For more than two decades, I’ve experienced applied behavior analysis (ABA) from two deeply connected perspectives. As the father of a 22-year-old son with autism spectrum disorder (ASD), I’ve watched him benefit from behavioral interventions throughout much of his life. As a clinician and researcher, I’ve also spent more than 20 years working alongside thousands of patients, families, and clinicians who are committed to improving outcomes and quality of life for the people they serve.
That’s why the recent headlines about ABA have been difficult to read.
Stories in The New York Times, The Wall Street Journal, and TIME, along with recent OIG Audit Reports, have painted a picture of a field plagued by fraud, questionable clinical practices, and financial incentives that put profits ahead of patients. Some of those stories describe real problems that deserve serious attention. But they also risk obscuring a much larger truth.
If the national conversation about ABA becomes defined solely by its worst examples, we’ll overlook the extraordinary work happening every day across the country. We also miss the opportunity to address the real challenges facing providers who are working to deliver high-quality, evidence-based care and build the systems needed to better demonstrate the value of that care.
Yes, The Bad Actors Are Real. But They Don’t Define an Entire Field.
There is no denying that fraud exists in the ABA field. Some providers have engaged in unethical practices, manipulated billing systems, or delivered care that fell short of acceptable standards. Those providers should be held accountable, and organizations that intentionally harm patients or exploit the system should no longer have a place in this field.
At the same time, it’s important to look at the field as a whole and consider the full context of the reported data. Recent Office of Inspector General (OIG) audits have brought increased attention to ABA, but not every finding represents fraud or intentional misconduct. Many findings involve documentation deficiencies, administrative errors, or compliance issues rather than evidence of deliberate abuse. In some cases, these issues reflect unclear requirements and a lack of guidance from state Medicaid agencies rather than intent to exploit the system.
These audits highlight areas where ABA needs stronger oversight, clearer documentation standards, and better quality measurement. But they don’t show that ABA providers as a whole are engaged in fraudulent activity.
The field can’t grow if every story of misconduct is used to indict the entire profession. Meaningful reform is needed in ABA, but it requires a balanced approach: holding bad actors accountable while investing in the infrastructure that helps ethical providers deliver better care, measure outcomes, and continuously improve.
The Science on Intensity: What the Headlines Got Wrong
One of the most debated topics in ABA today is treatment intensity. Critics have raised concerns about children receiving 20 to 40 hours of therapy per week. Unfortunately, the conversation has often become oversimplified. There is no single “right” number of therapy hours for every individual. The appropriate level of support depends on the person receiving care.
A frequently cited study in this debate is the JAMA Pediatrics meta-analysis by Sandbank and colleagues, which concluded there was little evidence that increasing intervention intensity improved outcomes for young children with autism.
However, interpreting those findings requires a closer look, and when we dig deeper, several methodological flaws are revealed. For example, the analysis combined studies that differed substantially in scope, participant populations, intervention models, and outcome measures. Comprehensive ABA programs were also analyzed alongside focused interventions that targeted only a handful of skills. Studies of direct treatment for autistic children were grouped with interventions delivered to caregivers or peers. And several well-established studies of comprehensive ABA were excluded. When fundamentally different interventions are combined, it becomes difficult to draw meaningful conclusions about the relationship between treatment intensity and outcomes.
In a subsequent analysis published in JAMA Pediatrics, my colleagues and I reexamined the data while accounting for differences in children's baseline cognitive abilities. We found consistently significant, positive, and clinically meaningful associations between intervention dosage and outcomes. Once important differences among children were considered, the relationship between treatment intensity and progress became much clearer.
These findings are also consistent with a broader body of evidence. An individual participant data meta-analysis by Eldevik and colleagues analyzed data from 341 children across 15 controlled studies of comprehensive ABA and found a clear dose-response relationship. Children who received higher-intensity comprehensive intervention demonstrated greater improvements across multiple domains, including cognitive functioning, adaptive behavior, and autism symptom severity.
This does not mean every child should receive 40 hours of therapy each week. Autism presents differently in every individual, and treatment intensity should be individualized based on each person's needs, developmental profile, and response to treatment.
Modern ABA Is Not What Critics Think It Is
Some of the criticism directed at ABA today reflects practices and perspectives from decades ago. As a relatively young field, ABA has undergone significant evolution throughout my career. Researchers and clinicians have continued to refine our understanding of autism, expand the goals we target, and improve how we support learners.
Yet, many conversations about ABA today focus on approaches that don’t reflect the best practices of modern care. Today’s ABA begins with a deep understanding of the individual: their strengths, challenges, learning history, motivations, and family dynamics. It’s not rote conditioning. It’s individualized, evidence-based clinical care.
Modern ABA targets the full spectrum of skills needed for adaptive functioning, such as communicating needs, engaging with peers, sustaining focus, and building independence. Many of these skills emerge naturally during a session, in transitions, in the hallway, or between structured teaching activities. A skilled clinician recognizes these moments and incorporates them into treatment in ways that reflect the natural flow of the individual’s life. This complexity is what the critics miss when they describe ABA as mechanical or rigid.
Families who have had poor experiences with ABA deserve to be heard and acknowledged. They also deserve to know that the field has changed, and that today’s best practices reflect decades of research, clinical experience, and ongoing commitment to improvement.
The Real Problem: We Need to Make Quality Care Visible
Most ABA providers genuinely strive to deliver ethical, quality, and compliant care. The challenge is not a lack of quality. It’s a lack of infrastructure to measure, document, and demonstrate that quality.
A typical therapy session generates far more clinical information than a traditional session note can capture. Much of it comes from planned teaching activities. But many naturalistic learning opportunities also emerge throughout the session: a child responding to a peer in the hallway, a moment of joint attention before instruction begins, or an independently completed transition. These are important clinical events that help clinicians understand progress and guide treatment decisions.
Beyond these individual moments, providers need better ways to measure factors that impact quality care, such as the number of distinct behaviors addressed, rates of skill acquisition, treatment fidelity, and a patient’s learning trajectory. Together, these measures would create a much richer picture of treatment than a brief narrative progress note alone.
This documentation gap has real consequences. Without the ability to capture the whole picture, securing authorizations becomes more difficult, opportunities for clinical improvement are limited, and it’s harder to demonstrate the impact of ABA services.
Closing this documentation gap requires two complementary forms of measurement. First, providers need rigorous, standardized assessments that identify the skills and behaviors most important for each individual and support meaningful outcome measurement. Second, providers need standardized therapy process metrics that capture what actually happens during treatment.
Modern technology makes this possible at scale. Mobile data collection allows behavior technicians to document clinical information at the point of care. And advanced analytics help transform that information into actionable insights that enable providers to continuously refine treatment.
When clinicians have access to better data and spend less time on administrative tasks, they can focus on what matters most: delivering high-quality, individualized care that promotes optimal outcomes.
What Comes After the Bad Actors Are Held Accountable?
The work to identify fraud, improve oversight, and hold the bad actors accountable is necessary. But it’s only the first step.
The next step, one that has been largely missing from the conversation, is to create an environment where high-quality providers have the resources and infrastructure to continue improving. That means investing in the workforce, increasing BCBA and RBT retention, supporting continuing education, and building the systems needed to measure and communicate quality of care.
Broad policy changes, such as across-the-board rate cuts or limits on hours of care, risk affecting providers who are committed to delivering high-quality services. In a field that has made significant progress toward continuous improvement, these actions do not represent meaningful reform. They risk moving the field backward.
The future of ABA depends on value-based care (VBC). As the field weeds out the bad actors, there must be an equal effort to reinforce those dedicated to continuous improvement and capable of reliably demonstrating quality outcomes.
A Field Ready for Its Next Chapter
I’ve witnessed ABA at its best. I’ve seen the progress my own son has made, and I’ve seen it as a clinician working alongside thousands of patients and their families.
ABA is still a developing field. Similar to other disciplines, it continues to build the infrastructure needed to measure quality, demonstrate outcomes, and continuously improve care at scale. That process is a natural part of the evolution of any field committed to serving people better.
The next chapter of ABA depends on a shared commitment to standardizing how we collect, analyze, and use data. By measuring both what happens during therapy and the outcomes achieved over time, providers can better demonstrate their value, clinicians can make more informed decisions, and individuals and families can have greater confidence that they are receiving the quality care they deserve.
The Conversation Doesn’t Stop Here
Watch the full roundtable discussion on what quality ABA looks like
and how to make it visible.
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