A pediatric therapy practice in Alabama, once trusted by families, transitioned from clinician-owned to a private-equity-backed company, sparking concerns about the direction of care. An occupational therapist, who had valued the practice's independent ownership for its alignment with her professional values, ultimately resigned over changes in clinical strategy.
When the practice was acquired, the new owners described themselves as a public benefit corporation and indicated that clinical leadership would remain important. The occupational therapist was invited to serve on an advisory board. However, she later realized that this sale was part of a broader national trend; between 2017 and 2022, private equity firms were responsible for 85% of mergers and acquisitions in the autism-services industry.
Despite the occupational therapist’s clear opposition, Applied Behavior Analysis (ABA) was added to the practice's services. According to the therapist, ABA soon appeared to drive the company’s clinical direction. This shift led to her resignation, as she did not believe the new direction reflected what was best for children.
ABA is a subject of ongoing debate within pediatric therapy. While some clinicians consider it helpful, autistic adults and self-advocacy groups have described harm from approaches that reward compliance and treat appearing “less autistic” as improvement. Neurodiversity-affirming care, by contrast, recognizes neurological differences not as deficits to be extinguished, but as variations. Therapy under this model aims to support communication, regulation, belonging, participation, relationships, safety, and quality of life without making conformity the primary goal.
Some providers now promote what they call “new ABA” or “Today’s ABA,” even using terms like “trauma-sensitive.” However, the occupational therapist remains unconvinced that any version of ABA she has encountered meets a basic ethical standard, after examining these newer models and listening to autistic self-advocates. She emphasizes that children need support recognizing their own body cues, communicating discomfort, and knowing their refusal will be honored.
Beyond clinical considerations, the profitability of ABA is a significant factor. Traditional therapies like occupational, physical, or speech therapy typically involve one to three hours of care per child per week. In contrast, intensive ABA can involve dozens of hours. Much of this direct care is provided by lower-paid behavior technicians under the oversight of a behavior analyst. This structure allows a clinic to bill significantly more hours per child, at a lower cost to the company, compared to traditional therapy services. When multiplied across hundreds of children in multiple clinics, this model clarifies why autism services attract private equity investors.
Researchers have found that investors entered the autism-services market most heavily in states with higher autism prevalence and more generous insurance mandates. What is presented as clinical expansion may, in some cases, actually be the replacement of lower-volume services with a service that generates more billable hours per child.
The occupational therapist stresses that not every ABA recommendation is financially motivated. However, families deserve transparency, especially when a recommended treatment is also the company’s most profitable service. Families already navigate complex issues such as testing, waitlists, referrals, insurance, school services, and conflicting recommendations. They should not also need expertise in corporate finance, according to the therapist.
Given the prevalence of private equity takeovers in the industry, families are encouraged to ask specific questions: Who owns this practice? Why are certain services promoted? How were the recommended hours determined? And critically, who benefits financially? It is also important for families to listen to autistic people, who have spent years describing harm from therapies like ABA that taught them to suppress discomfort or obey. The therapist notes that non-autistic perspectives cannot substitute for autistic people’s lived experience.
The occupational therapist expressed her love for her colleagues, the families she served, and the work they did. She acknowledges that many clinicians continue to fight daily to provide care based on what is best for each child. However, she believes parents deserve to understand the pressures those clinicians may face, including mandates to recommend profitable services and to discount autistic voices regarding what truly helps or harms them. Autistic children, she concludes, are not untapped markets, and their needs should not be seen as opportunities for maximizing billable hours. Their families should never have to question whether a recommendation was made for the child’s best interest or an investor's best return.
