The autism therapy industry is dominated by applied behavior analysis (ABA), so much so that it is largely the first and only option of insurance-covered services geared toward the condition.

In no small part, ABA’s centrality and dominance have been enabled by private equity’s interest in the industry and the relatively new 50-for-50 state autism therapy services mandate. The availability of investor dollars makes autism therapy providers that exclude ABA much less common than ABA-exclusive or ABA-inclusive care models.

Organizations are increasingly incorporating services other than ABA into their offerings. In the best cases, non-ABA care is integrated as part of a whole-person approach,  but that’s not always the case. Those services include some combination of speech therapy, occupational therapy and physical therapy in addition to ABA. These models de-emphasize ABA and place it in line with other therapies, a stark contrast to the industry’s ABA-first-and-only past. However, several experts tell Autism Business News that total abandonment of ABA is somewhat unlikely to become the norm.

“If you can run a clinic where you have all those services combined [that] work in collaboration, that is the superpower of what can be done,” Mike Cairnes, CEO and president of JoyBridge Kids, told ABN. “The challenge is that it’s stupid hard to pull off. But once you get it and figure it out, it’s absolutely the way to go because it is what will accelerate the development of these kids.” 

The Mount Juliet, Tennessee-based provider was founded in 2020. It operated two locations before securing investment from Charleston, South Carolina-based Frontline Healthcare Partners. Today, it operates 12 clinics across Georgia, North Carolina and Tennessee.

Cairnes met Joybridge Kids founder Rogers Clayton and joined the company in 2021, the first year the company began treating patients. The early ideals of the company called for a multidisciplinary approach because it’s “in the best interests of the children as well as for the families,” he said.

But what about a no-ABA care model?

The care model at JoyBridge Kids holds ABA “at the core.” This is similar to any number of other providers that seek to add alternative forms of treatments for those with autism, including SPOT therapies and other services, including medical specialties. Some of these companies include Cortica, Gracent and MySpot.

One relatively new provider excludes ABA altogether. McLean, Virginia-based Positive Development centers its model on developmental relationship-based intervention (DRBI), which focuses on improving symptoms by using the parent-child relationship. It also offers mental health care, occupational therapy and speech therapy.

Positive Development decided to diverge from mainstream care models for both economic and clinical reasons. From a clinical standpoint, the company believes that DBRI better affirms a child’s neurodivergence and motivates lasting improvements by requiring engagement and buy-in from parents.

Strategically and economically speaking, the company seeks to provide what the company says is a clinically effective alternative to ABA-centered care models.

“Each child is an individual with different needs; each family has its own culture and values, and our understanding of neurodiversity is about building on strengths,” Dr. Josh Feder, executive medical director for Positive Development, told ABN. “Despite calls from families for more quality options, the vast majority had no choices. We saw this as an opportunity to create more personalized forms of care for each child and their specific needs, paid for by insurance.”

Mike Suiters, the company’s CEO, also noted that a plethora of providers offer ABA. While other providers offer DRBI on its own or as a suite of services, Suiters said, most aren’t covered by insurance or aren’t reimbursed well enough at scale to be accessible.

Suiters says Positive Development has been able to get wide coverage for its services because its model requires fewer hours compared to ABA-centered models. Therefore, the company can serve more children each week. “We also require higher rates per hour than typical ABA programs to make our economic model work.” Suiters said.

However, Suiters maintains that the lower intensity level and positive outcomes lead to significant overall savings compared to ABA-center care models. He maintains that ABA is now a major spending item in the behavioral health payer budgets. It’s fast-growing too. This motivates payers to seriously consider alternatives. The company also engages in several alternative payment models that require care quality, outcomes, costs and demographic data tracking.

“High-quality, low-cost developmental therapy is the most straightforward solution to this issue, and as a result, payers representing over 60 million Americans have adjusted their medical policy to cover our developmental therapy over the last five years,” Suiters said.

The company has also been able to woo investors with its approach.

In June, Positive Development disclosed that it secured an investment from Healthworx, the investment arm of the nonprofit Blue Cross Blue Shield health plan Carefirst Inc. Public documents available at the time state the company secured about $10 million of a $12 million round.

What won’t work

Adnan Bhanpuri, an owner of Treehouse Pediatric Therapy, maintains that lower levels of the right therapies are preferred.

Based in Chicago, Treehouse Pediatric Therapy didn’t start off specifically seeking to treat those with autism.

The company was founded by Iymen Bhanpuri, wife to Adnan, in 2012. Iymen was a physical therapist who had previously worked in hospital systems. The practice originally offered physical therapy and occupational therapy and added ABA in 2020. It recently hired a licensed clinical social worker to offer pediatric mental health services.

Treehouse Pediatric Therapy operates two locations and employs about 40 people.

“The idea is that we’re a place where mom and dad can come, and they’re truly getting all the services for their child as needed from one coordinated care team,” Bhanpuri said. “In the future, I think the models that work are those where a child gets all those services under one roof, where [providers] nail them all together.”

Bhanpuri maintains that ABA-centric legacy models “overtherapize” — provide too much therapy — to children. But he also maintains that the ABA of yesterday is not the ABA of today. Plus, in models where ABA is “not the main part,” families have more time to engage in other activities meaningful to the family.

Bhanpuri doesn’t embrace the traditional high-number-of-hours ABA model but said it can’t be excluded out of hand.

“[ABA] will always be a portion of care, but it’s likely to be less in the past,” Bhanpuri said.

Anya Perea, CEO of Jade Health, said the accreditation body has sought to standardize ABA within the clinical “toolbox” the industry has to work with. Other treatments shown to improve the lives of those with autism are also encouraged.

“What I don’t recommend and am passionate about is not villainizing or polarizing one treatment over another,” Perea said.

Perea, who was trained as a licensed clinical social worker (LCSW), compared autism therapy models to treating patients with depression worsened by grief through either talk therapy or psychedelic-assisted therapy. One may be more appropriate for each patient, and vice versa.

“Is one better or worse than the other? No. … You would have to look at a slew of other factors.”