Over the past five years, the Department of Defense (DoD) has spent over $1.53Billion on ABA services, serving almost 16,000 individuals with ASD. The average cost per participant in FY2019 was $23,253. In 2016 Congress authorized funding for a report to examine whether the ABA services they have been paying are effective. Like all military health insurance services, these services are administered through TRICARE Insurance, health care program for United States uniformed service members, retirees, and their families around the world.
With 3,794 participants, this is the largest study ever conducted of ABA effectiveness. The 31-page report entitled, “The Department of Defense Comprehensive Autism Care Demonstration Annual Report 2020” concluded that “ABA services are not working.”
Specifically, they state (page 24 of the report):
“… these findings demonstrate that … the delivery of ABA services, is not working for most TRICARE beneficiaries in the ACD.”
“ … the Department remains very concerned about these results, and whether the current design of this demonstration, as well as ABA services specifically, is providing the most appropriate and/or effective services to our beneficiaries diagnosed with ASD.”
This was the second report prepared for Congress by the DoD reporting that ABA was not an effective therapy for individuals with autism. In last year’s report of over 709 individuals with autism, 76% showed no improvement after one year of treatment, 16% had improved, but that 9% were worse after a year of treatment. For both studies, results are based on the Pervasive Developmental Disorder Behavior Inventory (PDDBI; Cohen & Sudhalter, 2005). The PDDBI is a rating scale completed by parents, every six months.
In addition to the PDDBI, two other outcome measures were required as part of the Department of Defense Comprehensive Autism Care Demonstration: the Vineland Adaptive Behavior Scale – Third Edition (Vineland – 3) which is a measure of adaptive behavior functioning; and the the Social Responsiveness Scale, Second Edition (SRS-2) which is a measure of social impairment associated with ASD. (Data from these measures were not reported, as no participants had the necessary two years of baseline data required for these assessments.)
Analysis-1: Pre/Post changes in PDDBI scores over 18 months:
In this report, they looked at pre-post (no control group) changes in PDDBI scores after 18 months. While they found small, but statistically significant gains in PDDBI scores, they concluded that though statistically significant, “it is unclear if any of the change is of clinical significance.” (page 19). In other words, just because something was statistically significant, didn’t mean that the effect was meaningful. Moreover, they pointed out that without a control group, it was not possible to attribute the gains to ABA, or maturation over time, because some of these kids were undergoing other treatments simultaneously.
Analysis-2: Relationship of Number of hours of ABA services with PDDBI scores:
If ABA is causing the PDDBI scores to improve, then one would expect that the more hours of services, the higher the PDDBI score. This was NOT the case; there was no correlation between hours of ABA service and improvement in PDDBI scores. In fact, some of the subgroup analyses showed a negative relationship, i.e., the more ABA hours of service, the poorer the scores on the PDDBI. “In other words, the number of hours rendered does not appear to impact outcomes.” (page 21).
Research Review – In addition to their own lack of evidence of the effectiveness of ABA, the researchers reviewed other medical studies. They report that:
“Two well-respected medical literature review services, external to DHA, continue to find the evidence for ABA services (Intensive Behavior Intervention) for the diagnosis of ASD is weak….” (page 15)
“The research literature available regarding ABA services predominantly consists of single-case design studies which does not meet criteria for “reliable evidence” under TRICARE standards.” (page 16)
Department of Defense Comprehensive Autism Care Demonstration is the only large-scale study ever conducted of ABA. The only conclusion one can take away from this report is that ABA is not effective.
Some might argue that this is only one study, compared to the many studies that support the effectiveness of ABA. Based on a count of studies, this might be true. But in a proper meta-analysis, inclusion should be weighed by the number of participants in each study. When weighed against this large-scale study, adding those single-case studies would be little more than rounding errors; their effect would not be merely negligible, they would be invisible.
This blog reported on the lack of evidence of the effectiveness of ABA. My previous blog (https://therapistndc.org/fundamental-research-problems-bcs-asd/), presented the case against the Board Certified Specialist in Autism Spectrum Disorders (BCS-ASD) that ASHA seems to be encouraging. A later blog will report on research questioning the safety of ABA.
ABOUT BARRY R. NATHAN, PhD
Barry R. Nathan, Ph.D., is the Advocacy Initiative Co-Chair for the Therapist Neurodiversity Collective. Barry is an organizational psychologist and founding director of Concierge Pittsburgh, a regional initiative to retain and attract African American professionals in Pittsburgh. Barry’s wife, Janice Nathan, is a certified speech-language pathologist who specializes in helping autistic children and neurodivergent children.