Insurance companies cover more therapy, especially ABA, for autistic children
By Lawrence Diller
First appeared on March 9, 2026, in Stat News
Lawrence Diller practices behavioral/developmental pediatrics in Walnut Creek, Calif.
“Does he have autism?” Robert’s mother asked anxiously.
I’m a behavioral/developmental pediatrician working in a front-line private practice for the last 45 years in a Bay Area suburb. The family had asked me to perform an evaluation on Robert, a 6-year-old who had already been to two other expert teams. The previous evaluators said Robert (not his real name) didn’t meet the criteria for autism spectrum disorder (ASD) and found his intellectual/cognitive development to be about two years behind expectations compared to his chronological age. The technical term for Robert’s condition was global delay. Why, then, were his parents still seeking an autism diagnosis?
One reason was the occupational therapist working with Robert and his mother. She felt Robert’s failure to improve could be because he had autism. However, school systems and insurance companies were unlikely to accept her opinion because she did not have the credentials, nor had she done any formal testing of Robert. So, Robert’s pediatrician referred the family to me.
I had met the parents before meeting Robert and then spent 45 minutes with the three of them, primarily watching them play together. I knew almost from the initial greeting that if Robert was autistic, it was very mild. But in watching them I saw too good a connection between the parents and child to make autism an accurate diagnosis.
I could also judge that Robert played and talked much more like a 4-year-old than a 6-year-old. I’d also use global delay as the preferred, more accurate diagnosis.
But I felt pressure from the parents to say “autism.” The parents needed an expert to confer the autism diagnosis so that their insurance company would pay for the treatment every parent of a toddler with problems seeks: applied behavioral analysis, or ABA.
By the time I was in a training fellowship in behavioral/developmental pediatrics at the University of California San Francisco, in the late 1970s, a marked shift had taken place in experts’ opinions about autism — from blaming “refrigerator mothers” to viewing the problem as neurobiologically based. While this shift freed parents of unfair responsibility and guilt, the new consensus was that the condition was incurable and untreatable.
ASD often presents with other early developmental problems, such as global developmental delay, specific learning disorders, and language delays. In the early 1980s, when faced with how to present to parents an explanation of their children’s problems, doctors wanted to avoid the absolutely devastating prognosis of autism. They would focus instead on these other diagnoses to offer parents some hope for a connection to their child.
So, in 1987 when Ivar Lovass at UCLA first published his findings on what eventually was called ABA, they were met with skepticism. Lovass claimed that clearly autistic 2-year-olds receiving up to 40 hours of behavioral treatments a week appeared normal and could attend regular kindergartens after two years of treatment.
While no other researcher’s findings could ever quite match Lovass’ initial outcomes, many could replicate to a degree the positive results of ABA.
ABA’s success revolutionized thinking about the autism diagnosis. Desperate parents clamored for ABA treatment for their children. Initially, insurance companies and school systems resisted providing the costly, labor-intensive services. Political pressure ultimately led both to cover ABA, but only if the child met autism criteria.
Parents began pushing doctors like me to provide the autism diagnosis, so that ABA treatments would be covered by their insurance or school system. This began nationally in the late 1990s, at about the same time the rates of what is now called ASD began to rise dramatically.
What was less well known to the public but clear to developmental specialists was that ABA treatments aided not just ASD but the many different conditions causing problems in toddlers and preschoolers. Even children with global delay can benefit from ABA. A child’s cognitive and intellectual abilities will grow as long as they are exposed to a developmentally appropriate environment.
There are no treatments to speed up that development. All children will learn. Some delayed children will catch up. For others, learning at a slower rate will continue.
However, ABA treatments can address children’s behaviors that may get in the way of the learning, like tantrums and distractibility when they are frustrated. ABA can improve the rate of learning if these behaviors are interfering.
The neurodiversity-affirming movement within the ASD advocacy community has recently challenged ABA goals, which aim to teach the affected child to adapt and cope with a less specialized, “normal” environment. They say that ABA forces them to “mask” their autistic behavior and that they are ultimately harmed more than helped.
They are right in that differences are not necessarily signs of sickness. But parents of moderate to severely affected children are still clamoring for ABA.
Robert’s parents, like so many others, did not want to leave any stone unturned. However, paying for the ABA treatments themselves was just not possible. A year’s worth of 30 hours a week of ABA treatments for Robert would cost the family about $70,000. So, they were again hoping that another expert might give them the diagnosis they needed. There are tens of thousands of families with Robert’s challenges.
Diagnostic rates of intellectual delay in children have declined in recent years in parallel with the rise of ASD diagnoses. Nearly half of children with community diagnosed ASD recruited for an MRI study were found not to meet criteria when evaluated by university researchers. Most attribute the soaring rates of ASD to broader ASD criteria and greater awareness. A few, ignoring copious scientific data to the contrary, claim the rise to is due vaccines and Tylenol.
Virtually no one, however, has raised the diagnosis’ economic incentives.
I asked Robert’s parents why they were so desperate for the ABA treatments. They said they felt lost in knowing how to further help their son. I asked them specifically what Robert was doing or not doing that made them most concerned. It turned out that Robert would get very upset in transitions or when they would try to set limits with him. Having watched the family in operation, I said that I could work with them and Robert to develop parenting strategies that would be respectful of Robert’s development and more specifically tailored to his personality. The parents liked what I had to say, and the issue of his having autism or not seemed to abate, at least for the moment.
But two weeks later the parents said they were going to seek a fourth evaluation for the financial benefits the diagnosis confers. I thought they were misguided in their belief that the only approach to helping their son was through ABA.
Insurance companies are tasked to cover medical conditions only. The only way to stop this desperation for an autism diagnosis is to offer financial support and services for all conditions that affect toddlers and preschoolers, though that is very unlikely to happen soon in the U.S.
Ironically, ABA results over the decades have proven less robust as the parenting culture has changed and some of the early Lovass approaches, which some likened to “kiddie boot camp,” have been watered down.
But the push for ABA treatments and the rise of the autism diagnosis have had an undeniable economic component that has not been sufficiently acknowledged. Why have autism rates soared? In considering one of the reasons for the ASD explosion, I suggest to “follow the money.”
Lawrence Diller, M.D., practices behavioral/developmental pediatrics in Walnut Creek, Calif. He is the author of several books on child behavior and psychiatric drugs.