To the Editor:
Re “Autism Clinics Pursue Profits From Preschoolers” (front page, May 25):
Your investigation into applied behavioral analysis, or A.B.A., provides long-overdue scrutiny of this industry’s enormous cost and the toll it takes on patients with autism.
Evidence for A.B.A.’s effectiveness is limited and often low-quality, and high-quality studies show that more treatment doesn’t cause better outcomes. Nonetheless, providers prioritize maximizing treatment hours (up to 40 a week), exhausting autistic children and disrupting their education.
A.B.A. methods can harm children, as they focus on suppressing autistic traits, even harmless or beneficial ones like lining up toys, or self-stimulatory behavior (stimming), over autistic patients’ welfare. The methods include aversives — for example, pain, unpleasant sounds and smells, restraint and taking away possessions. Many autistic adults report trauma from A.B.A., and studies link it to increased mental health hospitalization.
States must expand access to other supports as they rein in A.B.A. Viable alternatives, such as occupational therapy and DIRFloortime, don’t use traumatizing methods or require exorbitant hours. It is vital to cover hands-on personal care and respite services for families. Reducing spending on Medicaid disability services almost always leads to substantial harm. In this case, however, covering alternatives instead of spending billions on A.B.A. would actually benefit autistic people.
Colin Killick
Washington
The writer is the executive director of the Autistic Self Advocacy Network.
To the Editor:
The article did not mention alternative services for children with autism and did not address what would happen to the children served by these centers, and their parents, should they be shuttered.
Though it mentions one misdiagnosed child who was placed in a community public school and “thrived,” there are many children diagnosed with autism who benefit from A.B.A. centers. If returned to inappropriate school placements, some of these children would engage in self-harm and injurious behaviors, such as banging their heads on the ground, biting themselves and others and throwing things while untrained teachers and aides watch, unable to assist constructively. Many others would end up at home, with hours of unstructured free time while their parents try to help.
The article does not take into account how A.B.A. can help eliminate behaviors such as aggression and self-injury. The reality of parenting a child with autism, and to understand why many of us choose to place them in these programs that offer bright and sunny classrooms with enthusiastic and warm caregivers, is hard to understand unless you experience it firsthand.
Julie Murphy
Queens
To the Editor:
Your investigation into A.B.A. clinics reveals a deeper scientific and ethical failure.
My take as a cognitive neuroscientist is this: We no longer tell an amputee to simply walk or a paraplegic person to try harder — we build prosthetics and ramps. Yet Medicaid spends billions annually for an intervention designed to make autistic children perform neurotypically, suppressing the neurological differences that define them. Research has linked intensive A.B.A. to PTSD-like symptoms in autistic adults.
Autism is not a deficit to be conditioned away. It is genuine neurological variation demanding accommodation, not correction. Our daughter is autistic and brilliant. We never used A.B.A. and don’t recommend it. We built her world around her mind. She is thriving.
Medicaid dollars must follow the science. Stop subsidizing behavioral compliance factories. Build environments for their minds — not the other way around.
David Ruttenberg
Boca Raton, Fla.
To the Editor:
The reporting on Medicaid abuses in autism treatment exposes a troubling paradox: Some autism clinics operate with less oversight than day care facilities, despite serving vulnerable, often nonverbal children. Well-intentioned Medicaid funding has been diverted to feed state-subsidized corporate greed backed by private equity, negatively affecting the reputation of the whole industry.
Corporate interests have corrupted the clinical needs of some children to serve the financial demands of investors. What can be done to fix the system? Increase regulatory oversight, including stricter licensing and accreditation practices to require more intensive teacher training, annual inspections and industry best practices for care.
Medicaid and private insurers should consider a more holistic model of payment that focuses on results over fee for service. The care of our children is too important to put in the unregulated hands of corporate profiteers.
Jessica Sassi
Southborough, Mass.
The writer is the president of the New England Center for Children.
To the Editor:
The article reports on how services for young children with autism are heavily guided by the profit motive, but even more detrimental may be the assumptions upon which A.B.A. is based: that by fixing behaviors, autism itself can be ameliorated and that if some is good, more is better.
Autism is, at its heart, a challenge of social communication. It is best addressed by focusing less on behavior change and more on supporting parents and early intervention, as well as preschool personnel who can integrate social learning into everyday experiences.
Over 20 years of research, we have achieved positive results from a developmentally based approach that aims to meet children where they are in their social learning path, support parents to guide their children’s social learning and integrate intervention into natural systems of support. (This intervention is the subject of a book to be published this fall by Teachers College Press, “Building Interactive Social Communication With Young Children.”)
This includes the early intervention programs that operate in all states to serve infants and toddlers and their families as well as preschool programs.
Hannah H. Schertz
Bloomington, Ind.
The writer is a principal investigator for the Building Interactive Social Communication Project.
To the Editor:
Your investigation into autism therapy clinics exposes a problem many families and clinicians have long recognized: when autism care is organized around billable hours rather than child development, children can be placed in programs that are too long, too narrow and insufficiently responsive.
The answer is not less care. It is better care, better oversight and real informed choice.
CareFirst BlueCross BlueShield has noted that A.B.A. programs often require 20 to 40 hours a week, while developmental relationship-based interventions (D.R.B.I.) typically require fewer hours, and support growth through play, connection and caregiver responsiveness. A 2024 paper describes D.R.B.I. as interventions grounded in children’s innate motivation for social engagement and learning and the relationships that support development. CareFirst also reported that D.R.B.I. approaches cost 68 percent less on average than comparable A.B.A. programs.
Autism intervention is not synonymous with Applied Behavior Analysis. The American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics and the American Medical Association advise that families be informed of choices of evidence-based approach to autism services.
The autism field needs standards that ensure high-quality services that make a real difference and should offer choices that are humane, developmentally focused and aligned with the child’s unique neurobiological profile and family’s parenting values.
Andrea Davis
Pasadena, Calif.
The writer is president of the Coalition for Developmental Approaches.
To the Editor:
As the clinical director of an early intervention A.B.A. clinic in North Carolina, I share concerns about unethical providers. Additional context is essential to separate ethical from unethical A.B.A. clinics.
By law, in North Carolina a child must attend school at the age of 7 or be registered as a home-school student through the state’s division of nonpublic education. This limits the hours a child can attend A.B.A. therapy.
Clinics cannot simply “fit in as many kids in a day as they could,” as one former employee at Compleat Kidz said. Board certified behavioral analysts (B.C.B.A.’s) are governed by a board which requires B.C.B.A.’s to adhere to a strict ethics code, including guidance on caseload limits.
In 2023, North Carolina required licenses for analysts and in 2026 the governor signed House Bill 696 into law, which allows Medicaid managed care organizations to oversee A.B.A. services throughout the state.
A.B.A. therapy is billed in 15-minute increments. The “seven-minute nap rule” refers to a child being woken up to participate in therapy for the required minimum of eight minutes in the 15-minute billing window. Ethical clinics recommend therapy hours based on individual needs, stop billing to allow for naps, employ experienced therapists earning over $20 per hour and provide crisis prevention training.
Parents should be educated on what questions to ask when searching for an A.B.A. clinic, regarding the clinic’s approach to affirming neurodiversity, assent, behavior reduction, stimming, caseload limits, staff turnover and nap policy.
Parents and clinicians have witnessed meaningful progress through ethical A.B.A., such as gains in communication, social skills, independent living skills and reduction in challenging behavior.
Karen Dawson
Wake Forest, N.C.
GLP-1 Use in Children
To the Editor:
Re “We’ve Missed the Point of GLP-1s for Children,” by Julia Belluz (Opinion guest essay, May 8):
As a pediatrician with a career-long passion for helping kids maintain a healthy weight, I shudder at the implications of GLP-1 use in children.
The basis of pediatric care is prevention and early intervention. Much of our time is spent in anticipatory guidance: heading off problems before they begin.
I counsel families to feed their children a diet free of preservatives, flavor enhancers and artificial colors. Kids need a restful night’s sleep. They need meaningful exercise. Less time should be spent with electronic diversions.
For starters, GLP-1s cause significant loss of muscle, which is the very tissue that burns calories.
The obesity epidemic in children demands a cultural shift and commitment to a healthy generation of our most valuable resource: America’s children.
Daniel J. Levy
Columbia, Md.
The writer is a past president of the Maryland chapter of the American Academy of Pediatrics.
