Monday, July 10, 2023

The American Medical Association Withdraws Support for ABA and Opens the Door for More Advocacy for DIR

At the American Medical Association House of Delegates annual meeting last month, they adopted a resolution (Resolution 706) originally entitled, “Revision of H-185.921, Removal of AMA Support for Applied Behavior Analysis” (American Medical Association [AMA], 2023, pp. 1179-1182).  The old policy which is focused on health insurance coverage simply stated that, “AMA supports coverage and reimbursement for evidence-based treatment of Autism Spectrum Disorder including, but not limited to, Applied Behavior Analysis Therapy”.  Even though it was a simple policy, it gave specific support for ABA and it gave ABA lobbyists support in their efforts legislatively and otherwise to garish support for ABA that was often obtained in a way that excluded other approaches like DIR®.

Thanks to this new resolution having been adopted as amended last month, the new policy will remove the explicit support for ABA and opens the door for supporting all evidence-based services, including DIR®.  They also moved away from the word “treatment” and will use “services” instead which I think is a wonderful acknowledgment that an autistic person may need support services, but the concept of treating and fixing the autistic person as if they were broken is wrong and needed to be changed.  Furthermore, the amendments made in the meeting expanded the language to widen the lens from just Autism Spectrum Disorder to include “neurodivergent individuals”.  These are all much needed updates.

The reality is this policy will most likely sit quietly among countless AMA policies, but it is an important one for all of us that have been working to raise awareness about the limitations and problems with ABA and for those of us that have been advocating for DIR®.

While a handful of you that read this blog may see the policy at some point, very few will probably ever see the language within Resolution 706 that gave the supporting rationale for the new policy change.  The rational provided is impressively well crafted and includes many of the exact things we have been including in our advocacy work here at ICDL.  It also includes acknowledgement of the research supporting DIR® as an evidence-based approach (which we obviously know, but it is good to see it being referred to correctly more often now).  So, I am going to include all the “Whereas” resolution rationale here for you.  Take a read, it is quite good.  You can view the entire resolution in the referenced document as well if you want.  It includes all of their citations to support these “Whereas” statements. 

From the AMA House of Delegate Handbook:

Whereas, A 2018 study from the Centers for Disease Control and Prevention (CDC) estimated the prevalence of autism spectrum disorder (ASD) among [children] aged 8 years to be 1 in 44; and

Whereas, Applied Behavioral Analysis (ABA) is currently the most widely available and commonly used state-funded form of autism therapy in Canada and the United States; and

Whereas, Autism treatment represents a fragmented industry that consists of a mixture of for profit and nonprofit organizations, with the top nine for-profit chains estimated to have a combined revenue of $547 million and a market value close to $2 billion with future growth expected; and

Whereas, An ABA software company reports over 3 billion in claims processed annually for about 1,300 practices highlighting the prevalence of ABA use as an intervention for individuals with autism; and

Whereas, Autism Speaks lists 3,194 centers across the United States who offer ABA therapy as of 2022; and

Whereas, ABA was conceived in 1961 by Dr. Ole Ivar Lovaas to condition neurotypical behaviors in children he viewed as “incomplete humans”; and

Whereas, Desired behavior is often defined by the adult or behaviorist without input or requirement of consent from the child and may include non-harmful stimming or coping behaviors; and

Whereas, ABA uses behavior modification techniques to eliminate behaviors deemed undesirable; and

Whereas, ABA practices are historically based in abuse such as holding autistic children's communication hostage through the use of their devices as leverage, and denying basic rights such as food and toileting privileges; and

Whereas, Modern ABA still abides by the founding principle of making a child appear “normal” or “indistinguishable from one’s peers”, which serves to separate the humanity of the individual with autism from desired behaviors; and

Whereas, A 2018 study found that Adults with autism who have received ABA are more prone to suicide; and

Whereas, ABA has been repeatedly linked to Post Traumatic Stress Disorder (PTSD), with 46% of 460 ABA participants meeting the diagnostic threshold for PTSD in an online survey; and

Whereas, Adults with autism have been continuously outspoken about the trauma incurred by ABA practices experienced in their childhood; and

Whereas, A 2012 literature review found the evidence base for services for adults with an ASD to be underdeveloped; and

Whereas, A 2018 Cochrane review recommend further research after reporting very weak evidence in support of ABA; and

Whereas, A 2022 informal online community survey found that 71% of adults with autism responded “disagree” or “strongly disagree” to the statement “Generally speaking, I support ABA therapy for autistic children”; and

Whereas, A 2020 Department of Defense report demonstrated a lack of correlation between improvement in symptoms and hours of direct ABA services, found that the improvements recorded were due to reasons other than ABA services, and ABA services did not meet the TRICARE hierarchy of evidence standard for medical and proven care; and

Whereas, A 2021 study on conflicts of interest (COIs) in autism early intervention research found COIs to be prevalent and under-reported, with 70% of studies containing a conflict of interest and less than 6% declaring them as such; and

Whereas, Current research supports alternatives to ABA such as the Developmental, Individual Differences, and Relationship-based (DIR®) program, the PLAY Project, individualized Early Social Interaction (ESI) and, Social Communication, Emotional Regulation, and Transactional Support (SCERTS®); and

Whereas, Current AMA policy supports the use of ABA through its advocation of coverage of ABA and the evidence-based treatment for autism and fails to recognize its harms or controversial nature within the community at large;

therefore be it RESOLVED… (American Medical Association [AMA], 2023, pp. 1179-1182)

As the proud leader of ICDL, I am thrilled to see our advocacy work making a difference.  It never moves as quickly as I would like, but it is moving and moving in the right direction. 

This is also an important step for all those in the broader DIR community outside of ICDL that have thought they needed to adopt aspects of ABA into their work, have been trying to combine ABA and DIR in some way, or think they have to use a service delivery approach modeled after ABA.  I understand that some thought this was the best strategic stance to take, but it is not the stance ICDL has taken nor will take.  DIR® is an evidence-based and effective approach to promote human development.  It is respectful, joyful, and allows each person to grow and develop in the context of their own authentic self.  I thank all of you who have stood with ICDL as we have held to our values with faith that others would fully recognize the limits and problems with ABA and would see the wonderful benefits of DIR®.  I am glad the AMA is moving in the right direction and I am hopeful others will follow. 




American Medical Association. (2023). AMA House of Delegates handbook (2023 Annual Meeting). American Medical Association .


  1. YES!! Keep up the amazing work!

  2. Finally! It is a great start!

  3. Felicidade! Precisamos mostrar ao mundo que existe uma alterativa mais humanizada e respeitosa para o acompanhamento das pessoas neurodivergentes!

  4. So great to hear!!

  5. “DIR® is an evidence-based and effective approach to promote human development.  It is respectful, joyful, and allows each person to grow and develop in the context of their own authentic self.”

    My hope is that more and more of us continue to understand the profound value of this statement. My family is beyond grateful to have found ICDL at the beginning of our journey. The evidence is in how our child has flourished, continues to grow while being his ‘authentic self’.

    This is such great news! Thank you for sharing and to everyone involved.

    1. Thank you for picking that quote to highlight. DIR provides such a wonderful balance that can help parents and professionals live up to their responsibility to help their children grow, but it does it in a way that honors and respects who the child is inside themselves. It really helps that authentic self gain voice and helps the child share who they are with the world while still challenging them to grow and develop at the same time. I am so glad you found ICDL and DIR. Best wishes on your continued journey.

  6. <3 <3 <3 <3 so wonderful to see this work being acknowledged for the incredible impact it has on our children!

  7. This is such great news and validates us clinicians who have been working hard for years to present a better way to work with children with Autism that is truly person-centered. Thank you for sharing!

  8. Best news ever!! We would not be where we are today if it wasn't for our early intervention therapists educating us about all the benefits of DIR. We are so truly thankful that we found DIR, as our area is mostly all ABA. That being said, we are now looking for extended DIR based to serve beyond the 2nd grade, or any educational services that are not so rooted in ABA to continue with his success throughout his educational journey.

  9. BRUNO SOARES DE OLIVEIRAJuly 12, 2023 at 5:22 PM

    Parabéns pela pesquisa e excelente trabalho algumas crianças simplesmente não conseguem se encaixar no padrão da "sociedade" e naturalmente tem incríveis habilidades a serem desenvolvidas.

  10. My son is autistic and is currently no longer using ABA services. His technician was amazing with him because she worked with who he was. Her supervisor or BCBA would come once or twice a week and swear my son was making NO progress because she could not get him to follow her plan and achieve the ABA milestones by a set time. He literally went from only making sounds to saying his ABCs, naming certain animals, saying "goodbye." Her exact words to me "he has not made any progress.

  11. Hi there! I tried to do some more research on this and it looks like the resolution was actually amended to the point of it not mentioning ABA specifically. They have not officially withdrawn support for ABA due to the new wording of the resolution. Hopefully it will be under review again and they will fully withdraw support in the future!

    1. Thank you for your comment. I understand what you are saying, but the fact that they removed ABA out of the policy that was previously specifically focused on ABA, in the policy title and content, is the end result of them withdrawing support for ABA. The actual policy itself is very short. The rationale and justification for the policy is much more extensive than the policy itself. That is I focused on the “Whereas” statements in my blog because they are so strong and never actually get into the policy. It will be very important for DIR advocates to understand and be able to talk about the rationale behind the change since the removal of ABA from the policy title and content and changing the policy to support all evidence-based services may seem minor to someone that does not know the history and the full text of Resolution 706 that led to this policy change. I hope this helps to clarify it a bit.

  12. There are doctors who refuse to help if you are not doing ABA even if you are doing speech or OT. There are doctors who claim they cannot prescribe anything other than ABA as they are physicians. And there are doctors who just listen to their ABA team and come in the way of general education placement. This move of removing ABA from the AMA policy will help keep such doctors in check and allow parents the choice of different services and also have their children integrate into community and promote inclusion.

  13. I am doing a capstone final project on gestalt language processing, in the treatment portion I am now including a footnote for ABA (which I have always hated and refuse to do) with this information, do we know which 2018 study they are referring to? I looked at the original document but can not find a reference page for it. Thanks

    1. I am not sure which study you are asking about. If you follow the link I included to the full document, each of their footnotes are referenced. There are a few 2018 studies they reference. Feel free to email me if you want to discuss more. We can figure it out.

  14. LARISSA SENA PEREIRA GONÇALVESJuly 23, 2023 at 10:44 AM

    Wonderful! In Brazil ABA has become a lobby! A lot of money involved! My criticisms of behavioral therapies are continuous!

  15. So is this stating that DIR services will be covered by insurance?

  16. No, not necessarily. However, it does support future supportive advocacy from AMA as we work to get broader insurance coverage for DIR. It is a nice step in the right direction.

  17. Thank you for the insightful update! The American Medical Association's withdrawal of support for ABA is a positive step, paving the way for increased advocacy for DIR. Awc Behavioral Health LLC


Thank you for your comment. -Jeff