The Comprehensive Autism Care Demonstration: Solutions for Military Families (2025)
Chapter: 1 Introduction
1
Introduction
Autism1 is a lifelong, complex neurodevelopmental condition characterized by differences in social communication and interaction and restricted or repetitive behaviors, all of which can greatly affect personal, occupational, and academic functioning. Autism is often accompanied by other morbidities, such as intellectual disability, attention-deficit/hyperactivity disorder, depression and anxiety, seizures, digestive disorders, and others. According to recent Centers for Disease Control and Prevention (CDC) estimates, the prevalence of autism in the United States measured in children aged eight is 1 in 31 (Shaw et al., 2025). One key characteristic of autism is that it is highly heterogeneous (i.e., presentation varies from person to person), and different individuals and families are affected in a wide range of ways. Consequently, individuals vary in the services they need to manage the condition in their daily lives. Autistic individuals can be found among all racial, ethnic, and sociodemographic groups, including within military-connected families.
One hallmark of autism for many individuals is that they prefer stable routines and often have difficulties coping with change. Frequent relocations and deployments of one or more caregivers are core features of military service and can profoundly affect military families. Moves occur on average every two to three years. While these aspects of military life are difficult and stressful for all families for a variety of reasons, they are
___________________
1 While this report will generally use the term “autism” to refer to the condition, the formal diagnosis is called autism spectrum disorder. In certain instances, such as discussions of specific diagnostic criteria or to reflect precise language used by sources in the reviewed literature, the committee will use the diagnostic term of autism spectrum disorder.
additionally challenging for families that include individuals with autism or other disabilities who have increased care needs and amplified difficulties with change. Children in general are vulnerable to the additional stressors and challenges that frequent moves and deployments pose on development of productive behavior and social skills (Cramm et al., 2019).
Interventions and proper supports can help those with autism manage change and stressful situations. However, for families receiving services to support individuals with autism, relocations mean finding new service providers in new communities they may not be familiar with and that often have long wait times to access needed care. This can result in lapses of care, which can lead to regression in autistic individuals and significant stress for families.
The well-being of service members and the ability to focus on the mission at hand is dependent on, among other factors, the well-being and stability of their families (Department of Defense, 2012a; National Academies of Sciences, Engineering, and Medicine, 2019). If a family member is not receiving the necessary medical, educational, and therapeutic supports, there can be a direct impact on a service member’s ability to stay mission ready, which may, in turn, affect the service member’s decision to remain on active duty.
Since 2001, military dependents with a diagnosis of autism have been eligible to receive applied behavior analysis (ABA) services through TRICARE, the federal healthcare benefit program with approximately 9.6 million beneficiaries that include active-duty and reserve component military service members, retirees, and their families (see Chapter 3 for a history of these mechanisms and programs). ABA is one of many interventions available to support the health and well-being needs of autistic individuals. ABA services are based on the principles of behavior analysis and are designed to improve individual functioning by targeting specific skill development or reduction of maladaptive behaviors (see Chapter 5 for fuller discussion on ABA and its evidence base). In 2014, the Defense Health Agency (DHA),2 an agency within the Department of Defense (DoD), established the Comprehensive Autism Care Demonstration3 (ACD) to provide reimbursement for ABA services to TRICARE-eligible beneficiaries with a diagnosis of autism and to evaluate the appropriateness of the ABA services tiered delivery model under TRICARE. The primary purposes of this report are to review the evidence on ABA and to examine the utilization and operation of the ACD as a mechanism for the receipt of ABA services.
___________________
2 DHA is the agency that manages TRICARE.
3 The term “demonstration” here connotes a program established on a temporary basis that serves as a pilot program, demonstrating how a new policy might work. Demonstrations can be a useful way to test new approaches to providing coverage and delivering services that could reduce costs and improve beneficiaries’ outcomes.
THE COMPREHENSIVE AUTISM CARE DEMONSTRATION
To date, DHA has neither considered ABA to be a medically or psychologically necessary intervention for autism within its statutory regulations nor made a determination regarding whether evidence for ABA meets the legal requirements for coverage as a TRICARE Basic benefit4 as defined in the Code of Federal Regulations for the TRICARE program under Title 32 (see Box 1-1). Consequently, DHA maintains that ABA services are not authorized for TRICARE cost-sharing as a Basic benefit (Comprehensive Autism Care Demonstration, 2014; DHA, 2023a; TMA, 2013a).
Until a determination has been made, ABA services have been offered to military-connected families through the ACD in accordance with DHA’s separate (and limited) demonstration authority found in United States Code, Title 10, Section 1092 (see Box 1-2) as implemented by 32 C.F.R.
BOX 1-1
DoD Criteria for Reliable Evidence of Proven Medical Effectiveness
- As used in § 199.4(g)(15), the term reliable evidence means only:
- Well controlled studies of clinically meaningful endpoints, published in refereed medical literature.
- Published formal technology assessments.
- The published reports of national professional medical associations.
- Published national medical policy organization positions; and
- The published reports of national expert opinion organizations.
- The hierarchy of reliable evidence of proven medical effectiveness, established by (1) through (5) of this paragraph, is the order of the relative weight to be given to any particular source. With respect to clinical studies, only those reports and articles containing scientifically valid data and published in the refereed medical and scientific literature shall be considered as meeting the requirements of reliable evidence. Specifically not included in the meaning of reliable evidence are reports, articles, or statements by providers or groups of providers containing only abstracts, anecdotal evidence or personal professional opinions. Also not included in the meaning of reliable evidence is the fact that a provider or a number of providers have elected to adopt a drug, device, or medical treatment or procedure as their personal treatment or procedure of choice or standard of practice.
SOURCE: Definitions, 32 C.F.R. § 199.2.
___________________
4 The committee uses the term TRICARE Basic benefit(s) as presented by DHA to reflect covered services and supplies that are determined medically necessary as defined by statute (Bienia, 2023b).
BOX 1-2
Federal Demonstration Authorities
The Secretary of Defense, in consultation with the other administering Secretaries, shall conduct studies and demonstration projects on the healthcare delivery system of the uniformed services with a view to improving the quality, efficiency, convenience, and cost effectiveness of providing healthcare services (including dental care services) under this title to members and former members and their dependents. Such studies and demonstration projects may include the following:
- Alternative methods of payment for health and medical care services.
- Cost-sharing by eligible beneficiaries.
- Methods of encouraging efficient and economical delivery of health and medical care services.
- Innovative approaches to delivery and financing of health and medical care services.
- Alternative approaches to reimbursement for the administrative charges of healthcare plans.
- Prepayment for medical care services provided to maintain the health of a defined population.
SOURCE: Studies and demonstration projects relating to delivery of health and medical care, 10 U.S.C. § 1092.
§ Section 199.1(o) (see Appendix E). The authority for the ACD began July 24, 2014, and was originally set to expire on December 31, 2018. Through an extension notice published in the Federal Register in November 2017, the authority was extended through December 31, 2023; a second extension notice was published in August 2022, this time extending the authority through December 31, 2028.
A stated purpose of the ACD is to analyze and evaluate the appropriateness of the ABA tiered delivery model under TRICARE authorities (DHA, 2023a). The ACD is also charged with “determin[ing] the appropriate provider qualifications for the proper diagnosis of [autism spectrum disorder] and the provision of ABA, assess[ing] the feasibility and advisability of establishing a beneficiary cost share for the treatment of [autism spectrum disorder], and develop[ing] a more efficient and appropriate means of increasing access and delivering ABA services under TRICARE while creating a viable economic model and maintaining administrative simplicity” (Comprehensive Autism Care Demonstration, 2014, p. 34291). Of note, the ACD covers clinically necessary and appropriate ABA services only for the core symptoms of autism—that is, challenges with social communication and interaction, and restricted or repetitive behaviors or interests, as defined in the DSM-5 APA, 2013.
See Chapter 3 for expanded background on the ACD and Chapter 4 for industry guidelines and standards of care for ABA services.
COMMITTEE CHARGE
Section 737 of Public Law 117-81, National Defense Authorization Act for Fiscal Year 2022 (FY22 NDAA), required the Secretary of Defense to enter into an agreement with the National Academies of Sciences, Engineering, and Medicine (the National Academies) to conduct an analysis on the effectiveness of the ACD and develop recommendations based on such analysis. Subsequently, Section 732 of Public Law 117–263, FY23 NDAA, made revisions to the required elements and timeline for the analysis. The Committee on an Independent Analysis of Department of Defense’s Comprehensive Autism Care Demonstration was assembled in late 2023 to carry out this analysis and produce this consensus report. The committee includes individuals with expertise in a wide range of fields, including behavior analysis research, psychology, human/child development, public policy, autism spectrum disorder research, lived experience of autistic individuals and parents of autistic children, healthcare systems and public health, clinical care, neurodevelopment, and biostatistics/outcome measurement. See Appendix A for committee members’ biographies. The full statement of task for the committee is provided in Box 1-3.
Study Approach
The committee began its work in the fall of 2023. Over the course of the study, it held eight total meetings: five hybrid meetings, of which three included public sessions to gather information; and three additional closed virtual meetings to deliberate on its findings. In addition, the committee conducted a series of public listening sessions to hear from military families, ABA providers, researchers, and other stakeholders in the autism community; these were held virtually in the spring of 2024 and November 2024. See study timeline below. See Appendix B for more details on the public information gathering sessions. Presentations and discussions at three of the public sessions are summarized in published proceedings available on the project webpage.5
|
Committee appointed |
|
Orientation meeting—included initial discussions of the statement of task and data available to the committee |
___________________
5 The summary of the presentations and discussions at three of the public sessions held by the committee can be found at https://www.nationalacademies.org/our-work/independent-analysis-of-department-of-defenses-comprehensive-autism-care-demonstration-program
BOX 1-3
Statement of Task
The National Academies will convene an ad hoc committee of experts to conduct an independent analysis of the Department of Defense’s Comprehensive Autism Care Demonstration addressing nine areas as identified in Section 737, which include:
- An assessment of all methods used to assist in the assessment of domains related to autism spectrum disorder broadly, including a determination as to whether the Secretary is applying such methods appropriately under the demonstration project;
- An assessment of the methods used under the demonstration project to measure the effectiveness of applied behavior analysis in the treatment of autism spectrum disorder;
- A review of any guidelines or industry standards of care adhered to in the provision of applied behavior analysis services under the demonstration program, including parental involvement in applied behavior analysis treatment, as well as a review of the effects of such adherence with respect to dose-response or health outcomes for an individual who has received such services;
- A review of health outcomes, including mental health outcomes, for individuals who have received applied behavior analysis treatments over time;
- An analysis of the increased utilization of the demonstration program from inception by beneficiaries under the TRICARE program, to improve understanding of such utilization;
- Such other analyses to measure the cost effectiveness, program effectiveness, and clinical effectiveness of the demonstration program as may be determined appropriate by the National Academies;
- An analysis on whether the incidence of autism is higher among the children of military families than in the general population;
- An analysis on whether the diagnosis and treatment of autism is higher among the children of military families than in the general population;
- The development of a list of recommendations related to the measurement, effectiveness, and increased understanding of the demonstration program and its effect on beneficiaries under the TRICARE program.
The committee will review all available data and research on Autism Spectrum Disorder, Applied Behavior Analysis services (understanding the limitations of the TRICARE demonstration authority in accordance with statute and regulation), and interview and/or receive input from qualified Autism Spectrum Disorder experts and Department of Defense officials, including data from DHA.
The committee will produce a report that synthesizes the information gathered regarding ABA services authorized under the ACD and addresses the eight areas of interest identified in Section 737.
The committee will ensure the report provides an independent analysis with an understanding of the coverage authority of the Military Health System and TRICARE.
|
Meeting #1 with public session |
|
Meeting #2 with public session |
|
Series of six virtual listening sessions |
|
Meeting #3 with public session |
|
Institutional Review Board (IRB) approval received |
|
Data Sharing Agreement received |
|
Meeting #4 |
|
Virtual public listening session |
|
Meeting #5 |
|
DHA data received by Westat |
|
Virtual committee meeting |
|
Virtual committee meeting |
|
Virtual committee meeting |
|
Committee’s draft report enters external review |
The listening sessions were not designed to be representative and do not reflect the full range of perspectives or experiences of the autism community; however, they provided important context for understanding the experience of those enrolled in the ACD and those receiving or providing ABA services, as well as the experience of those living with autism. These sessions served as a backdrop for the committee’s review and assessment of the available empirical literature and provided context for, though not the basis of, its conclusions and recommendations.
Additionally, the committee made an open call for public feedback on the project webpage that enabled the public to submit written information for the committee to consider in its deliberations. A summary of this input can be found in Box 1-4, and comments and stories gathered as part of that process are excerpted throughout the report. These stories are relevant because they show where improvements can be made and they illustrate the diversity of needs among military-connected families regarding ABA. In these excerpts, the reader will encounter statements of those using the ACD, whose emotion-laden voices provide reminders of the challenges for families serving in the military who are also supporting individuals with severe autism and navigating complex healthcare systems.
The committee also commissioned two papers: an updated meta-analysis review of ABA comprehensive programs to examine the state of the evidence for ABA-based interventions for young children with autism (see Chapter 5); and an overview of generally accepted standards of care and practice in the ABA field for the treatment and support of autistic individuals (see Chapter 4). To gather additional information on topics raised by the public and invited presenters, the committee prepared two sets of questions for DHA. These
BOX 1-4
Summary of Public Input
During the course of the study, the committee received 95 comments from the public, including people who identified themselves as military parents, ABA providers, researchers, and other healthcare professionals. Their input reflects experiences with ABA and with the ACD, particularly changes to the ACD since 2021.
Public comments from family members regarding their child’s progress with ABA were predominantly positive. They reported gains in communication skills and reduction in interfering behaviors such as self-injury, aggression, and elopement. Families expressed being able to engage in their community and decreased family/parental stress. Some commented that the credentials of the provider working with them may affect the outcomes.
A few public comments from family members regarded ABA negatively, suggesting that ABA teaches autistic people to mask their authentic selves to assimilate into society, and attributed ABA intervention to negative mental health consequences. Others noted that the focus on ABA through the ACD has funneled attention away from other interventions like speech and occupational therapy and that ABA is not a “one-size-fits-all” for autism.
Multiple commenters expressed frustration with the variability in access to ABA services following the ACD changes in 2021. Commenters raised concerns about ABA provider availability and suggested that burdensome assessment and training requirements, decreased procedural/clinical flexibility, unnecessarily detailed audits, and lack of consistency with other insurance plans impacted provider staffing, turnover, and availability. Military parents noted difficulty navigating ACD eligibility requirements, including form completion, confusion with diagnostic forms, and having services dropped if specific deadlines were not met. Military parents also complained about the frequency, length, and intrusiveness of assessments as well as questioned their usefulness. Many comments expressed notable dissatisfaction with the regular administration of the Parenting Stress Index-Short Form and/or the Stress Index for Parents of Adolescents. Both ABA providers and military parents were also concerned about the focus on core symptoms and the accompanying restrictions limiting delivery of ABA services in schools and other settings outside the home and clinic.
Some comments questioned the discriminatory nature of the ACD policies and questioned why the diagnosis of autism has such significant barriers to care compared to other conditions. Some providers commented on the audit process being unnecessarily detailed, time-consuming, and disruptive.
questions and DHA’s responses can be found in Appendix C. References to some of these responses are made throughout the report where relevant.
The committee also completed its own review of the relevant literature as part of its work for this report. Further, to assist the committee in answering the questions in the statement of task, the National Academies entered into an agreement with DHA to acquire data on ACD participants and
additional claims data on TRICARE beneficiaries with an autism diagnosis. The committee designed analyses that were carried out under subcontract by Westat, a research and analysis company with extensive experience in rigorous statistical analysis of large healthcare and military datasets.
It is worth noting that the process to acquire the data was lengthy,6 which in turn limited the time available for analysis. As such, the committee prioritized analyses that would inform the utilization of the ACD, including comparisons among ACD participants compared to autistic individuals who did not receive ABA services (see Chapter 6). Description of the methodologies for the data analyses can be found in Appendix D.
Study Scope
By design, this study and report focus specifically on the ACD, its history, recent changes in policy and operations, and delivery of ABA services to autistic individuals within military families. In carrying out its charge and assessment of the ACD, the committee notably had to review developments in the ABA field, both the progress and professionalization of the practice of ABA (see Chapter 4) and the state of evidence from research across ABA practices (see Chapter 5).
There were aspects of its charge that the committee could not address, including assessing the cost-effectiveness of the demonstration project and whether rates of treatment of autism are higher for military families than the general population. For the former, the committee did not have access to cost information to conduct a determination of cost-effectiveness. For the latter, the committee is not aware of any research or data that would inform a reasonable comparison of treatment use between military families and the general population.
Also of note, the committee was asked to conduct “an assessment of the methods used under the demonstration project to measure the effectiveness of applied behavior analysis.” While the committee does critique methods used under the demonstration, it is not possible to scientifically determine
___________________
6 The process of acquiring data for this study involved multiple conversations with DHA in order to understand the nature of the data available to the committee and to determine which data fields to ask for across several databases, the range of which was necessary to address the questions in the committee’s charge. Once the committee determined the appropriate request for data and developed an initial plan of investigation, IRB approval was acquired through the National Academies and the request and plan with data safeguards were sent through DHA privacy office. After the data sharing agreement was made, a DHA data subcontractor prepared the requested data from its databases, de-identifying the data and preparing linking codes, and collapsing ZIP codes and small cell information to avoid personal identification. When the datasets were ready, another layer of review was required before the data could be released. Westat received the data via DoD SAFE on January 22, 2025.
the effectiveness of ABA with data collected through the ACD. The ACD is not a randomized clinical trial nor was it set up to conduct research. DHA acknowledges that it is not conducting research and that “no determinations regarding the effectiveness of ABA services have been made” in its response to committee questions (see Appendix C, Question 34).
While this report focuses on ABA, the committee recognizes that there is a range of interventions appropriate to support the needs of autistic individuals. This report is not meant to be an endorsement of ABA as better than or preferable to any of the other interventions. Some of these interventions that are covered under TRICARE, and available to those that participate in the ACD, are briefly reviewed in Chapter 2. However, the report provides only a cursory overview of the evidence and practice of these other interventions.
The committee also recognizes that concerns have been raised about ABA. These include concerns that too much attention has been directed at ABA at the expense of other interventions, that there is significant variation in the training of ABA providers and the implementation of ABA services, and that some questionable billing requests and reimbursements have been investigated (Office of the Inspector General, 2017, 2018, 2024). These are important concerns but not specifically attended to in this report. The committee, however, kept this context in mind during its deliberations.
Another critique is expressed in arguments by some that traditional approaches to ABA are overly harsh and might have encouraged autistic individuals to mask or hide certain behaviors and autistic traits to conform with social norms (Garey, 2024; Mathur, Renz, & Tarbox, 2024). However, currently, data available on the impact of ABA approaches on the mental health of autistic individuals receiving specific practices are limited. Such concerns rise from beliefs that ABA relies on compliance that may be advantageous to behavioral gains in the short term but may come at the expense of individual well-being (Allen et al., 2024; Anderson, 2023; Leaf et al., 2022); that ABA services are often presented as the only option to parents seeking supports for their children (Mathur, Renz, & Tarbox, 2024); and that autistic individuals are rarely offered a chance to consent to ABA services or research (Autistic Self Advocacy Network, n.d.). Some autistic individuals have come out strongly against ABA strategies as being highly coercive with goals aimed at normalization and compliance (Rodriguez, Tarbox, & Tarbox, 2023). Other autistic individuals report these practices as abusive and causing post-traumatic stress responses and ongoing anxiety (Anderson, 2023). Furthermore, some autistic individuals have argued that the focus of interventions, including ABA, on normalization of behaviors and reduction of autistic traits treats the person as though they are or have a problem to be fixed (Anderson, 2023; Autistic Self Advocacy Network, n.d.). Increasingly, individuals with
autism express a preference for support in ways that acknowledge and build on their strengths (Dwyer, 2022).
At the same time, many caregivers, including those caring for autistic individuals with high support needs and parents seeking early intervention, report that strategies based on ABA have provided significant support to their children and families, increased community inclusion, and reduced potentially dangerous behaviors such as self-injury or elopement (Gitmoghaddam et al., 2022). It’s also important to note that in response to criticisms, ABA researchers—often in collaboration with autistic adults—have begun to develop approaches and ethical frameworks (Contreras, Hoffmann, & Slocum, 2021; Schuck et al., 2021) for the implementation of ABA programs inclusive of neurodiversity-affirming (Mathur, Renz, & Tarbox, 2024) and trauma-informed approaches (Rajaraman et al., 2022). An example of this is the move toward more naturalistic developmental behavioral interventions which, when applied well, work with an autistic individual’s interest to support development of communication and other skills in a more collaborative way.
While it is beyond the scope of this report to fully examine the broad perspectives on interventions for autistic individuals, including those specifically around ABA, the committee acknowledges that these varying viewpoints are illustrative of the enormous diversity within the autism community. As discussed further in Chapter 2, autism presents differently in different individuals, and autistic individuals and their families have a range of options, many of which are not discussed here. This report is intended to examine (a) whether ABA is a viable and safe option to support the needs of autistic individuals; (b) whether ABA meets criteria of medically necessary services; and (c) how ABA services are delivered to military-connected families through the ACD and identify areas for improvement. The chapters that follow document the committee’s review, findings, conclusions, and recommendations. The growth in the ABA field, experiences of families, and evidence for ABA as a suitable intervention for autism are convincing. However, such findings are not meant to infer that ABA should be required or is an appropriate intervention for all autistic individuals. Autism is a highly individualized diagnosis, and therefore treatment and services should be tailored to individual needs.
Terminology
This report will generally use the term “autism” to refer to the neurodevelopmental condition characterized by challenges in social communication and interaction and restricted or repetitive behaviors. The formal diagnosis is autism spectrum disorder; thus, in certain instances, such as discussions of specific diagnostic criteria or to reflect precise language used by sources in the reviewed literature, the committee will use this diagnostic term. The
report refers both to individuals with autism and autistic individuals. The latter—an example of identity-first language—can be preferred by people who feel their condition is an integral part of their identity (Kapp et al., 2013; Taboas, Doepke, & Zimmerman, 2023; Wooldridge, 2023).
Language and word choice are constantly evolving in the medical context as well as in general use. Medical terminology is important for clinical diagnoses, medical coding and billing, and identification of medically necessary interventions. However, some of the terms used to describe a condition medically may be viewed as offensive when describing individual needs. For example, many people consider the terms “disorder,” “deficits,” “abnormal,” and/or “impairment” stigmatizing. Advances in medicine and research on neurodevelopment disabilities have challenged traditional medical models of disability and helped shift them (and, increasingly, society at large) from viewing them solely as deficits to recognizing them as variations in human cognition and development with unique strengths and perspectives (Dwyer, 2022; Pukki et al., 2022).
Similarly, for the autism community, the term “treatment” can be perceived as offensive, as in the need to find a cure, and many prefer the terms “interventions,” “supports,” or “services.” This report tends to use terms in more common use and preferred by the autism community. However, where appropriate, it uses terms such as “autism spectrum disorder,” “disorder,” “deficits,” and “treatment” when referring to medical diagnoses and definitions and terminology in ACD policies. Notably, ACD policies and industry guidelines make frequent reference to treatment plans in regard to delivery of ABA services, and this reference is retained throughout the report.
This report uses the terms “military families” and “military-connected families” interchangeably. The terms are used broadly to reference family members of both active-duty service members and non-active-duty service members in all military branches, including the reserves and retired military personnel, and others registered in the Defense Enrollment Eligibility Reporting System.7 Enrollment in the ACD is open to dependents of military-connected families enrolled in a TRICARE health plan who have an autism diagnosis from an approved diagnosing provider.8
___________________
7 For more information about eligibility in the TRICARE healthcare program, see https://tricare.mil/Plans/Eligibility
8 Approved diagnosing providers include TRICARE-authorized pediatric physicians, pediatric family medicine physicians, and pediatric nurse practitioners; physicians who are board-certified or board-eligible in developmental-behavioral pediatrics, neurodevelopmental pediatrics, child neurology, or child psychiatry; doctoral-level licensed clinical psychologists; or board-certified doctors of nursing practice, as defined in the TRICARE operations manual.
OVERVIEW OF APPLIED BEHAVIOR ANALYSIS
ABA is the application of learning theory and behavior analytic principles to address behaviors important to individual health and well-being (Baer, Wolf, & Risley, 1968; Cooper, Heron, & Heward, 2020). Interventions based on the principles of ABA are intended to use a systematic approach to understand socially important behaviors to build new skills and/or reduce behaviors that are not serving the individual. ABA providers use a range of practices based on ABA principles to promote skill acquisition and use in autistic individuals. Examples of ABA practices include discrete trial training, reinforcement, prompting, naturalistic developmental behavioral interventions, and task analysis that can teach skills including communication and adaptive skills (Wong et al., 2015). ABA practices follow behaviorist theories that suggest that behavior is caused and molded by external stimuli in the environment, including things that happen before a behavior occurs (antecedent) and those that happen after (consequence). Most ABA services use what is referred to as an A-B-C approach for addressing behaviors—that is, identifying antecedents, the resulting behavior, and subsequent consequences (Autism Speaks, n.d.a). However, more modern approaches also consider developmental science, sensory differences, and individual preferences when developing goals and specific ABA strategies.
While ABA practices can be used to target specific behaviors (e.g., self-injury), comprehensive interventions address a wide range of outcomes, including developmental, learning, motor, daily living, social, and/or behavioral, and often have manualized program procedures9 (Odom et al., in press). Many applications of comprehensive ABA services are characterized by “(a) beginning in early childhood, when possible between three to four years of age; (b) having a high intensity (20–40 hours/week); (c) being personalized to meet the individual needs of each child; (d) addressing several skills at the same time instead of promoting just one specific skill (e.g., joint attention); and (e) using multiple behavior analytic methods” (Eckes et al., 2023, pp. 1–2). ABA services, as discussed later in this report, need to be individualized and developed in coordination with autistic individuals, their families, and other healthcare providers to address specific support needs and be structured to fit the family environment and in the context of other developmental services. A more detailed overview of ABA and its history, programs and practices, implementation, evidence-base, and outcomes is included in Chapter 5 of this report.
___________________
9 In other words, interventions that are performed according to specific guidelines for administration, maximizing the probability of being conducted consistently across settings, providers, and clients (APA dictionary).
ORGANIZATION OF THE REPORT
Following this introductory chapter, Chapters 2 and 3 provide background for readers: Chapter 2 provides an overview of autism, including estimates of prevalence and a description of the evolution of autism diagnosis and its impact on military families, and Chapter 3 traces the history of coverage of ABA under various DHA mechanisms, including the ACD and recent policy changes. The rest of the report captures the committee’s different literature reviews and data analyses and its findings from this work. Chapter 4 outlines recent developments in the ABA industry and standards of care and compares policies on key aspects of ABA delivery across the ACD, commercial payors, and industry guidelines. Chapter 5 examines the scientific literature and evidence base on ABA. Chapter 6 presents data on the characteristics of ACD participants, drawing on findings from DoD’s reports to Congress and the committee’s independent data analyses of demographic and clinical information. The final chapter (Chapter 7) summarizes the committee’s conclusions and critique of methods and measures used by the ACD and offers a set of recommendations to improve the delivery of ABA services to TRICARE-eligible beneficiaries. A set of appendices provides biographical sketches of committee members and staff, agendas from public sessions, committee questions posed to DHA, the methodology for the data analyses conducted for this study, legislative background on the ACD, position statements on ABA from medical and health professional organizations, and a review of commercial insurance coverage of ABA.
