When private equity came for the clinic where I worked

I am a licensed and registered occupational therapist, and I used to work at a pediatric therapy practice that families across Alabama trusted.

When I took the job, the practice being clinician-owned mattered to me. I believed I could practice occupational therapy in a way that aligned with my values. Over time, trauma-informed and neurodiversity affirming care became central to my work.

Then the company that I loved was sold to a private-equity-backed company.

The new owners told us they were different. The company described themselves as a public benefit corporation, said clinical leadership would remain important, and invited me to serve on an advisory board.

I did not understand that our clinic was part of a larger national trend. Between 2017 and 2022, private equity firms were responsible for 85% of mergers and acquisitions in the autism-services industry.

I was clear that I opposed adding Applied Behavior Analysis (ABA) to our services. Yet, against my recommendation, ABA was added. ABA soon appeared to drive the company’s clinical direction. I ultimately resigned because I did not believe that direction reflected what was best for children.

ABA is not an uncontroversial pediatric therapy. Some clinicians consider it helpful, while autistic adults and self-advocacy groups described harm from approaches that reward compliance and treat appearing “less autistic” as improvement.

Neurodiversity-affirming care begins somewhere different. It recognizes that neurological differences are not deficits to extinguish. Therapy should support communication, regulation, belonging, participation, relationships, safety, and quality of life without making conformity the goal.

Some providers now promote a “new ABA” or “Today’s ABA”, even describing their approach as “trauma-sensitive”.  New language may reassure families, but it does not resolve ABA’s history or ensure that children experience genuine safety. Children need support recognizing and trusting their own body cues, communicating discomfort, and knowing their refusal will be honored.

After examining these newer models and listening to autistic self-advocates, I remain unconvinced that any version of ABA I have encountered meets a basic ethical standard.

But there is another reason to pay attention: ABA can be highly profitable.

A child may receive one to three hours of occupational, physical, or speech therapy a week.  Intensive ABA can involve dozens of hours. Much direct care is provided by lower-paid behavior technicians under a behavior analyst’s oversight. A clinic can then bill far more hours per child, at a significantly lower cost to the company, than traditional therapy services can. Multiply that by hundreds of children across clinics, and it is easy to understand why autism services attract private equity investors.

Researchers have found that investors entered most heavily in states with higher autism prevalence and more generous insurance mandates. What is presented as clinical expansion may actually be just replacing lower-volume services with a service generating more billable hours per child.

This does not mean every ABA recommendation is financially motivated. But families deserve transparency when a recommended treatment is also the company’s most profitable service. Families already navigate testing, waitlists, referrals, insurance, school services, and conflicting recommendations. They should not also need expertise in corporate finance.

Yet, with private equity takeovers so prevalent, they should now ask: Who owns this practice? Why are certain services promoted?  How were the recommended hours determined? And unfortunately, who benefits financially?

Families should also listen to autistic people, who have spent years describing harm from therapies like ABA that taught them to suppress discomfort or obey. Those of us who are not autistic cannot substitute our perspective for autistic people’s lived experience.

I loved my colleagues, families, and the work we did.  I know clinicians who still fight every day to provide care based on what is best for each child. But parents deserve to know what those clinicians may be up against, including pressure to recommend profitable services and discount autistic voices about what helps and what harms.

Autistic children are not untapped markets. Their needs are not opportunities for maximizing billable hours. Their families should never have to wonder whether a recommendation was made because it was the best choice for their child or the best return for an investor.