Alabama OT Says She Quit After a PE-Backed Buyer Added ABA Over Her Objection

When occupational therapist Rachel Ashcraft joined an Alabama pediatric therapy practice, clinician ownership mattered to her, she writes. Then a private-equity-backed company bought the practice and, against her recommendation, added applied behavior analysis (ABA), which “soon appeared to drive the company’s clinical direction.” She says she resigned because she did not believe that direction was best for children.

Her essay appeared Oct. 7 in the Alabama Reflector and on The Washington Post’s Ripple platform. Ashcraft argues that ABA “can be highly profitable” because clinics can bill more hours per child than for other therapies. She urges families to ask who owns the practice, why certain services are promoted, how recommended hours were determined, and who benefits financially.

The buyer, she writes, described itself as a public benefit corporation, said clinical leadership would remain important, and invited her to serve on an advisory board. She does not name the practice or the buyer, and her account has not been independently verified for this article.

Her Two Objections

Ashcraft, who co-edited a 2021 occupational therapy textbook on trauma, objects first on ethical grounds. She acknowledges that some clinicians consider ABA helpful, but cites harm that autistic adults and self-advocacy groups attribute to approaches that “reward compliance and treat appearing ‘less autistic’ as improvement.” She links to a May statement from the Autistic Self Advocacy Network that says ABA “does not help autistic people.”

Ashcraft is also skeptical of efforts to rebrand ABA. Some providers promote a “new ABA” or describe their approach as “trauma-sensitive,” she notes. Her response: “New language may reassure families, but it does not resolve ABA’s history or ensure that children experience genuine safety.” After examining those models and listening to autistic self-advocates, she writes, “I remain unconvinced that any version of ABA I have encountered meets a basic ethical standard.”

Her second objection concerns financial incentives. “A child may receive one to three hours of occupational, physical, or speech therapy a week,” she writes. “Intensive ABA can involve dozens of hours.” Lower-paid behavior technicians deliver much of that care under a behavior analyst’s oversight, she says, allowing clinics to bill more hours “at a significantly lower cost to the company.”

“Autistic children are not untapped markets.” – Rachel Ashcraft, occupational therapist, writing in the Alabama Reflector, Oct. 7, 2026

Ashcraft argues that expanding services may mean replacing lower-volume therapies with more billable hours per child, while acknowledging that not every ABA recommendation is financially motivated. She cites a 2023 Center for Economic and Policy Research report attributing 85% of tracked autism-services mergers and acquisitions from 2017 through the third quarter of 2022 to private equity. A JAMA Pediatrics study she cites found private equity entry associated with higher state-level childhood autism prevalence; its maps also suggested a pattern involving more generous insurance mandates.

The Field’s Record on Hours and Outcomes

The field's practice guidelines also address how recommended hours are determined. The Council of Autism Service Providers (CASP), a provider trade association, took over the guidelines from the Behavior Analyst Certification Board in 2020. The third edition was released in 2024.

A review of that edition published by the Association for Science in Autism Treatment (ASAT) summarizes its dosage section this way: “Multiple studies have shown that 30-40 hours of direct treatment per week produce better outcomes than treatment at lower dosages.” The review links that discussion to comprehensive programs that address multiple areas of development and emphasizes individualized assessment and treatment planning.

The relationship between hours and outcomes remains contested. In January, Catalight researchers published a retrospective study of 725 autistic children in the Journal of Autism and Developmental Disorders. Over one year, more treatment hours were associated with a higher proportion of individual goals met, but not with greater gains in adaptive behavior, including communication, socialization, and daily living skills. The study could not establish cause and effect. The authors said guidelines “should temper language around dosage and ABA,” while calling for more research.

An umbrella review published Oct. 1 in the same journal examined six meta-analyses covering 36 distinct studies. All six reported higher average IQ and adaptive behavior scores for young autistic children receiving comprehensive ABA than for comparison groups. The reviews overlap substantially, so they do not represent six independent evidence sets.

A National Academies committee considered an earlier version of the review in 2025. It concluded that comprehensive ABA can improve targeted outcomes, while cautioning that the underlying evidence has limitations, including small samples and a lack of randomization. In that earlier analysis, most comparison groups received usual care or programs combining different approaches.

The Ownership Question

Sen. Elizabeth Warren, D-Mass., and Rep. Maggie Goodlander, D-N.H., introduced companion versions of the Corporate Crimes Against Health Care Act in February. The proposal would require covered providers, including behavioral health treatment facilities, to report ownership, control, and financial information to the U.S. Department of Health and Human Services for public disclosure. Both bills remained in committee as of Oct. 21.

Minnesota state Sens. Zaynab Mohamed and Scott Dibble, both Minneapolis Democrats, sought greater ownership disclosure for autism providers after The 74’s investigation, the outlet reported Oct. 1. CASP chief executive Lorri Unumb told The 74 in an email: “Bad actors exist in every healthcare profession, including ABA, but that doesn’t mean they are prevalent.” She also said CASP supports accountability for fraud, waste, and abuse.

The 74’s Oct. 1 report did not include bill text or an introduction date. Under current state law, the Minnesota Legislature is scheduled to convene Jan. 12, 2027.

AT A GLANCE

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