors and ABA network owners from liability

With corporate headquarters in Farmington, Michigan, Centria Healthcare was founded in 2009 as a pediatric nursing provider. When one of its early patients needed ABA, the company created an autism-focused division. Today, it owns centers in 11 states. 

Because the company is privately owned, its finances are largely shrouded in secrecy. But, according to the investor intelligence service Pitchbook and data gathered for the Center for Economic and Policy Research, Centria was purchased in 2016 by Martis Capital, a private equity firm specializing in acquiring North American healthcare providers. Over the next three years, Centria expanded to nine states. 

As part of a 2018 , the Detroit Free Press reported that Michigan鈥檚 attorney general was looking into claims that Centria had engaged in improper billing and service provision. The story was based on interviews with former company executives, documents obtained by reporters and allegations detailed in a defamation lawsuit the company filed against some of the past employees. 

The paper also reported that two Michigan counties had after local mental health officials cited the company for billing and care issues and an employee was abusing a child. 

Martis Capital did not respond to a request for comment.  

In a statement to the newspaper, Centria CEO Scott Barry vigorously denied the claims: “Whatever these allegations are, yes, they’re very outrageous, but they’re not true. And we’re trying to do a good job to help kids and help families and help our community.”

At the time, the company was in line for an $8 million job-creation grant secured with the backing of the state鈥檚 lieutenant governor, described by the Free Press as a longtime advocate of autism therapy. Five weeks after then-Lt. Gov. Brian Calley made the recommendation, a key company investor hosted a party kicking off Calley鈥檚 gubernatorial bid. Guests donated more than $100,000 to his campaign, the paper reported.      

The grant was put on hold while the state investigation unfolded. In March 2019, the state closed the probe, saying that while it had noted potential billing irregularities, there wasn鈥檛 enough evidence to merit criminal complaints. The grant was not reissued. 

Three former executives later sued Centria, resurfacing their allegations. Both lawsuits were eventually dismissed by the parties.

In a statement to 社区黑料, Centria CEO David Harbour said the company focuses on quality and access.

鈥淥ur work is grounded in a commitment to ethical care, clinical quality and supporting children with complex needs 鈥� including families who may have struggled to find services elsewhere,鈥� Harbour wrote. 鈥淲e strive to identify the needs of children, families and the broader healthcare system as it continues to evolve 鈥� delivering ethical, individualized care that supports the unique needs of each child and family we serve.”

But Centria doesn鈥檛 have to report whether the scandals had any impact on its bottom line. 

鈥淸Private equity firms] have nothing to lose if something goes bankrupt,鈥� says Rosemary Batt, one of the authors of the Center for Economic and Policy Research report and a professor emeritus at the Industrial and Labor Relations School at Cornell University. 鈥淚f a company gets caught in fraud, it鈥檚 just the cost of doing business.鈥�

In 2019, Centria was sold to a different private equity fund, Thomas H. Lee Partners, for $415 million. Since then, according to 社区黑料鈥檚 analysis, the company has been the country鈥檚 largest Medicaid biller, bringing in more than $440 million during our six-year window. That鈥檚 more than twice as much as the second-largest ABA company by Medicaid revenue, Lighthouse.

Thomas H. Lee did not respond to a request for comment. 

Ryan Leitner, a researcher at the Private Equity Stakeholder Project and the author of a on the ABA industry, worries that states鈥� efforts to crack down on Medicaid abuses won鈥檛 address the underlying cycle that allows investment funds to pass off a business that they鈥檝e saddled with problems.      

鈥淎 great place to start is the concept of joint liability between these [investment] firms and the company that they own and operate,鈥� says Leitner. 鈥淵ou need to have assurances that the care is going to meet some kind of benchmark, that there’s going to be some kind of joint liability if there is a problem.鈥�   

Some states, he adds, are trying to give their attorney general or another regulator the ability to stop the sale of a healthcare facility if they determine the company won鈥檛 run it properly or if a private equity firm has problems elsewhere. 

Private equity providers gravitate toward high-reimbursement states 

Writing in the January 2026 issue of the American Medical Association journal JAMA Pediatrics, a group of researchers , one showing the prevalence of children with autism diagnoses and the other assigning states 鈥済enerosity scores鈥� assessing their insurance rules regarding autism. 

Using a commercial deal tracker, they identified 574 autism service delivery sites acquired by private equity between 2015 and 2024, which they overlaid on the maps. The upshot: The states with the highest rates of diagnosis and the most generous benefits have the largest concentration of private equity-owned ABA centers. 

Home to some of the first acquisitions, Colorado, with 6 million residents, had 38 private equity-owned centers, the third-largest concentration in the country and a likely undercount, the researchers noted. Only California, home to more than 39 million people, and Texas, which has 32 million residents, had more private equity-owned ABA centers 鈥� 97 and 81, respectively. 

In February, the Department of Health and Human Services’ Office of the Inspector General released the fourth of eight state audits, finding that Colorado鈥檚 Medicaid spending on ABA mushroomed from $60 million in 2019 to $163.5 million in 2023. 

The auditors examined claims made in 2022 and 2023, finding at least $78 million in improper payments, plus an estimated $207 million in 鈥減otentially inappropriate鈥� claims. 

In Wisconsin, they found $18 million in improper payments in 2021 and 2022, plus $94 million more in potentially inappropriate payments. In Maine in 2023, $45 million in claims were improper and $22 million potentially so. In Indiana, a total of $56 million were improper in 2019 and 2020, with another $76 million potentially improper.

In Colorado, the investigators examined monthly billing records for 100 children, finding improper and potentially improper claims in every case. Seven facilities could not supply individual patients鈥� diagnoses or referrals.

Two providers 鈥� including one that auditors said 鈥渨as purchased by a nationwide ABA company that subsequently closed all of its ABA facilities in Colorado鈥� 鈥� did not respond to requests for records from state and local investigators. 

In the 96 months auditors examined, providers didn鈥檛 describe the services in some claims; four providers didn鈥檛 submit any treatment notes at all. One facility routinely said a child had engaged with peers even though the therapy was delivered at home with no other children present.          

Numerous bills described unallowed 鈥渃ustodial care,鈥� such as bathing, dressing and eating. In 67 months, facilities billed for one-to-one therapy but described group activities. 

ABA companies in Colorado

In May, the Colorado General Assembly took up legislation aimed at . At an , state officials testified that they believed there were between 410 and 500 clinics but could not say with precision because, unlike day cares, summer camps and similar facilities, autism therapy centers are not required to register with the state.  

In 2025 alone, officials received 35 reports of endangerment, including physical abuse by staff, medication mistakes, inappropriate restraint and a registered sex offender working at one center. But because ABA providers and facilities are unregulated, the state lacked jurisdiction to investigate. 

It might be the tip of the iceberg, the state officials warned lawmakers, because many participants can鈥檛 tell their families when something is wrong. At least a third of Colorado children in ABA are nonverbal, and more than 18% are age 3 or younger. 

The bill would create a behavior analyst licensing board and require the state Department of Human Services to craft standards for clinics. The board would consist of three credentialed behavior analysts, one assistant 鈥� or technician 鈥� and one member of the public. It would grant licenses to people who have been given credentials by organizations created by the ABA therapists associations.

To proponents of ABA, many of whom have nursed concerns that private equity is sullying the public profile of their industry, the bill was a huge win. But to many in the disability community, it was one more step in the wrong direction. They feared that new standards would enshrine a treatment they oppose, crowding out public support for alternatives that may be more effective and humane.       

Two parents submitted imploring legislators to oppose or amend the bill. Both cited ABA’s eugenicist roots and research on its harms.  

鈥淎utistic adults often compare ABA to gay conversion therapy, because the goal is often to make autistics appear less autistic, rather than helping them live safely and comfortably as themselves,鈥� wrote Boulder parent Jenny Thamer. 鈥淚n fact, both practices were developed by the same founder.鈥�

Among other changes, she asked lawmakers to appoint a licensed mental health professional and an autistic adult 鈥渨ho provides lived experience鈥� in place of two of the three analysts on the board; to require discipline for practitioners who engage in harmful punishments, including physical restraint and seclusion 鈥� mostly outlawed in Colorado schools 鈥� and to remove references in the bill to ABA as 鈥渂ased on scientific research.鈥�

鈥淭his bill will have lasting consequences for autistics for decades,鈥� Thamer concluded. 鈥淚 respectfully urge you not to expand this system without strong protections, independent oversight and meaningful representation from the autistic people most often harmed by these practices.鈥�

On June 2, Gov. Jared Polis signed the bill without her recommended changes. 

Graphic design by Eamonn Fitzmaurice

This investigation was produced with support from the Education Writers Association Reporting Fellowship program.

Jenny Thamer had low hopes for the meeting called by the superintendent of the Boulder Valley School District to hear from families of autistic students.

From her experience, such so-called listening sessions are often pro forma events, staged more to assuage parents than to actually brainstorm change. 

This one had been called hastily, after a handful of caregivers had complained about persistent problems in their children’s classrooms. 

The meeting was scheduled for the day after Memorial Day, after the end of the Colorado district’s 2022-23 school year. Many families would likely have already left town for summer vacation. 

Worried no one would show up, Thamer and a couple other parents put together an anonymous online survey they could present if attendance was low. 

They need not have feared. Some 50 district parents came, cautiously optimistic that Superintendent Rob Anderson would hear their pain. 

鈥淚 have to give him credit,鈥� says Thamer. 鈥淗e listened to every single caregiver story without interrupting, without rushing people. Like, he was there for it.鈥�

The meeting was scheduled to last an hour, but went on for more than four, as families described repeated phone calls from school staffers demanding they pick up their child midday, kids too anxious to go to school, trauma caused by punishments 鈥� and, in nearly every case, schools鈥� lack of interest in parents鈥� ideas.

As it happened, Anderson鈥檚 own child received special education services. 鈥淚 could understand not just in a way a superintendent could understand,鈥� he recalls, 鈥渂ut as a parent could.鈥� 

While people talked, administrators and the school board president took notes on poster-sized pads stuck to the walls. At the end of the meeting, the parents presented the leaders with the results of their survey, which drew 65 responses.

Anderson listened. And then he promised to create an autism advisory team made up of parents, community members and staff with a goal of using feedback from autistic people 鈥� who usually are not consulted about their own conditions 鈥� to change the district鈥檚 approaches. Thamer, whose child received special education services, was asked to co-chair the team. 

A year later, Boulder Valley implemented what is likely the nation’s first 鈥� and only 鈥� neurodiversity policy. Adopted by the school board in 2024, it commits district schools to using 鈥渟trategies to affirm a student’s identity, rather than trying to 鈥榝ix鈥� or 鈥榗ure鈥� them.鈥� The policy applies to all kids, not just autists. 

It鈥檚 a work in progress 鈥� in part because the policy calls for a sea change in how Boulder schools have approached educating autistic students. Intending to provide good services, the district 鈥� like a handful of mostly affluent school systems across the country 鈥� had invested heavily in hiring practitioners of an intervention called applied behavior analysis. 

Commonly referred to as ABA, the therapy was pioneered in the 1960s by Ole Ivar Lovaas, the UCLA psychologist who created LGBTQ conversion therapy. Both use a system of rewards and punishments to condition a person to act and appear 鈥渘ormal.鈥� Lovaas’ approach was quickly recognized as a human rights violation when applied to LGBTQ people, but not to autistic kids.

Lovaas did not see autistic children as fully human, which he believed justified using electric shocks, slaps and the withholding of food, among other 鈥渁versives,鈥� to 鈥渆xtinguish鈥� atypical behaviors. In a trial now regarded as dangerously flawed, he claimed to have 鈥渞ecovered鈥� 鈥� cured 鈥� nine of 19 children by subjecting them to repeated 1-on-1 drills for up to 40 hours a week.

The Lovaas Method, as ABA was originally known, is now considered the gold-standard autism intervention. Parents are typically urged to enroll their children as quickly as possible after diagnosis, as young as 2, to give them their best shot at a 鈥渘ormal鈥� life.  

Over the last decade, as laws were enacted requiring insurance coverage of autism diagnosis and therapy, the rate at which children have been identified as autistic has tripled. To serve them, a very profitable and largely unregulated treatment industry has mushroomed, pulling in nearly $2 billion a year from Medicaid alone.     

For-profit ABA is particularly strong in Colorado, in large part because of the state鈥檚 history of offering relatively generous benefits for people with disabilities. Because of ABA’s dominance 鈥� and the accompanying perception that it is the most effective way of treating autistic children 鈥� school districts are increasingly turning to practitioners to staff their special education programs, whether or not it is the proper approach for a particular child.      

Modern practitioners defend the intervention, saying ABA no longer subjects children to physical punishment. Yet documentation of its harms is mounting, as researchers 鈥� including autistic adults who underwent ABA as youngsters 鈥� gather evidence that the therapy has caused widespread PTSD. Autistic children may no longer be subjected to electric shocks or slaps to the face 鈥� and the word “aversive” may sound kinder than “punishment” 鈥� but they are routinely denied food, toys and comfort items, as well as adult attention, a strategy practitioners industrywide call 鈥�.鈥� ABA providers still frequently restrain children or confine them in isolation 鈥� practices recognized as so dangerous and traumatic as to be illegal in most circumstances in Colorado schools.

At the listening session, Thamer presented the superintendent with the results of the survey, which echoed what he had heard from parents in person. One-fourth felt the need to shorten their child鈥檚 school day because teachers could not provide a full day鈥檚 support, and nearly half had unenrolled or considered withdrawing their children. 

One-third of respondents said they had been asked to pick their kids up early from school for behavioral reasons 鈥� some frequently. A fourth said their children had been excluded from field trips and other activities. And 13% had out-of-school suspensions and 9% in-school suspensions.

Some 16% were aware their child had been subject to physical restraint or seclusion 鈥� likely a wild undercount, given the number of parents at the in-person meeting who said their kids were restrained several times a week. Historically, Colorado did not require schools to report restraint until two years ago, and still doesn鈥檛 mandate data collection on seclusion. 

More than 40% said schools focused on fixing behavior rather than uncovering the reasons for it; paid more attention to students’ 鈥渓agging neurotypical skills鈥� than to their capabilities; and used inappropriate instruction strategies. 

The families鈥� experiences were common, but the opportunity to share and be believed was novel, says Thamer. Many of the caregivers at the listening session were meeting one another for the first time. Many had assumed they were alone in rejecting guidance from the district鈥檚 supposed experts, or that no one would believe the 鈥済old standard鈥� in treatment was actually making things worse for their children. 

Just sitting in a room with so many other people sharing the same experiences was cathartic. 鈥淚 had tears hearing other people’s stories,鈥� Thamer says. 鈥淧arents carry a lot of trauma from advocating for their kids.鈥�

‘Daddy, help! Daddyyyy!’ 

One of the parents present was Sarah Piril盲. In 2019, she had come home from work to hear her 5-year-old screaming in the basement. He was working with two technicians from a local private ABA center who, in an effort to stop a meltdown, had barricaded him in a room and turned their backs on him.  

This was not a new experience for P, who is being referred to by his first initial to protect his privacy. He had been through this rewards-and-aversives cycle at home, in private childcare centers 鈥� which were quick to show the family the door 鈥� and even public school-based early childhood education. As he got bigger, so did his meltdowns.          

But on this day, Piril盲 says, she heard something very different in P鈥檚 screams. 

鈥淒addy, help,鈥� he shrieked. 鈥淒addyyyy!鈥� 

She bolted down the stairs and instantly recognized that her son wasn鈥檛 being stubborn. He was terrified.

A series of realizations crystalized in an instant, she recalls. P was being punished, over and over, for not understanding what was expected of him.

In the process, he had learned to fear interactions where he could become overwhelmed and lose control. And his parents, whom he needed to keep him safe, had invited the people meting out the punishment into his life.

In schools, isolating or confining children is known as seclusion and restraint. The psychological and physical harms are . Most states have laws limiting the practices to rare episodes in which students pose an immediate threat to themselves or others.  

Yet P鈥檚 therapists were using the tactic on purpose, in the belief that after enough repetitions 鈥� delivered under the guise of benign therapy 鈥� it would 鈥渆xtinguish鈥� some of the boy鈥檚 autistic traits.

On the surface, the goal seems perfectly rational: Grownups were trying to teach P that following instructions brings rewards. But when he didn鈥檛 comply, they鈥檇 double down, sensing defiance. The stricter the adult, the more dysregulated the child鈥檚 response. 

Piril盲 knew ABA practitioners often describe the moment she was witnessing as an 鈥渆xtinguishment burst鈥� 鈥� a last willful attempt by children to get their way by ratcheting up negative behavior. If she went to P鈥檚 aid, in the therapists鈥� eyes, she would be guilty of setting back their hard work.   

She faced a horrible dilemma: follow the therapists’ advice and let the moment play out, or listen to her gut and defy experts who could document her poor judgment in a file with P鈥檚 name on it.  

In the moment, she chose her son, scooping him up and letting him cry.

She had no way of knowing how hard it would be, even after telling the boy鈥檚 private therapists she would no longer tolerate ABA鈥檚 strategies, to keep P out of the therapy. 

Over the next seven years, the district would move him to five schools, not counting distance learning during COVID and a year when P was so traumatized that Piril盲 homeschooled him. In all but one of the schools, he was subjected to ABA.

But she had an unlikely ally. The behavior technician who had stood nose-to-nose with Piril盲 in her basement is a man named Blake Ross. And that confrontation marked a watershed moment for him, too.

The core epiphany Piril盲 had during the episode was that P鈥檚 meltdown had been perceived by the adults as a choice, when in fact it was an involuntary stress response 鈥� the fight-or-flight instinct that鈥檚 a normal part of the human nervous system. Everyone has it, but it鈥檚 especially easy to trigger in a child with an acutely sensitive neurotype. 

Ross adored P. He was devastated to realize the boy was scared of him. 鈥淭here are protocols for stuff like this,鈥� he recalls. 鈥淲e were following them, and it was making things worse.鈥�

In the ensuing weeks, Ross and Piril盲 came to an understanding. The family couldn鈥檛 meet the boy鈥檚 needs alone, and Ross was committed to finding a better way to help. Together, they started trying to understand how entrenched P鈥檚 fight-or-flight responses were, and what would happen if they developed strategies to help his nervous system avoid that traumatic response. 

Things really clicked during third grade when, with help from Ross, Piril盲 started homeschooling P mid-year. With their strategies finally working, the following year Piril盲 searched for a classroom where the adults would try what she called 鈥渘euro-informed accommodations.鈥�   

In the meantime, seeking the flexibility to use their new approach with other kids, Ross and his wife, Jenn Snow, also an ABA provider, had started their own autism therapy practice. They met with Piril盲 and the members of P鈥檚 prospective school special educators to talk about their work.  

鈥淟uckily, we found a team that would actually try it,鈥� says Snow. 鈥淎nd to magnificent effect.鈥�

A data-minded mom literally charts a new course

Before she quit her job to manage P鈥檚 needs, Piril盲 was an engineer and data strategist. Both ABA and special education are supposed to be data-driven. The theory behind ABA 鈥� the analysis being applied, as it were 鈥� is that therapists record a child鈥檚 responses to behavioral drills, routines and tasks, and then use the information to refine their tactics.

An individualized education program, the legal document that spells out how special education will meet a child’s needs, is also supposed to contain quantifiable goals and measures of progress, as well as information on behavior, adult time spent delivering services and the amount of time the student spends in a segregated classroom rather than integrated with typically developing peers. 

All special education parents quickly accumulate boxes of IEP-related documents, but Piril盲 had more: reports P鈥檚 schools sent home when he was physically restrained or isolated, forms announcing he had been suspended and messages asking her to come pick him up early. 

Because P, like many autistic kids, often refused to go to school, Piril盲 tracked his attendance. She also recorded how often he met the school鈥檚 behavior goals, his reading and writing achievement, how much time he spent in different classrooms and how many special ed services he received. 

In January 2025, after P had been enrolled in a new district school willing to work with her ideas, Piril盲 put 340 pages of IEPs and other documents 鈥� 4,000 data points collected over eight years 鈥� into a database. The results were striking.

When P was being treated with ABA, he achieved the school鈥檚 behavioral goals 25% to 50% of the time. When he was in a classroom where the adults were willing to try Piril盲鈥檚 neuro-informed strategies, his success rate was 75% to 100%.

When he was allowed to spend fewer hours and days in the school environment, his attendance actually stabilized 鈥� and his reading and writing scores shot up. As P鈥檚 fight-or-flight episodes subsided, he grew more willing to work on his least-favored tasks. As adults listened to him when he advocated for himself, he spoke more frequently.  

Piril盲 created a presentation for P鈥檚 teachers and aides, with two dozen charts showing how his IEP and ABA interventions fluctuated in effectiveness. There was a one-year window 鈥� labeled 鈥渁utistic burnout鈥� 鈥� when P was restrained 20 times, sent home another 20 times and suspended three times. 

But there were also slides listing which specific, neuro-informed strategies were in place when things were going really well: 鈥淧hysical management is to be avoided entirely鈥�; 鈥淧roactive is better than reactive鈥�; 鈥淧鈥檚 words must work or he will stop using them鈥�; 鈥淔lexibility from you = flexibility from P.鈥�

At the start of the last school year, the boy鈥檚 teachers stopped pushing ABA, Piril盲 says. But when she gave them a draft IEP written from a nervous system response lens, the educators in charge of the planning process rejected it.

Everybody on the IEP team agreed with the support plan, she says. But one team member, an ABA practitioner employed by the district, said they needed to rework it to conform with ABA鈥檚 structure. 

In Boulder Valley classrooms, what that has historically meant is that when a student exhibits a problematic behavior, educators must create a hypothesis for why it鈥檚 occurring. These hypotheses assume the child is choosing to misbehave, e.g., to get attention or to avoid an activity they don鈥檛 like. Then the therapists and teachers create goals that outline the steps of an ABA strategy for addressing the student’s actions.

鈥淭he [lead therapist] said the way I wrote it from a nervous system response perspective was much more helpful,鈥� says Piril盲. 鈥淏ut then [she] also said that she can鈥檛 use that structure, that she wasn鈥檛 able to structure an alternative path for families like mine that specifically request non-ABA approaches.鈥�  

The format of a support plan may seem like a small thing to someone who has not struggled to get their child an atypical IEP, Piril盲 says. But to her, it suggests the adults in the district are not ready to step away from something that鈥檚 not working.  

A shaky substitute for real special ed       

In 2022, the Colorado General Assembly took up a bill to allow families to request an ABA therapist of their choosing be allowed to accompany their child to school. Legislators ended up passing a dramatically amended law requiring districts to have a policy addressing the question. 

The debate, however, revealed that much of the time, schools and families were using private ABA therapy to make up for gaps in special education, childcare and disability services writ large 鈥� something also highlighted in federal audits of Medicaid spending in Colorado and several other states.   

Many of the therapists and industry representatives testified that their clients didn鈥檛 have time for both ABA and school, attended schools that had declared students鈥� needs too profound to manage or said that because they were understaffed, they could support autistic students for only a few hours a day. 

The parents who urged passage of the bill said they needed ABA to close a caregiving gap. Several said schools and preschools were quick to demand they pick their kids up midday 鈥� sometimes threatening to call the police if they didn鈥檛.

鈥淪chools are happy to abbreviate their day and make this someone else鈥檚 problem,鈥� said one. 鈥淎nd I just don鈥檛 think that鈥檚 right.鈥� 

Other parents said their kids were behind academically because they split their time between a therapy center and school. 

A lack of school staff with autism expertise and of out-of-school caregiving options for families are real problems, says Julie Reiskin, co-executive director of the Colorado Cross-Disability Coalition. But behavioral therapy is not intended to address those problems. 

鈥淲e need to have childcare and schools that are not calling parents, that can keep their kid through the whole day,鈥� she says. 鈥淏ut if that’s the need, then that’s what we should be funding, not one specific kind of therapy. 

鈥淲e could do it for a lot less money than this,鈥� adds Reiskin. 鈥淎nd maybe the kids will also be having more fun.鈥� 

Lindsey Trott told lawmakers there are more effective methods for helping students than ABA, but that schools lack the resources to use them. She鈥檚 now an occupational therapist, but as a teenager in the late 1990s, she was hired by a family that was implementing the Lovaas Method in their home with their nonverbal 4-year-old.

For 10 months, three days a week after school, Trott said in an interview with 社区黑料, she would sit with the boy and perform what are known in ABA as 鈥渄iscrete trials鈥� 鈥� repetitive drills of tasks like making eye contact or copying a structure made of blocks. She rewarded his compliance with a fruit snack or a cartoon break.

鈥淎fter a couple of months of working with me, when I would show up at the door, he would cry and run away,鈥� says Trott. 鈥淗e made no progress.鈥� 

In hindsight, what she thinks the family really needed was respite care. 鈥淎t the end, I felt more like I was there supporting the mom,鈥�  she recalls. 鈥淚 would stay and she would tell me things. She was sad and frustrated.鈥�        

That experience was a catalyst. In search of solutions, Trott went on to earn a master’s degree in special education and then two degrees in occupational therapy. When she was training, she shadowed a veteran OT, as the specialists are typically referred to in schools. 

They drove to several small gyms, where the experienced OT stood alongside kids doing simple gymnastics, talking to them about what they were doing. 

鈥淔or the first time, I saw nonverbal kids having fun,鈥� says Trott. 鈥淎nd I felt something about what I was seeing.鈥� 

All people regulate their emotions or nervous systems by what鈥檚 known as 鈥渟timming鈥� 鈥� making repetitive motions or noises. In contrast to things neurotypical people do unconsciously, like twisting a strand of hair, autistic peoples鈥� stims can be dramatic, such as pacing or rocking. Schools and therapists often attempt to stop stims.  

Occupational therapy鈥檚 descriptions of this are much closer to Piril盲鈥檚 ideas about the nervous system than to ABA鈥檚 concepts. Proprioceptive input 鈥� what OT refers to as 鈥渉eavy work,鈥� like jumping or other activities that engage muscles 鈥�  calms nerves and enables self-regulation. Vestibular input 鈥� sensory information the brain receives from the inner ear when a person swings or spins, among other motions 鈥� facilitates balance and movement.

If schools taught children about their nervous systems, lots of students鈥� needs would be met, not just the autistic kids鈥�, Trott believes: 鈥淚f we had a special ed teacher for every grade level and we had an OT for every campus, schools could look very different.鈥�

A 74 analysis of Medicaid billing claims revealed that spending on ABA just for children with this public, safety net healthcare now totals $2 billion a year. If that money were added to schools鈥� annual budgets, every district in the country could add one full time and one half-time occupational therapist. 

Neurodiversity training goes only so far

One of the first things Boulder Valley leaders did with the input from its Autism Advisory Team was to put together mandatory neurodiversity training for every staff member in the district. 

In a departure from typical practice, a training video was created using input from community members, says Michelle Brenner, director of special education for the district. Two of the four presenters in the video are autistic. Trainers emphasize that understanding what it means to be neurodiversity-affirming is good for everyone. 

The with a discussion of fight-or-flight and other autistic behaviors, which appear when a student feels physically unsafe or 鈥� something that is much harder for a neurotypical person to anticipate 鈥� socially unsafe.

鈥淲hen a student engages in those behaviors, often they are trying to tell us, 鈥業 feel unsafe all the time,鈥� 鈥� explains a speech-language pathologist. 鈥淭hat is the autistic experience.鈥� 

Then, an autistic high school teacher, Wren Roberts, describes what it is like to go through life in a state of hyperarousal. Indeed, she confesses that she feels unsafe talking on camera. 

鈥淚 have spent my entire life learning to hide it,鈥� she explains. 鈥淭hat鈥檚 called masking.鈥� 

Just as existing with a continually activated nervous system causes mental health issues, she notes that autistic people who mask experience high rates of depression, anxiety, insomnia and suicidal ideation.  

Up next in the video, an autistic man who volunteers in a district afterschool program outlines how a neurotypical person can figure out whether a student is feeling unsafe, and why. Finally, a high school teacher reminds the audience that while this cycle is often pronounced for autists, 鈥淥ther students are likely feeling the same way.鈥� 

As progressive as this seems compared with most other districts鈥� approaches, the mandatory training was relatively simple, says Shannon Gamble, Boulder Valley鈥檚 director of multi-tiered systems of support. Her specialty is differing strategies that are used to help students struggling with literacy or other skills.  

District leaders have created an internal data dashboard tracking how often students are restrained, how many are restrained repeatedly, whether teachers and therapists have looked for the 鈥渞oot causes鈥� of repeated problems and other indications that changes are being implemented and whether they are working. 

The training is a start, Gamble says. 鈥淎 big part of what needs to shift is mindset and understanding, and the way that we view each other and our students.鈥� 

Some families want their children to continue to receive ABA in school. But to others, who continue to push against it, the pace of change can feel glacial, they say.

鈥淥ur families come in and they’re like, ‘All right, why don’t you just go tell people to do this thing?’ ” says Gamble. “There’s things we can do right away. We can change [the language on] a form, right?鈥�  

Altering mindsets is a longer-term proposition, she continues: 鈥淚t’s going to take more than us just telling people what to do 鈥� especially things like neurodiversity, where many of our educators were taught in a way that maybe is not what our neurodiversity philosophy is telling them we believe.鈥�

Because district leaders had invested in what they thought was the best intervention for students, a number of the people leading its special education efforts hold some of ABA鈥檚 highest credentials. The persistence of their beliefs is visible in district materials.  

For example, families point to an educator training created more than a year after adoption of the neurodiversity policy that makes numerous rewards-and-consequences recommendations even as it acknowledges trauma鈥檚 role in children鈥檚 behavior. Forms distributed to classroom aides have grids for charting ABA interventions.    

A outlining the neurodiversity policy and resources also links to that outlines Boulder Valley’s ABA strategies: 鈥淭he behavior analyst is responsible for the implementation of skill acquisition and behavior support strategies aligned with current best practices from the field of applied behavior analysis (ABA) as well as responsibilities and duties within the school special education collaborative team.鈥�

Restraint and seclusion

In 2022, the U.S. Department of Education to avoid restraining and isolating students with disabilities unless a child鈥檚 behavior poses 鈥渋mminent danger of serious physical harm to themselves or others.鈥� Not only are the practices dangerous and abusive, it said, but there is no evidence they help modify disability-related behaviors. 

They are also discriminatory, the agency warned. Students with disabilities are three times more likely to be physically restrained or confined than their non-disabled classmates. Often, they face discipline because they lack proper services. 

In practice, however, it is devilishly difficult to get schools to move away from restraint and seclusion. Over the last couple of years, in several states that of even just preschoolers and early elementary age children, education administrators have lobbied statehouses to repeal the bans.  

Disability advocates push back, saying schools need to do more to support educators who are left without effective alternatives. As a result, when seclusion is prohibited, schools often simply rebrand the spaces where children are confined as time-out rooms. 

How does Boulder Valley stack up? 

Brenner and Gamble say the district鈥檚 internal data shows small improvements since the adoption of the neurodiversity policy, including a 鈥渟light reduction鈥� in the number of autistic students who are repeatedly restrained and secluded and a dramatic drop in the number subjected to formal threat evaluations under Colorado鈥檚 school safety protocol.

But in terms of collecting data on restraint, Colorado鈥檚 history is tangled. The state鈥檚 first restrictions on when a child could be physically controlled were intended to address solitary confinement and punishment in juvenile detention centers. 

The practices were supposed to be rare in schools, but the state didn鈥檛 collect any data that would allow it to measure compliance. In 2022, the Colorado General Assembly passed a law requiring districts to begin reporting by the end of the 2024 school year. 

It did not, however, address seclusion as a specific form of restraint 鈥� which all but a handful of districts interpreted as a mandate to report only episodes when a child was physically or mechanically controlled. Legislators rejected a 2025 attempt to clarify the law.

For the 2024-25 academic year, Boulder Valley told the state it physically restrained just 42 students. It did, however, of 鈥渄etrimental behavior鈥� 鈥� conduct that has a negative impact on the welfare or safety of other students or staff 鈥斕齛mong children with disabilities. Students with IEPs make up 15% of the district鈥檚 student body, but comprise one-third of those disciplined.听

While ABA practitioners鈥� stances vary, they often don鈥檛 think they are restraining a child but rather 鈥� much as took place in Piril盲鈥檚 basement 鈥� believe they are engaging in a therapeutic strategy that is to the child鈥檚 benefit.   

In 2010, the Association for Behavior Analysis International opposing 鈥渋nappropriate鈥� restraint and seclusion but supporting the interventions when used by practitioners as part of a formal plan: 鈥淲hen used in the context of a behavior intervention plan, restraint in some cases serves both a protective and a therapeutic function. These procedures can reduce risks of injury and can facilitate learning opportunities that support appropriate behavior.鈥�

In May 2025, 社区黑料 reported that the Arizona Autism Charter Schools 鈥� a network of ABA schools whose founder was chosen by President Donald Trump to oversee special education 鈥� restrained and secluded students at unusually high rates even though state law restricted the practice to emergencies.    

Often, when autistic children are sent to 鈥渂lue zones鈥� or 鈥渃ool-down corners,鈥� schools fail to see and report it as seclusion. The distinction that鈥檚 lost: a space students can retreat to of their own volition when overwhelmed 鈥� and leave when calmer 鈥� is different from seclusion.

The fact that the district has adopted a neurodiversity policy but also proclaims ABA will remain in place infuriates Piril盲. If you ask her, there鈥檚 no reason state and local officials can鈥檛 do their own version of her analysis of which strategies contributed to P鈥檚 dysregulation and which enabled him to stay calm and engaged. They鈥檙e just choosing not to.  

‘The most important message’

One of the first things Jenny Thamer did as co-chair of the Autism Advisory Team 鈥� a role she played for two years before moving on 鈥� was to send out a second survey, consisting of a single, open-ended question: 鈥淧lease tell us the most important message(s) you or your child want educators to know.鈥�

The replies were consistent: 

鈥淚t is our job as adults to figure out why [kids] are not doing well. Children should never be left to figure it out on their own.鈥�

鈥淢y child does not need to make eye contact to be listening. He is not avoiding instruction by not making eye contact.鈥�

鈥淢y child may look fine on the outside to you, but inside they are almost paralyzed with anxiety.鈥� 

鈥淢y child may communicate differently, but that doesn鈥檛 mean he doesn鈥檛 want to be involved.鈥�

Anderson, the superintendent, says he鈥檚 committed to fully implementing the district’s neurodiversity policy. True recognition of the array of ways in which people experience Boulder Valley鈥檚 schools will benefit every student and educator, he says, autistic or not.   

鈥淭he idea that we understand the challenge and the needs of a neurodiverse community, and that we are locking arms to meet those needs, that鈥檚 good for all kids,鈥� he says.    

鈥淭his is really hard work. I鈥檓 not here to tell you we鈥檝e solved the problems. But these things aren鈥檛 hidden anymore. They鈥檙e not whispered.鈥�

After publication, the district provided data showing 42 students were physically restrained during the 2024-25 school year.

This investigation was produced with support from the Education Writers Association Reporting Fellowship program.

The coverage mandates these parents helped secure have driven hundreds- and even thousands-fold increases in Medicaid spending on ABA 鈥� an unproven, even harmful, behavior modification system that uses rewards and punishments to try to eliminate certain behaviors.

Over the last decade, the ready flow of cash has attracted private equity, a type of investment that purchases large shares of companies that are not publicly traded. Through cost cutting and other restructuring methods, these short-term investors try to boost revenue before selling the businesses for a profit. With scant state or federal oversight, they have also acquired nursing homes, facilities for people with intellectual and developmental disabilities, medical equipment providers and other healthcare industries that rely on taxpayer dollars to profit.      

Now, states 鈥� which put few regulatory guardrails on the ABA industry, on private equity鈥檚 role in healthcare in general or on Medicaid reimbursement 鈥� are cracking down. Even before a series of damning federal commissioned by the Biden administration were released in recent months, lawmakers and health officials have proposed capping the amount of ABA an individual child can receive and how much providers can bill, as well as imposing standards on clinics and therapists. 

As states have revisited Medicaid reimbursement rates and other policies that impact providers鈥� financial bottom lines, two types of ABA-related debates have played out in statehouses. One involves the ABA industry鈥檚 entrance into state-level political spending; the other, efforts by providers and caregivers to require public schools to allow the therapist of a family鈥檚 choosing to accompany their student to class.  

The start of statehouse spending 

Individual state legislative races are relatively cheap to influence. While parents have long packed hearing rooms to testify against threatened cuts to autism services, in recent years some of the industry鈥檚 largest, private equity-owned ABA providers have begun making campaign donations to candidates for state-level office who could sway legislation on ABA oversight, Medicaid reimbursement rates, whether private autism therapists should be allowed in schools and other laws that impact providers鈥� profits.  

Lobbying and campaign finance reporting requirements vary widely from state to state. Using records compiled by the political spending watchdog group Open Secrets, 社区黑料 was able to identify instances when ABA lobbyists donated to state-level campaigns around the country at consequential moments, to benefit the companies the lobbyists represented. 

In 2022, Florida lawmakers passed a law allowing behavior technicians from private, for-profit ABA centers to accompany kids to school 鈥� opening a new and potentially lucrative market. While reimbursement rates vary by state, private ABA centers typically bill insurers for behavior technicians鈥� time at $50 to $100 an hour. Special education classroom aides employed by public schools, in comparison, frequently make about $25 an hour.  

Campaign contributions made that year by two of ABA鈥檚 largest private equity-owned concerns, Hopebridge Autism Therapy Centers and Acorn Health, would barely cover a lobbyist鈥檚 bar tab at a Washington, D.C., watering hole. 

Hopebridge Autism Therapy gave a total of $10,000 to nine incumbent lawmakers and one challenger. Acorn Health gave $7,500 to the state House Republican Campaign Committee and $3,333 to the Florida Republican Party. 

It was a small expense for two of the country’s largest autism therapy companies, which between 2019 and 2024 brought in almost $200 million 鈥� nearly $134 million for Hopebridge and more than $63 million for Acorn, according to a 74 analysis of Medicaid ABA billing records. 

The largest company by Medicaid revenue, Centria Healthcare, was paid more than $400 million between 2019 and 2024, according to 社区黑料鈥檚 analysis. The company spent almost $200,000 in Oregon and Indiana in three election cycles: 2020, 2022 and 2024. 

In 2024 in Indiana, where a federal audit would soon find up to $133 million in improper Medicaid ABA claims from multiple providers, sparking caps and cuts, Centria gave $25,000 to gubernatorial candidate Michael Braun.

As governor, Braun created a state applied behavior analysis to consider ways to rein in costs while continuing to serve autistic children. The group鈥檚 membership is dominated by ABA practitioners.

In Oregon, the company gave former Rep. Dan Rayfield $55,000 during his last two terms as House speaker, followed by $25,000 for his successful 2024 run for attorney general. The state House Democratic Campaign committee received $50,000, while 13 other lawmakers got contributions of $1,000 to $10,000.

On the table: A to expand the state鈥檚 private insurance autism therapy mandate until 2030 and a to extend Oregon鈥檚 ABA mandate to conditions other than autism, such as intellectual and developmental disabilities 鈥� potentially opening significant new markets. The law mandating continued coverage of autism treatment was enacted.

The bill to expand the disability categories for which ABA practitioners can be reimbursed faced significant pushback. Testimony submitted to lawmakers included of research on the therapy鈥檚 effectiveness for conditions other than autism, such as Down syndrome, cerebral palsy and epilepsy. It concluded the evidence is thin. The measure is still pending in the state House. 

Facing Medicaid rate cuts, Utah Behavior Services (now known as Bridgeway Integrated Healthcare Services) 鈥� with Medicaid revenue of some $196 million, according to 社区黑料鈥檚 dataset 鈥� spent some $41,000 to influence 21 contests, including state auditor. Action Behavior Centers, which collected $1.7 million in reimbursements between 2021 and 2024, spent $2,500 .  

Must schools allow private ABA in classrooms?

Special education law requires schools to provide 鈥渕edically necessary鈥� services to children whose ability to attend school and learn depends on them. For the most part, school districts can pass these costs along to Medicaid or another public healthcare plan, or to a family鈥檚 private insurer.   

Commonly cited examples are children who need a nurse to manage their airway or feeding tube, or have a condition that requires physical therapy. Historically, ABA has not been recognized as a medically necessary service. Schools typically try to meet students鈥� behavioral and communications needs in other ways.    

In 2022, two Colorado lawmakers introduced a bill to require school districts to enshrine autism therapy as medically necessary. Administrators from the Colorado Consortium of Directors of Special Education, the Englewood and Cherry Creek school districts and others expressed concern with the bill. 

They would be liable for the in-school conduct of a technician they don鈥檛 employ, several of those commenting said. And, most practically problematic, schools would be legally responsible for figuring out how to make up the academic instruction that students would miss while engaging in therapy during the school day.

The General Assembly eventually passed a version of the bill not specifically addressing ABA. Instead, it requires districts to have policies outlining how they will address medically necessary services.  

Louisiana and Pennsylvania recently enacted laws saying schools must accept autism therapy technicians. The requirements are too new to assess results.

This investigation was produced with support from the Education Writers Association Reporting Fellowship program.

Diana Diaz-Harrison, whose son is autistic, said that in she hopes to continue her efforts to help others launch autism charter schools throughout the country. Her schools, she said in remarks captured on , are a testament to what happens 鈥渨hen parents like me are empowered to create solutions.鈥�

鈥淢y vision is to expand school choice for special needs families 鈥� whether through charter schools, private options, voucher programs, or other parent-empowered models,鈥� she said in a statement to 社区黑料. .

The five-school network uses a controversial intervention that attempts to train children to appear and behave like their neurotypical peers. Created by the researcher behind LGBTQ conversion therapy, applied behavior analysis, or ABA, is widely depicted as the gold standard despite scant independent evidence of its effectiveness and mounting research documenting its harms. 

Diaz-Harrison opened the network鈥檚 first school in 2014 as a free, public alternative to private schools for autistic children, which are popular in Arizona but typically charge tens of thousands of dollars a year in tuition. Her Arizona charter schools are a 501(c)3 nonprofit financed by state and federal per-pupil funds. ABA is specifically endorsed by Arizona education officials as a strategy to use with autistic students.

In the time since those charters opened, ABA has grown to be a national, multi-billion-dollar industry, with for-profit companies tapping public and private insurance to pay for as much as 40 hours a week of one-on-one therapy. The intervention uses repeated, rapid-fire commands that bring rewards and punishments to change a child鈥檚 behavior and communication style.

A 74 investigation last year showed that most data supporting ABA’s effectiveness is drawn from research conducted by industry practitioners. Independent analyses, including a years-long U.S. Department of Defense review, found little evidence the intervention works. Former patients who underwent the therapy as children reported severe, lasting mental health effects, including PTSD.

Diaz-Harrison told 社区黑料 the therapy is both valuable and sought-after. 鈥淔or the autism community, specifically, many families seek schools that integrate positive behavioral strategies,鈥� she says. 鈥淭he evidence supporting behavioral therapy is extensive and well-established. It has been endorsed by the U.S. surgeon general and the American Academy of Pediatrics as an effective, research-backed approach for individuals with autism.鈥�

During her visit, McMahon told students and staff she was eager to tell President Donald Trump about the schools. 鈥淗e doesn鈥檛 believe any child, whether they have neuro-difficulties or any other problems, should be trapped in a school and not have the facilities that they need,鈥� she said. 

Since Trump鈥檚 second inauguration, he has issued numerous orders that have alarmed disability advocates and the autistic community. Though both edicts contradict longstanding federal laws, in March he ordered the closure of the Education Department and said responsibility for special education will be transferred to the U.S. Department of Health and Human Services.

About half of the Education Department鈥檚 staff has been fired, including most of the people responsible for investigating what had been a backlog of some 6,000 disability discrimination complaints. Though it鈥檚 unclear whether Trump and McMahon may legally disregard special education funding laws and allow states to spend federal dollars as they see fit, both have said they favor giving local officials as much decision-making power as possible.

Meanwhile, HHS Secretary Robert F. Kennedy Jr. has stoked fear in the autistic community by announcing a new effort to tie autism to vaccines or other 鈥渆nvironmental toxins鈥� 鈥� a hypothesis discredited by dozens of studies. The man he appointed to head the study has been cited for practicing medicine without a license and prescribing dangerous drugs to autistic children. 

Last week, the new head of the National Institutes of Health announced that an unprecedented compilation of medical, pharmaceutical and insurance records would be used to create an autism 鈥�disease registry鈥� 鈥� a kind of list historically used to sterilize, institutionalize and even 鈥渆uthanize鈥� autistic people. HHS later walked back the statement, saying the database under construction would have privacy guardrails.

Among other responsibilities, the offices Diaz-Harrison will head identify strategies for improving instruction for children with disabilities and ensure that as they grow up, they are able to be as independent as possible. The disability community has raised concerns that the administration is retreating from these goals.   

Advocates have said they fear the changes pave the way for a return to the practice of separating students with disabilities in dedicated special ed classrooms rather than having them attend class with typically developing peers. The Individuals with Disabilities in Education Act guarantees special education students the right to instruction in the 鈥渓east restrictive environment鈥� possible.          

Families鈥� preferences vary widely, with some parents of autistic children refusing any form of behavior therapy, while others want their kids in settings with children who share their needs. Many insist on grade-level instruction in general education classrooms 

Diaz-Harrison has a master’s degree in education and worked as a bilingual teacher in California early in her career. From the late 1990s until she began supporting her son full time, she worked as a public relations strategist and a reporter and anchor for the Spanish-language broadcast network Univision. 

In 2014, frustrated with her son鈥檚 school options, she who applied for permission to open what was then a single K-5 school serving 90 children. The network now has about 1,000 students in all grades and features an online program. 

At the end of the 2023-24 academic year, of the network’s students scored proficient or highly proficient on Arizona鈥檚 annual reading exam, while 4% passed the math assessments.      

In December 2022, the network won a $1 million , an award created by Jeff and Janine Yass. The billionaire investors have a long track record of donating to Republican political candidates and organizations that support school choice. 

One of the award’s creators, Jeanne Allen, is CEO of the Center for Education Reform. The center nominated Diaz-Harrison for the federal role. 

Yass award winners were featured at the 2023 meeting of the American Legislative Exchange Council, or ALEC, a conservative forum where state lawmakers are given model bills on education and other policies to introduce in their respective statehouses. 

Diaz-Harrison has partnered with a Florida autism school to create a national to help people start schools like hers throughout the country. She told 社区黑料 the effort has so far supported teams of hopeful school founders from Louisiana, Texas, Florida, Alabama and Nevada. 

Parents of young autistic children and autistic adults often disagree about ABA. Told by their pediatrician or the person who diagnosed their child as autistic that they have a narrow window in which to intervene, families fight to get the therapy. Adults who have experienced it, however, report lasting trauma and have lobbied for research 鈥� much of it now at risk of being defunded by Kennedy 鈥� into more effective and humane alternatives.

It worked. Reimbursements rose from $1.7 million in state funds to 41 providers in 2017 to to 328 providers in state and Medicaid funds through the Early Intensive Developmental and Behavioral Intervention benefit in 2023.

Most of those new centers engaged in applied behavior analysis. ABA is an intensive behavior modification technique that aims to make autistic children act more like their typically developing peers by “extinguishing” certain traits through compliance with specific repeated commands. (A 74 investigation last year demonstrated that there is no reliable data to show the treatment works, and that it may actually cause harm to patients.)

Last year, the FBI began investigating whether some of those treatment centers have defrauded Medicaid, billing for services never provided. Though investigators have not said how many for-profit centers they are looking into or who their clients are, many are believed to enroll the children of East African immigrants, who are particularly vulnerable because of the lack of culturally appropriate services. There are also indications the alleged fraudsters may have ties to defendants in the country鈥檚 largest , in which nonexistent food distribution sites supposedly created to provide children with meals during COVID-related school closures billed the state for hundreds of millions of dollars.

As the 2025 legislative session gets underway, state lawmakers are holding hearings on proposals to tighten oversight. Most of the testimony has centered on to require services to be provided by licensed professionals in safe settings. But some autism advocates have expressed concern that those standards will entrench ABA as the dominant approach 鈥� one that, among other things, is replacing other special education services in schools 鈥� instead of supporting alternatives that they say are more effective and humane.     

One of those who testified is Native American Jules Edwards, the autistic parent of three autistic youth, ages 11, 19 and 21, and a member of the Anishinaabe Eagle Clan. After , she told a state Senate committee that ABA is not a therapy, but 鈥渁 specific methodology that was created by the same people that created gay conversion therapy.鈥�  

Right now, providers are not required to be licensed; are allowed to describe employees who may have only a high school diploma as therapists; and are not held to the same safety standards as even home day care centers, Edwards testified. 鈥淒espite the ABA industry lobbying for more power over the autism community, they need their power restricted until they can prove with empirical and independent evidence that they are doing what they claim they are doing鈥� in terms of providing effective, safe services.  

Edwards recently expanded on her testimony in an interview with 社区黑料. This conversation has been edited for length and clarity.

What motivated you to testify?

When my children were diagnosed with autism, I threw myself into research. I learned about autism and I learned about interventions. I learned from professionals, parents and autistic adults that autism is a social, communication and sensory disability, and not a behavioral disorder. I learned that applied behavior analysis is a behavior modification program that requires autistic children to suppress their natural way of being in order to please the adults around them. 

That didn’t make sense to me. Why wouldn’t we want to address any underlying needs first? Typically, autistic kids specifically need to learn the why, because we’re bottom-up learners. We like to gather information about things before taking action. But ABA requires a top-down, authoritative approach, where autistic children are not allowed to ask why. They are required to comply with authority, and that poses a lifelong danger to that child. 

Testifying was an opportunity to highlight the fraud, waste and abuse that happens within the ABA industry. American taxpayers pay billions of dollars per year to enrich private equity investors under the guise of an autism therapy that works. However, ABA isn’t a therapy, and it hasn’t been proven to improve quality of life. 

The Department of Defense鈥檚 2020 reported that 76% of children in ABA showed no improvement after one year, 16% had improved, but 9% were worse after a year of treatment. That really brings into question the cost-effectiveness of ABA. When we’re talking about fraud and waste of Medicaid dollars or taxpayer dollars generally, we need to be honest about the actual outcomes. 

But there’s little oversight. The state doesn’t require health and safety procedures, behavior guidance, standards, first aid, CPR. They aren’t required to have a mental health response, crisis response or suicide intervention plan. They don’t have to provide culturally responsive treatment practices. 

A 5-year-old child was just in a hyperbaric chamber in an unaccredited ABA center in Troy, Michigan. The chamber exploded with the child inside, and he passed away.  We know that hyperbaric chambers aren’t actually a treatment or cure for autism or anything like that. It’s not approved by the FDA. If there was oversight, if there was licensing, if there were safety requirements that prevented this kind of alternative treatment it could have saved that boy鈥檚 life. 

The state鈥檚 suggests 鈥渕odern鈥� ABA has largely stopped using punishments to discourage certain behaviors. But I have heard parents and autistic adults who have experienced ABA say it is still coercive. Can you give us an example?

Planned ignoring, which is a technique used in ABA, basically denies the humanity of the child who is subjected to it. When we’re children, whether you’re autistic or not, and you’re hanging out with another kid, and the other kid is pretending you don’t even exist, it’s dehumanizing. But now, within ABA, the adults do that to the children.

Say a child is throwing a toy that they shouldn’t be throwing. They may not be hurting anybody. They might be throwing it because they like the sound. It could be stimming [the term for a repetitive sound or motion an autistic person may use for emotional regulation or to express ]. It could be anything. The adult doesn’t want the child to play with the toy that way. 

They might try other interventions before planned ignoring, but then the child is being ignored completely, whether the child is trying to gain the attention of the behavior tech or not. This can cause increased 鈥渂ehaviors鈥� of the child escalating, trying to gain that attention. But no matter how much the child tries, the adult is not going to give in.

We can see how frustrating that must be, particularly if that’s a child who may be struggling with communication and may not say, 鈥楬ey, I really want to play ball right now.鈥� That kid is maybe unable to ask for what they want, or the way that they’re asking is a behavior that the behavior tech doesn’t like.

Is there a danger that as the state creates standards and licensing procedures to protect children, it will further codify this industry as the dominant treatment? 

Absolutely. ABA is currently the dominant treatment. They have lobbyists. They absolutely can persuade legislators to further empower the industry. Because they have the most money, they have the most power right now. 

A lot of the research about ABA, claiming it’s the gold standard treatment, etc., is funded by and conducted by the people who profit from it. We need to be sure that decision makers are looking at facts and data and information that isn’t that doesn鈥檛 involve a conflict of interest. It’s really important that we refer to outside, independent researchers, like the Department of Defense study.

There was a push at one point for board-certified behavior therapists [credentialed ABA supervisors] in Minnesota to be able to diagnose autism. They would then be able to enroll those children in their services. That is dangerous, because children who need a diagnosis need to go to an actual medical professional and have other conditions ruled out. They need to be evaluated for potential co-occurring conditions, etc. If a behavior therapist is able to diagnose autism, but they can’t diagnose anything else, then all of that child’s underlying conditions or additional conditions may be overlooked. 

If my children didn’t have full-team neuropsych evaluations, I wouldn’t know about their learning disabilities, and I wouldn’t know how to provide support. I wouldn’t know how to advocate for my children in school. My child used to be punished for his writing disability until we learned, through that neuropsych evaluation, there’s a dysgraphia issue. So let’s provide writing prompts. Let’s provide support for writing. Let’s provide adaptations and assistive technology. If he only had an autism diagnosis, that would have been met with behaviorism, he would have been rewarded for doing well, punished for struggling, and he wouldn’t have had access to the tools that he needs. 

There are definitely other treatments that don’t have that same level of influence but may be more effective, may be more humanizing. A lot of those are not as widely available. 

Many kids spend half or or all of their day in an ABA center rather than in a school where their learning would be attended to.

It’s a problem that begins in preschool. Children are often pushed out of public schools when a school or preschool doesn’t have the knowledge or resources to care for the child. They say, “Maybe this isn’t the best fit for you.” That’s something that my family has heard from our local public school. That’s not really a thing that a special education director should be saying to any family, and we should be concerned about the people who are most marginalized in our communities. When those kids are excluded from public schools, parents are often left with very few options. 

ABA centers market themselves as being able to help children to gain skills and become more independent. But if that were so, why isn’t inclusion in public schools the ultimate goal of ABA centers? ABA centers are not schools. They’re not accredited to provide education. There are very few ABA centers that have transition paths or goals for kids to move out of ABA and into mainstream schools. Instead, many children remain in ABA, sometimes throughout high school, deprived of the opportunity to learn what their peers are learning. It’s a form of educational neglect. 

Children in ABA often aren’t allowed to learn the most basic things. For example, [behavior therapists] often dissuade spelling to communicate, which means that they’re not encouraging autistic kids in ABA to even learn the alphabet. They aren’t taught literacy, they aren’t taught math, they aren’t taught history. That’s sad and scary, because then when these children grow up, all they’ve learned how to do is comply with authority.

There was a hearing a couple of days after yours where a number of East African parents testified about the conditions that compelled them to take advantage of ABA. There’s an element of desperation, in terms of a lack of alternatives, that must be clouding the picture.

It’s a sad reality that there’s a history here in Minnesota of people preying on immigrant communities. For example, in 2017 there were 75 cases of measles identified in the Somali population in Hennepin County alone, a result of anti-vaxxers who saw an opportunity to push their narrative that vaccines cause autism. They targeted immigrant communities with fearmongering tactics. 

The ABA industry pushes itself onto parents by claiming to be the only hope for their children. I’m very concerned that marketing targets immigrant communities without sharing balanced information that will help parents make informed decisions for their families. I’m worried about the conditions in which ABA is the only option. 

A lot of the time, parents are in a desperate situation where it’s like, 鈥淚 have to go to work to pay the bills, and I have to have a place for my child to be that is safe and supervised.鈥� And instead of lobbying for inclusion, for appropriate support and services in schools, we’re saying, 鈥淲ell, this kid can go to ABA instead.鈥� 

That’s not good for anyone, because inclusion benefits all of us. Inclusion benefits abled and typically developing people just as much as it benefits disabled people. I think we can see that right now in our current political climate, where it’s been so normalized to 鈥渙ther鈥� people. That causes harm to all of us. 

ABA is problematic in your culture.

I’m Anishinabe. ABA could never meet my needs as a Native person. “Culturally responsive” essentially means to adapt services to meet the needs and values of a person’s culture. Some cultures, particularly settler-colonial culture, values assimilation. Settler-colonial culture prefers when people blend in and are agreeable to authority. ABA is rooted in that.

Behaviorism seeks to control a person’s behavior with the carrots-and-sticks analogy. We reward the things we want to see, we punish the things that we don’t want to see. We all do get rewarded for doing certain actions, and we all could potentially be punished by other actions.

But it’s not the same micro-management of behavior 鈥� you can only communicate the way I want you to communicate. You can only experience your senses the way I want you to experience your senses. You can only socialize the way that I have determined is a valid way of being. 

There’s the stereotype that autistic people don’t make eye contact, but that eye contact is a cultural phenomenon. Not every culture thinks eye contact is this great thing. Some cultures find it disrespectful, but ABA doesn’t always take that into account. It’s determined by the [therapists], not necessarily the child and their family and their culture. 

We should all have some self-determination with how we use our bodies. If I’m not hurting anyone else, I should be able to stim. If I communicate best by writing, that should be encouraged, and I should be provided support and tools to do that. Rather than what happens often in ABA, where parents are told, “This will help your child speak,” but it’s not speech therapy. 

One of my children didn’t speak until he was a little bit older. Starting when he was about 2, he would use one or two words here and there, but he wouldn’t combine them. It was tough, because at the time, we didn’t have a diagnosis, we didn’t have any sort of speech language therapy. As a parent, I relied on very basic sign language. And I was thrilled because I could communicate with my kid whether he was using mouth words or not. Do I wish that we had speech language pathology at the time? Yes, absolutely, that would have been great. But we didn’t. I think that if we had pushed that particular child into using mouth words, I think it would have built resentment.

Now he can speak, but his preferred language now is music, which is really cool because he’s a musician. Music is a really strong cultural practice that’s traditional for Anishinaabe people or Ojibwe people. It’s healing for us, something that we love. Why don’t we encourage that, rather than the ABA ideal of mouth words?

It was huge news. At the time, an autism diagnosis frequently meant life in an institution for the child in question. The opening of a path to a version of a 鈥渘ormal鈥� life seemed nothing short of a miracle. Few people questioned the history of Lovaas鈥檚 research or the ethics of his methods.

Rather, determined to do right by their children, parents fought hard to get the new therapy, dubbed applied behavior analysis, or ABA 鈥� though it was as expensive as it was supposedly game-changing. Today, there is an excellent chance that a child diagnosed as autistic will receive a referral to a provider of ABA, routinely described as 鈥済old standard鈥� therapy that uses behavior modification techniques to eliminate traits deemed undesirable. 

As the rate of U.S. children identified as autistic has risen to 1 in 36, an entire industry has grown up around them. Where once parents had to sue to force school systems, social service agencies and insurers to pay for what was billed as an autistic child鈥檚 only fighting chance, today there are ABA treatment centers where families and schools can send a child; therapist degree programs; at least 100 companies running networks of ABA centers; countless standalone programs; dedicated ABA schools that students attend full time at public expense; and ABA training for special education teachers. With all this comes the potential for profit 鈥� up to , according to investment firms 鈥� and thus an army of lobbyists and public relations specialists making sure ABA is the first, and often only, therapy available. Armed with testimonials of success, parents became 鈥� and many remain 鈥� their zealous ambassadors. 

But 37 years after Lovaas’s bombshell article, researchers, therapists and autistic adults who themselves were ABA patients as children are pushing back. Proponents of other approaches and some educators 鈥� as well as the U.S. Education Department 鈥� have expressed frustration over the depth with which ABA has become ingrained, to the exclusion of other therapies and the potential detriment of potentially hundreds of thousands of children. A critical mass of advocates is challenging the notion that non-disabled diagnosticians should get to decide how autistic children should be treated 鈥� indeed, how the entire concept of disability should be defined. 

The U.S. Department of Defense, among other research organizations, has called into question whether ABA actually works. And scholars are investigating whether it causes harm to the children subjected to it. Some who experienced the intervention say it absolutely does.

The problems with ABA started early on, beginning with Lovaas’s own beliefs.

“You start pretty much from scratch when you work with an autistic person,鈥� he told Psychology Today in 1974. 鈥淵ou have a person in the physical sense 鈥� they have hair, a nose, a mouth 鈥� but they are not people in the psychological sense.” 

This lack of humanity, Lovaas did not shy away from saying, justified using electric shocks, slaps, withholding of food and other forms of physical punishment to 鈥渆xtinguish鈥� autistic traits 鈥� even joyful ones 鈥� and replace them with 鈥渘ormal鈥� behaviors. 

Simultaneously, Lovaas was using the same methods to 鈥渢reat鈥� suspected homosexuals and transgender people 鈥� so-called conversion therapy, which was quickly recognized as a human rights abuse. But the same reasoning that propelled the research community to turn away from using 鈥渙perant conditioning鈥� on LGBTQ people was not extended to autistic children. Instead, proponents charged ahead 鈥� even though Lovaas鈥檚 own landmark study does not come close to what many . The Norwegian-born psychologist, who died in 2010 at age 83, had personally decided which children received his pioneering intervention and which became the control group. Six years after his initial publication, Lovaas conceded that ABA becomes less effective over time, because, 鈥淭hese people are so used to pain that they can adapt to almost any kind of aversive you give them.鈥� 

More concerning, a growing body of research from, among other sources, the and a multi-disciplinary team of university scholars called Project AIM has found the evidence base for ABA is too thin and of too poor quality to justify its widespread adoption. The majority of studies that have found it effective are rife with industry conflicts of interest. 

And many former patients who were subjected to ABA as children believe the treatment is abusive. found that just 5% of autists 鈥嬧�嬧�� a term used by some people with autism 鈥� support the therapy, with a majority of neurotypical relatives of autistic people opposing it. 

As neurodivergent adults have moved into the ranks of academic and independent researchers, some have begun compiling evidence that ABA subjects are more likely than other autists to suffer from PTSD and other serious mental health problems. 

鈥淚t doesn’t seem to be on anyone’s radar that these interventions could cause harm,鈥� says Kristen Bottema-Beutel, a Boston College professor and an author of the Project AIM . 鈥淭here seems to be this unwillingness to listen to autistic people who say that it does.鈥�

It鈥檚 a Catch-22, she continues: 鈥淭here’s no evidence. But the reason there’s no evidence is because we are unwilling to collect it.鈥�

‘My monkey tricks were impressive but dehumanizing’ 

Unlike Lovaas, most of today’s ABA therapists don’t wield paddles or electric shocks. But they continue to push for compliance in ways many parents and autistic adults describe as controlling and abusive. There鈥檚 no more slapping, but toys, treats and 鈥� possibly most damaging 鈥� attention are frequently withheld when a child is not compliant. The goal remains 鈥渆xtinction鈥� 鈥� the term still used for the process of drilling until an autistic behavior no longer takes place. The centerpiece of this conditioning still bears the name Lovaas gave it: the discrete trial.

Often delivered for long periods, and beginning at ages when children are too young to sit still and obey commands, ABA involves a therapist giving an instruction 鈥� such as asking the child to make eye contact, fold their hands in their lap or speak out loud. Positive and negative feedback comes repeatedly and rapid-fire, sometimes including physical reinforcement like turning the child鈥檚 head or holding their hands down. When the patient complies, a new command is introduced. 

Sometimes, the targeted behavior is dangerous for the child, such as head-banging, or exhausting for caregivers, such as smearing food or feces. Other times, it鈥檚 simply a visible deviation from 鈥渘ormal.鈥� Either way, the goal is to train the child to respond differently to the surrounding environment. 

The upshot, say many adult autists, is that because patients appear more neurotypical, non-disabled people may believe they are 鈥渂etter,鈥� when in fact they may well have sunk into a state of burnout and are developing mental health issues. 

From a non-autistic perspective, many of ABA鈥檚 goals seem entirely reasonable 鈥� indeed, even a kindness undertaken to facilitate a child鈥檚 chances of social acceptance. It鈥檚 hard to make neurotypical friends, the reasoning goes, if your affect is flat or you make guttural noises when you are excited. Teachers can鈥檛 deliver lessons if they鈥檙e trying to keep a student from bolting from the classroom. It鈥檚 nigh unto impossible for a parent to finish the grocery shopping with a kid who has melted down and may be physically out of control.

ABA, autistic adults say, may train a child to stop some of these behaviors. But it does nothing to address the underlying causes or teach coping skills, and comes at a tremendous psychological cost. To someone who is easily overstimulated, buzzing fluorescent lights, hyperactive siblings or continual changes of setting and activity can make classrooms and public spaces a sensory nightmare.

Take, for example, the common ABA goal of asking a child to make eye contact. While there are several levels of expertise, and therapists鈥� training varies, the board that certifies ABA practitioners 鈥渞equires no education and training on autism in general, let alone [its] cognitive and neurological characteristics,鈥� the journal . So therapists who compel eye contact 鈥� even going so far as to turn the child’s head so they are face to face 鈥� may not know that the portion of autistic children鈥檚 brains that is primarily responsible for anxiety. 

One way autists cope with anxiety is to 鈥渟tim鈥� 鈥� make sounds or movements, such as hand-flapping or rocking, that discharge this overstimulation. The more overstimulated a child gets, the more pronounced the behavior. Unable to self-soothe or leave an overwhelming environment, the child is likely to melt down. In trying to eliminate stims, the authors of the Cogent Psychology article report, ABA makes 鈥渁rbitrary distinctions between which movements are pathological and which are not.鈥�

鈥淎 lifetime of being punished for certain movements, and being forced to engage in eye contact despite the physiological pain and discomfort of doing so, is psychological and physical abuse,鈥� they write. 鈥淎 lifetime of being forced to sit still with no regard for actual cognitive abilities can create further emotional and psychological harm.鈥� 

Autists describe attempting to appear 鈥渘ormal鈥� as masking or camouflaging. It often takes so much effort that it can suck up all of a person鈥檚 energy, meaning they may not actually hear a lesson being delivered or be able to engage with a conversation. If directed to do something that is a physical impossibility, a child may not even be able to mask. 

Nor will behavioral therapies do anything to change what a person鈥檚 neurotype 鈥� the scientific label for a brain and body that operate differently 鈥� physically prevents them from doing.

鈥淭hey are neurological problems, not problems with my social understanding or intellect,鈥� one adult who experienced ABA told researcher Laura Anderson for published in the journal Autism. 

Research on the harms of masking is mounting. published in Advances in Autism found ABA participants were 86% more likely to meet the diagnostic criteria for PTSD than autistic people who were not exposed to the therapy. Nearly half of those affected displayed PTSD symptoms that would be considered at 鈥渆xtreme levels of severity.鈥� 

An suggests that separate from mental health conditions, with heightened risk of suicidality, already than the general population. 

Summarized one participant quoted in Anderson鈥檚 report: 鈥淢y monkey tricks were impressive but dehumanizing.鈥� 

Who wouldn’t want to hear, ‘I love you’?

When Elizabeth鈥檚 daughter Lily was diagnosed at age 3, she was told to start ABA as soon as possible, preferably for 40 hours a week. 鈥淚t鈥檚 just overwhelming,鈥� Elizabeth recalls. 鈥淚 didn鈥檛 know anything about the diagnosis. I didn鈥檛 understand what it could mean.鈥� (To protect the child鈥檚 privacy, Elizabeth and Lily are pseudonyms for a mother and daughter who live in a Massachusetts city that is home to a number of universities.)

A scientist, Elizabeth downloaded all the research she could find and immediately became concerned. Because of ABA鈥檚 focus on how many correct responses a child provides, there was data galore. But it documented the number of times it takes to extinguish or create a behavior. None of it told her how Lily鈥檚 life might change. 

Lily is hyperlexic, meaning that for such a little girl she had a huge vocabulary. But she is sometimes nonverbal. For some autists, speaking out loud may be physically difficult, even impossible. Coordinating the complex physical and mental functions that go into talking may take so much effort that it wears them out or sends them into a meltdown.

A common criticism from autistic adults who experienced ABA is that they used precious energy struggling to say what the therapist wanted to hear just to get the exercise to stop. A therapist may eventually succeed in getting the child to name the toy they want, but it often stymies meaningful communication.   

Unaware of the hurdles speech can pose, parents are often thrilled when ABA teaches their child to speak 鈥� after all, who wouldn’t want to hear, “I love you”? They rarely realize that other approaches could facilitate more interaction while taxing their child less.

In fact, because ABA is frequently offered in place of speech-language therapy or assistive technology 鈥� such as programmable electronic 鈥渢alkers鈥� that allow children to piece together pictures or symbols into sentences or even stories 鈥� parents and teachers may not be aware of how much language a child actually has.

Lily spoke as a small child, but as she got older, she would stop talking for a day or two at a time. Elizabeth wanted to teach her to sign but was discouraged by health care providers who had heard from ABA therapists that children given alternate means of communication are less likely to become verbal. 

When Elizabeth was first looking into ABA鈥檚 research base, she saw that among the evidence that it works was data on the number of times a patient speaks. To her, this was a poor substitute for knowing whether Lily could describe how she felt or what she was thinking about.

Lily now has a device she can use when she can鈥檛 or doesn鈥檛 want to speak. Often, Elizabeth says, the girl is much more expressive with it. 

鈥淵ou can train any mammal to do the things that ABA can train your kids to do,鈥� Elizabeth says. 鈥淗ow a kid is feeling and growing in terms of their relationships and their anxiety and feeling comfortable with people 鈥� that鈥檚 really different than sitting at a table and pointing at a picture nine times out of 10.鈥� 

Based on data gleaned from the nearly 10 million military dependents it insures, the U.S. Department of Defense has repeatedly called the evidence supporting ABA “,” noting there is no research to determine whether the small number of participants who show improvement 鈥� 15% 鈥� do so because of treatment or simply because a child has matured. After a year of the therapy, the department reported to Congress in 2019, 76% of 16,000 participating autistic children saw no change, and 9% worsened.

(The private nonprofit National Academies of Sciences, Engineering and Medicine is conducting a federally mandated of the Defense Department鈥檚 autism intervention research. Its findings are slated for release in summer 2025.)

Even accepting more typical behavior and communication as legitimate goals, research has found scant evidence that the treatment achieves those outcomes. Results of a randomized trial in England, for instance, 鈥渟uggest lack of clinical effectiveness,鈥� in 2020. A of the 鈥淟ovaas Method鈥� by the U.S. Department of Education鈥檚 What Works Clearinghouse looked at 58 studies, concluding that only two even partially met its standards.  

Project AIM’s , published in 2020, found little high-quality research 鈥� and little evidence in the investigations that did meet rigorous standards 鈥� that supported ABA鈥檚 efficacy. Of the 150 investigations undertaken between 1970 and 2018 the Project AIM team examined, had serious conflicts of interest, which less than 6% disclosed. 

After an autistic researcher, Michelle Dawson, pointed out that Project AIM had not considered whether the studies it analyzed reported side effects or harm, members reexamined them and found that only 11 included even cursory mentions of participants鈥� psychological or physical distress.

Including adverse events data should be standard, says Bottema-Beutel, the Boston College professor and Project AIM author: 鈥淚t is in other fields, and it absolutely isn’t in autism research. 鈥� It’s especially important because there is an enormous community of autistic people who say that they have been harmed by participating in these interventions.鈥�

A related flaw in the overall body of research, Bottema-Beutel adds, is that it disregards what autistic people say they want in the way of therapeutic support. 鈥淚t would be difficult to find studies that were well designed, that don’t have risks of bias [and] that show improvement on meaningful outcomes that autistic people care about,鈥� she says. 鈥淪how me an ABA study where they improve quality of life.鈥�

‘It was so humiliating being there’

Concerned about the way ABA-affiliated researchers defined and quantified success, Elizabeth went back to the internet and searched for opinions from autistic adults. 鈥淚 just wanted to hear from older autistic people who experienced therapy,鈥� she says. 鈥淎nd try to understand that from my daughter’s perspective, because at the time, she certainly couldn’t tell me.鈥�

What she heard were responses like these:

鈥淚t resulted in corrosive damage to self-esteem and deep shame about who I really am,鈥� told a University of California researcher in 2017. 鈥淣o effort was made to explain autism to me or to explain the role of sensory overload in issues like meltdowns, shutdowns, etc.鈥�

Therapists, another former participant at the Autistic Self Advocacy Network, 鈥渢each you to anticipate that when you say 鈥榥o,鈥� they鈥檒l bulldoze through that because you don鈥檛 own your own body.鈥� 

Another said she was left with crippling social anxiety: 鈥淎ll of those things that I was doing wrong would automatically go through my head any time I was in a social situation. … I would be inherently super judgmental and self-critical about everything I was doing to the point where even in some social situations, I just shut down.鈥�

And: 鈥淚t was so humiliating being there.鈥� 

Perhaps the most painful element of the swelling controversy about ABA is the clash of perspectives of neurotypical parents and autistic adults who say 鈥� often bluntly 鈥� that the effort families are making to do right by their child is misguided. The conversation is especially freighted because both groups have unhappy histories. Until Lovaas, poor parenting was blamed as the root cause of autism. For their part, many autistic adults are enraged that they are not routinely invited to help shape research and policy. 

Autistic adults who believe they were harmed by ABA are quick to say they believe their parents were doing the best they could with the information and resources they had. 鈥淚 am not mad at them for their effort,鈥� one autistic woman looking into trauma rates. 鈥淭hey weren鈥檛 disrespectful. They just had a flawed paradigm for autism, and therefore, what they tried didn鈥檛 work. That doesn鈥檛 make them bad people.鈥�

Many parents wholeheartedly believe ABA delivers great victories. Often, they are proud that after their struggles to find services and pay for them, their child talks, follows directions and has far fewer disruptive behaviors.  

One of the most visible advocacy organizations, has played a leading role in helping families of autistic children press for expanded access to ABA . 

The organization鈥檚 stance on ABA is that it may be effective for some people and not others; therapies should be tailored to the individual and should not attempt to enforce behaviors based on social norms. When implemented properly, the organization holds, 鈥淎BA can lead to improvements in IQ, adaptive behavior, communication skills, social skills and a reduction in challenging behaviors.鈥� 

The evidence behind behavioral science is sound, says Andy Shih, Autism Speaks鈥檚 chief science officer. But as with any other treatment, there can be differences in how a therapy is conducted 鈥� particularly given the range of training and experience among therapists. A skilled practitioner working in the right conditions can succeed in changing behavior, he says, most notably eliminating those that endanger a child.    

鈥淓verybody experiences ABA differently,鈥� says Shih. 鈥淭he setting in which we see them, the quality of the service provider, they all make a difference, I think. In general, even though there are established standards and criteria in terms of what a good autism service should look like 鈥� just like in other branches of medicine, what is ideal and what is actually delivered, sometimes there’s a big gap.鈥�

Eileen Lamb, director of social media for Autism Speaks, credits nine years of ABA for helping one of her children, who is nonverbal and has a potentially dangerous eating disorder called . The boy, Charlie, is now able to express his basic needs.

鈥淗e鈥檚 also learned safety skills like being able to 鈥榮top鈥� when someone asks him to,鈥� Lamb said in a statement provided by Autism Speaks. 鈥淎BA was also successful in helping Charlie through his fear of the doctor and dentist. We don鈥檛 have to put him under anesthesia for dental exams/interventions anymore, which is incredible.鈥�

Similar glowing recommendations from parents abound. Last summer, a group of Indiana parents after being alerted by their kids鈥� therapy centers that the state wanted to cut reimbursement rates. They gathered outside the governor鈥檚 mansion, holding signs that said, 鈥淎BA is the way鈥� and, 鈥淭hey wouldn鈥檛 be who they are today without ABA.鈥� 

In Virginia, then-Delegate Bob Thomas kicked off a 2019 press conference announcing a push to expand access to autism therapy by asking the grandson of a local advocate to step to the dais. 

鈥淢ark is a great example of why we are here today,鈥� , explaining that the child had once been unable to speak. 鈥淭hanks to the services and the resources Mark had access to, he’s now able to stand here in front of a roomful of media, media cameras and lead us in the Pledge of Allegiance.鈥�

In response to a reporter鈥檚 question about what was at stake, a mother of three autistic boys stepped to the mic: 鈥淚f it weren鈥檛 for the behavior therapy that we receive, we would not be able to go out in public like this today.鈥�  

Add to displays like these on , memoirs penned by parents who credit ABA with their children鈥檚 miraculous recoveries and that the therapist’s arrival gives them a much-needed break from kids who require constant supervision. 

Research has begun to probe the disconnect between parents鈥� and children鈥檚 perceptions. The , for example, predicted that nearly half of autistic children exposed to ABA will meet the threshold for a PTSD diagnosis within four weeks, while caregivers鈥� satisfaction will rise as the treatment goes on.

Still, the study noted, 9% of caregivers surveyed discontinued the therapy because they didn鈥檛 see enough progress or saw negative changes. Overall, 鈥渃aregiver satisfaction was generally reported within the neutral range. The longer a child was exposed to ABA, the more likely a caregiver was to rate the intervention as effective for improving overall functioning.鈥� 

Have you seen Mr. Potato Head?

Denise鈥檚 son Logan was 27 months old when a neurologist at the prestigious Boston Children鈥檚 Hospital diagnosed him with autism. He was smart and carefree but very rambunctious, more likely to throw toys than play with them. He never spoke words but used his voice to stim. (To protect Logan鈥檚 privacy, he and his mother have been given pseudonyms. The family lives in western Massachusetts.) 

Home to numerous elite research universities 鈥� including Harvard, where behaviorist B.F. Skinner planted ABA鈥檚 conceptual roots 鈥� Massachusetts is considered a great place for autistic children. It was one of the first to mandate insurance coverage for autism services and now contracts with 22 companies to provide intensive early interventions. ABA dominates the offerings. 

Eager to get her son as much help as possible, Denise got him on wait lists for two treatments: ABA and a lesser-known approach called Floor Time. Within two weeks, an ABA therapist was spending 14 hours a week with Logan. 

For a while, Denise says, things went fine. But when COVID-19 forced the therapy online, Logan balked. 

鈥淭he idea that he was hiding in the closet because I was turning on the computer for ABA was just like a total alarm going off,鈥� she says. 

Denise told the therapist the discrete trials didn’t seem like a good fit, fears that were compounded when in-person services started back up. At her first visit, the therapist invited Logan to jump on a trampoline with her. She pointed a finger skyward and said, 鈥淯p, up, up.鈥� Pointing his own finger, a delighted Logan started shouting the word with her. Saying words out loud was new for him.

The victory was short-lived. The therapist moved on, asking Logan to put his hands in water. Still excited, he kept pointing and chanting, 鈥淯p, up, up鈥� instead. The response was gentle but devastating: The therapist folded his finger down and moved his hands where she wanted them. The boy shut down. 

鈥淭o see the joy disappear from his face 鈥� all of a sudden he鈥檚 no longer a willing participant,鈥� Denise recalls. 鈥淭here was no abuse or anything, but she made him comply.鈥� 

Denise canceled Logan’s ABA. Meanwhile, his name had come up to the top of the Floor Time wait list. Floor Time uses play-based activities that the child chooses. The aim is to make interactions increasingly complex.

During the first session, Logan picked up a Mr. Potato Head and threw it. Denise watched with bated breath, anticipating negative reinforcement. But the new therapist started throwing toys, too. And then wandered the room picking up toys and asking in a silly voice if they had seen Mr. Potato Head.

鈥淎ll of a sudden, [Logan] is picking up a toy and perfectly imitating her intonation 鈥� without words, but her tone perfectly,鈥� says Denise. Next, he held toys in front of his mouth and said words for them. Soon, Logan was a chatterbox, talking about the dream he had the night before, ways to defeat bad guys, becoming a superhero 鈥� everything. 

Insurance codes and new markets to mine

As recently as the year 2000, insurance coverage was not required for autism therapies, which cost from $10,000 to $100,000 per year. After fierce lobbying, by 2017 advocates succeeded in pushing laws requiring reimbursement in 46 states. As this sea change was taking place, ABA therapists were among the few people with formal credentials who could step into jobs created to help families access newly covered services. 

This meant that ABA practitioners were often the ones who created insurance billing codes, referral networks and other systems, making them de facto gatekeepers. As a result, though many states require coverage for other types of therapy, getting care other than ABA can be incredibly difficult. Parents who get referrals for speech and occupational therapists, or for augmentative and assistive communication technology for their nonverbal children, often find that the only available providers typically offer ABA.

Revel Weber has firsthand experience with this. A clinical social worker and the autistic parent of four children, one of them autistic and two with ADHD, several years ago she was asked to create a program to serve autistic children belonging to the White Earth Nation in northern Minnesota. As part of her research into treatments that would both benefit tribal families and qualify for public funding, Weber took some online ABA training courses. 

She quickly decided it wasn鈥檛 appropriate for White Earth children. In addition to being uncomfortable with the focus on compliance, Weber, who is not American Indian, believed ABA could play negatively into historical trauma associated with attempts to assimilate Native children. 

Like many states, Minnesota requires insurers to pay for a number of autism therapies, but as Weber explored alternatives to ABA, she ran into a maze of red tape. In their rush to provide the greatest access to services, the government created Medicaid reimbursement codes 鈥� the backbone of health care billing 鈥� that reflected the most available treatments. The majority were ABA. Thirty-seven years after Lovaas’s bombshell study, there are numerous ways to become an ABA therapist, ranging from full-fledged degrees to online courses. But there are far fewer providers of other kinds of treatments. Those ABA therapies are now locked into the codes, meaning billing for anything else can be difficult.

The ABA sector’s strategies for making its services widely available were smart, says Jeffrey Guenzel, head of the International Council on Development and Learning, which provides Floor Time training. But it has made it challenging for other therapies to become established. 

The intervention鈥檚 rapid spread has also resulted in uneven quality, even supporters like Shih, of Autism Speaks, say. Some practitioners hold credentials that may require an advanced degree and long experience, while others 鈥� typically identified as technicians 鈥� may have taken only a few hours of virtual training.    

Venture capitalists are up front in saying the increase in autism diagnoses and continued unmet demand suggest the sector is poised for explosive growth. In , one investment company asserted that there are about 1 million autistic children in the United States. In 2020, the analysis said, ABA programs generated $1.4 billion 鈥� a figure expected to grow to $2.45 billion by 2025. And there are new markets to mine.   

鈥淎BA treatment is widely recognized as the most effective method for treating [autism], but its evidence-based treatment methods are applicable beyond [autism] alone,鈥� the brief asserts. 鈥淢ental health issues in schools and the provision of more providers will ultimately expand ABA recognition beyond [autism] exclusively.鈥� Other areas of opportunity, the investment bankers鈥� materials say, include ADHD, Obsessive-Compulsive Disorder, Panic Disorder, Oppositional Defiant Disorder and PTSD.  

The one and only option

For the first few years after earning a degree in special education, Ryan Haenze, himself autistic, taught in Twin Cities school districts. His training was to let students鈥� interests steer his instruction, but this wasn鈥檛 what his higher-ups wanted. They wanted behavior management, he says 鈥� specifically, compliance. 

The kind of instruction he favored because of his autism 鈥� sensory accommodations, interactive projects and movement breaks for the kids 鈥� earned him bad evaluations. 鈥淚 had administrators saying, 鈥榃hat you are doing is not best practice. You need to physically put these kids into chairs, do hand-over-hand,鈥� ” says Haenze, meaning moving the child鈥檚 hand with his own. 鈥淚t needed to be those specific, very structured methods.鈥� 

Haenze repeatedly pointed out that those strategies often lead to explosive behavior. Once, he said, he watched helplessly as one of his third graders was removed from school in handcuffs. 

At many schools like Haenze’s, administrators adopt ABA principles because they are viewed as best practices. But other places take a more formal approach. For example, Boston Public Schools now offers ABA in every school. Between 2011 and 2021, , the number of behaviorists in the district doubled. Families with autistic kids in Cambridge Public Schools are routinely placed in ABA-aligned classrooms.

Many communities have privately operated ABA schools that students attend full time at district expense. Haenze says most of his students received therapy at ABA centers as toddlers and preschoolers. In kindergarten, they began spending half their day at school and the rest at an ABA center 鈥� a common arrangement.

However, the U.S. Department of Education鈥檚 Office of Special Education and Rehabilitative Services has warned schools not to let ABA crowd out other services that are supposed to be considered for students鈥� Individualized Education Programs. Specifically, the department said it had received reports that a growing number of children were not being evaluated by the range of professionals who typically determine what the appropriate 鈥� and under a child’s IEP, legally mandated 鈥� services are.

鈥淪ome [special education] programs may be including applied behavioral analysis (ABA) therapists exclusively without including, or considering input from, speech language pathologists and other professionals who provide different types of specific therapies that may be appropriate,鈥� . 鈥淲e recognize that ABA therapy is just one methodology used to address the needs of children with [autism] and remind states and local programs to ensure that decisions regarding services are made based on the unique needs of each individual child.鈥�

Communication support is one accommodation that has become increasingly scarce as ABA鈥檚 strategies for teaching children to be verbal have spread, says Zoe Gross, director of advocacy at the Autistic Self Advocacy Network. Because many people believe spoken words are superior, special educators often aren鈥檛 trained in the alternative technologies, she says. 

For Haenze, being an autistic teacher unable to convince his co-workers he had useful insight was maddening, he says. Receiving poor evaluations from supervisors unwilling to consider that his ideas might make classrooms calmer and students more engaged was demoralizing. Worse, he says, was neurotypical teachers鈥� misunderstanding of their students鈥� capacity for self-expression 鈥� and, by extension, their intellect.

Midway through his sixth year, Haenze quit teaching and went to work for the Minnesota Disability Law Center as an advocate.

‘I don鈥檛 ever want them to feel shame’

Given the prevalence of ABA, it is difficult even for parents who don’t want to engage with the treatment to avoid it entirely. Denise says that for a long time, she was asked at Logan’s pediatrician check-ups whether he was getting the therapy. It made her nervous to say no, over and over again, and know that answer is being entered into an official record. Eventually, though, it was so clear the boy was thriving that the conversations stopped. 

Elizabeth, too, rejected offers of ABA interventions many times, simply saying her family doesn鈥檛 think it is a good fit for Lily. She believes she got away with turning down services because her daughter doesn鈥檛 engage in many behaviors that schools typically try to eliminate.

Weber has gone a step further 鈥� choosing, based on her experience as both a therapist and an advocate for her children, not to have her autistic son diagnosed or evaluated for special education, where she would have to fight to turn down ABA-related services. 

鈥淚 am trying to avoid that,鈥� she says, choosing instead to work with the boy and his two neurodivergent brothers herself, at home. 鈥淚 don鈥檛 ever want them to feel shame. I always want to instill pride in who they are.鈥�

The 1975 passage of what is now known as the Individuals with Disabilities in Education Act established that every child, no matter how profound their needs, has a right to a 鈥渇ree and adequate鈥� public education. In 1990, the Americans with Disabilities Act enshrined in law the right of people with disabilities to enjoy the fullest possible access to jobs, housing and other pillars of a life of dignity. It meant they were entitled to have a wheelchair ramp, sign language interpreter or other forms of assistance that would help them literally take a place at the tables where discussions of their needs were underway. 

Once included, people with disabilities pushed for a shift in thinking about how disability issues should be framed. In the past, the non-disabled people making decisions about how to meet the needs of people with disabilities employed what was often described as the medical model. The goal was to determine how to make up for physical, neurological and intellectual deficits. 

Today, many disabled people prefer what they call the social model, which instead identifies systemic barriers to participation in society, including ignorance, bigotry and social exclusion. The new goal is to make the environment more inclusive and hospitable to everyone. 

Nowhere has this change of attitude been more apparent than among autistic people. Autism, once blamed on poor parenting, is now understood, in scientific terms, to be a neurotype 鈥� not a condition resulting from a lack of anything physical or psychological, but a body and brain wired differently. Not only is it impossible to fix or cure autism, many autistic adults say, it鈥檚 not desirable; autists have abilities that non-autistic people don鈥檛. 

And they are demanding a voice in how their own needs should be met. As the motto of the Autistic Self-Advocacy Network puts it: 鈥淣othing about us without us.鈥�

One flashpoint is applied behavior analysis 鈥� long described as the 鈥済old standard鈥� intervention for autism. Developed and nurtured into a multi-billion-dollar industry by neurotypical researchers, parents and service providers, ABA is now the chief therapy recommended when a child is diagnosed as autistic. 

Created in the 1980s, ABA aimed to condition autistic children to act as neurotypically as possible using punishments including slaps, electric shocks and withholding of food. Many parents saw its goals as desirable 鈥� autistic youngsters can exhibit behaviors that can exhaust caregivers and teachers, and make friendships difficult, if not impossible. Over the years, ABA has moved away from physical punishment, and many families credit the therapy with helping their child make miraculous strides. 

But many adult autists believe even its more recent methods of withholding toys, treats and attention and physically compelling patients to make eye contact 鈥� which some find extremely painful 鈥� can be extremely damaging to their mental health. Some, who have become autism researchers themselves, have documented harms ranging from dramatically higher incidences of PTSD to a debilitating focus on compliant behavior that impairs participants鈥� ability to act independently as adults.

And research from, among other sources, a multi-disciplinary team of university scholars and the 鈥� which insures thousands of autistic military dependents who have undergone the treatment 鈥� has found the evidence base for ABA thin and of poor quality. This is particularly troubling to critics of ABA, as it is often the only therapy offered to parents, to the exclusion of other, possibly more effective, treatments.

During , Julia Bascom, until recently the network’s executive director, offered an example of how changing the prism through which disability is viewed clashes with the most prevalent therapies and services:

鈥淚n the medical model, autism means that my senses are disordered. If sounds hurt me, the solution is to fix how my brain is processing those sounds, or teach me how to get used to it, or at least how to hide my discomfort. The problem is located in my body. In the social model, the solution to auditory overload is to give me a pair of headphones. 

鈥淭he social model also allows us to acknowledge complexity 鈥� that the same painful sensitivity might also make my experience with music uniquely transcendent. The same thing that makes wool unbearably itchy might also make water between my fingertips more soothing than anything else in the world. Maybe not all of those things need a 鈥榮olution.鈥� Maybe autism might need a more nuanced approach than has traditionally been offered.鈥�

There are also concerns that trying to alter a fundamental aspect of a person鈥檚 identity 鈥� especially without their consent, as in young children 鈥� violates their rights.

An assistant professor who teaches bioethics at the University of Pittsburgh School of Nursing, Daniel Wilkenfeld was diagnosed as autistic after an evaluation of one of his children 鈥� a common occurrence. ABA鈥檚 goal of trying to train youngsters to act in ways found socially acceptable is unethical, he wrote in a 2020 paper published in the Kennedy Institute of Ethics Journal.

鈥淎utism advocates are fully justified in their concerns,鈥� wrote Wilkenfeld and co-author Allison McCarthy. 鈥淭he rights of autistic children and their parents are being regularly infringed upon. Specifically, we will argue that employing ABA violates the principles of justice and nonmaleficence and, most critically, infringes on the autonomy of children and (when pushed aggressively) on parents as well.鈥�

The most basic problem, they say, is that the therapy is promoted even though it may not benefit children themselves: 鈥淚f we are correct that the use of ABA at least frequently violates the standard principles of bioethics, then this has massive implications for health care and society generally.鈥�

Like many critics, Wilkenfeld notes that ABA was developed in tandem with so-called conversion therapy used to 鈥渢reat鈥� suspected homosexuals and transgender people 鈥� in the same lab, by the same researchers. But the reasoning that soon turned the research community away from using 鈥渙perant conditioning鈥� on LGBTQ people has not been extended to autistic children. 鈥淭hankfully, most of society recognizes that being gay is not a problem,鈥� he says. 鈥淭here is less recognition that, for the most part, being autistic is a perfectly valid and helpful identity to have.鈥�

Indeed, one rarely discussed aspect of attempting to replace autistic traits with more 鈥渘ormal鈥� ones is that it can wipe out the ways in which neurodivergent people like to socialize and play. 鈥淪tims鈥� 鈥� self-soothing rocking, hand-flapping and vocalizations that some autistic people use to cope with overstimulation 鈥� can also be expressions of joy. ABA discourages both.

鈥淲ould you tolerate being told that the proper way to express happiness is to spin in circles, but then be punished when you smiled or laughed instead?鈥� Chloe Everett, a psychology student at the University of North Carolina Asheville who experienced ABA as a child, asked in a . 鈥淚 don’t think so.鈥�