The Hidden Costs of the Medical Model in ABA: Are We Helping or Hurting?

Imagine sitting across from a family who desperately wants support for their autistic child. They trust you—their BCBA®—to help, but before you can even begin, you’re required to write a treatment plan that frames their child’s unique way of thinking, communicating, and experiencing the world as a set of deficits to be fixed.

You know this child is incredible—brilliant, creative, and full of potential. But the insurance company won’t approve services unless you list what’s “wrong” with them. You type the words: impaired social communication, restricted interests, deficits in adaptive functioning. You feel a knot in your stomach because you know this language doesn’t reflect the whole child. It’s just a means to an end—to secure funding for services that could genuinely help.

But at what cost?

Every day, BCBAs® face this ethical dilemma. We entered this field to make a difference, to empower, to uplift. Yet, the medical model forces us into a box where autism is something to be treated rather than understood and embraced. The unintended consequence? A system that often overlooks the strengths of the individuals we serve, leaving them feeling broken instead of supported.

How did we get here? And more importantly, how do we move forward?

In this article, we’re diving into the hidden costs of the medical model in ABA—how it shapes our field, the harm it can unintentionally cause, and what we can do to shift toward a neurodiversity-affirming approach that truly honors the dignity of the people we serve.

Let’s rethink how we define success in ABA—together.

Key Takeaways

• The medical model in ABA requires providers to frame autism as a disorder to justify insurance coverage, reinforcing a deficit-based approach.

• This system prioritizes impairment over strengths, which can negatively impact autistic individuals' self-perception and well-being.

• BCBAs® can shift their language in treatment plans to focus on skill-building and autonomy rather than compliance and deficit reduction.

• Neurodiversity-affirming ABA emphasizes self-advocacy, flexible communication, and individualized support rather than enforcing neurotypical norms.

• Practical strategies include reframing goals, educating caregivers and RBTs, and advocating for policy changes to reduce reliance on deficit-based narratives.

• Research supports strength-based goal setting, which leads to better long-term outcomes, including increased self-determination and improved mental health.

• Systemic change requires individual action, including revising treatment plans, engaging in professional discussions, and pushing for more ethical insurance policies.

The Medical Model in ABA: A System Built on Deficits

ABA therapy is widely recognized as an evidence-based approach for supporting autistic individuals in developing meaningful skills. Yet, every BCBA® working within the insurance system knows the challenge that comes with it: to provide services, we must first frame autism as a disorder that requires treatment.

This is the reality of insurance-funded ABA. In order for services to be approved, they must meet strict medical necessity criteria, which means treatment plans must emphasize impairments, skill deficits, and behaviors that deviate from neurotypical development. The intent may be to ensure access to care, but the impact can be harmful—both for the autistic individuals receiving support and for the BCBAs® striving to practice ethically.

Why Is ABA Tied to the Medical Model?

Most insurance policies classify ABA as a treatment for autism spectrum disorder (ASD) rather than a framework for individualized support. To meet medical necessity, BCBAs® must:

• Identify functional impairments that justify the need for intervention.

• Describe deficit-based goals that align with insurance criteria.

• Demonstrate that the individual is not meeting “typical” developmental expectations.

This requirement forces treatment plans to include language such as “deficits in social communication,” “impaired adaptive functioning,” and “maladaptive behaviors.” These phrases are not just descriptors of challenges; they are required to secure coverage. As a result, ABA providers must highlight what an individual cannot do, rather than what they can.

The Deficit-Based Language Trap in ABA

For many BCBAs®, this creates an ethical dilemma. In practice, we work to build autonomy, self-advocacy, and meaningful communication—yet our documentation must frame these same individuals in terms of deficits. This contradiction can be frustrating—not only for providers but for autistic individuals and their families, who may feel that their strengths are being ignored in favor of a focus on impairments.

Research suggests that this deficit-focused approach has broader consequences. Mathur, Renz, and Tarbox (2024) argue that when ABA is framed solely around impairments, it reinforces stigma and limits autonomy. By requiring clinicians to emphasize what autistic individuals lack rather than what they can build upon, the medical model contributes to a system where autism is positioned as something to be "treated" rather than understood and supported.

Pathologizing Neurodivergence: The Unintended Consequences

When ABA providers must frame autism-related behaviors as symptoms that require reduction, it can have significant unintended consequences:

• Masking and suppression of authentic behaviors. Many autistic individuals learn to hide their natural tendencies, such as stimming, to conform to neurotypical expectations. This can lead to long-term stress and burnout.

• A focus on compliance over autonomy. If interventions emphasize following directions without question, individuals may struggle with self-advocacy in adulthood.

• Increased mental health challenges. Studies have linked deficit-based approaches to higher rates of anxiety, depression, and internalized ableism among autistic individuals.

This raises a crucial question: If ABA is meant to improve quality of life, why is it tied to a system that requires clinicians to focus on what an individual lacks rather than what they can achieve?

Barring a complete overhaul of insurance policies, BCBAs® must find ways to navigate medical necessity requirements while ensuring their practice remains affirming and ethical. Understanding these challenges is the first step toward meaningful change.

🎧 Listen to our podcast episode about The Medicalizaation of Autism on Action Insights: The Intersection of ABA and Mental Health to explore this issue in-depth and earn 0.5 CEU while joining the conversation.

Moving Toward Neurodiversity-Affirming ABA

The limitations of the medical model in ABA are clear, but change is possible. While insurance companies still require treatment plans to emphasize deficits, BCBAs® can make small but meaningful shifts in language and practice that align with a neurodiversity-affirming approach. These shifts don’t just help practitioners feel more ethical in their work—they directly impact how autistic individuals experience services and how they see themselves.

Shifting the Focus from Deficits to Strengths

One of the most powerful changes BCBAs® can make is reframing how goals are written. Instead of emphasizing the reduction of “problem behaviors,” we can highlight skill-building and autonomy. Below are examples of traditional deficit-based goals and how they can be reframed in a way that is more affirming and functional.

Stereotypic Behavior (Stimming)

• Deficit-Based Goal: Decrease hand-flapping by 80% in structured settings.

• Neurodiversity-Affirming Goal: Expand coping strategies for self-regulation, allowing for movement-based sensory input.

Social Communication

• Deficit-Based Goal: Increase spontaneous greetings with unfamiliar peers in school settings.

• Neurodiversity-Affirming Goal: Expand options for initiating interactions in preferred contexts and modalities (e.g., verbal, AAC, written).

Compliance with Adult Directives

• Deficit-Based Goal: Increase compliance with adult instructions within three prompts.

• Neurodiversity-Affirming Goal: Enhance ability to communicate disagreement, request alternatives, and self-advocate in structured settings.

Eye Contact

• Deficit-Based Goal: Make eye contact with communication partners in 80% of conversational exchanges.

• Neurodiversity-Affirming Goal: Explore alternative ways to demonstrate active engagement in conversations (e.g., gesturing, looking at a shared object, verbal affirmations).

Functional Play Skills

• Deficit-Based Goal: Engage in pretend play using toys in expected ways for 5 minutes.

• Neurodiversity-Affirming Goal: Encourage self-directed play by expanding opportunities for creativity and engagement with preferred materials.

Self-Advocacy and Autonomy

• Deficit-Based Goal: Reduce non-compliance with daily routines by 50%.

• Neurodiversity-Affirming Goal: Increase ability to negotiate and modify daily tasks in a way that respects personal autonomy.

Conversation Skills

• Deficit-Based Goal: Reduce excessive talking about special interests.

• Neurodiversity-Affirming Goal: Support engagement in reciprocal conversations while maintaining space for passionate discussions about personal interests.

Research supports this shift. Strength-based goal setting has been associated with better long-term outcomes for autistic individuals, leading to increased self-determination and improved mental well-being. For instance, a study exploring community strengths-based programs found enhancements in autistic adolescents' health, social relationships, confidence, and sense of belonging over a three-year period (Lee et al., 2024). When treatment plans emphasize growth and capability rather than impairment, they foster motivation and engagement—key components of meaningful intervention.

The Role of Self-Advocacy in Goal Setting

ABA has historically been criticized for prioritizing neurotypical norms over the needs and preferences of autistic individuals. A neurodiversity-affirming approach requires that treatment plans be developed with—not just for—autistic clients.

This means:

• Actively involving individuals in choosing their own goals, rather than assuming what is “best” for them.

• Recognizing that some behaviors labeled as “deficits” may be adaptive strategies that support self-regulation and comfort.

• Ensuring that intervention goals align with the client’s personal values, rather than external pressures to conform.

These small but significant shifts reinforce the idea that autistic individuals are valued for who they are—not just for how well they can mimic neurotypical behaviors.

Implementing these changes while working within insurance constraints is challenging, but it is possible—and necessary—if we are to create an ABA field that truly supports, rather than pathologizes, neurodivergent individuals.

Bridging the Gap: Practical Strategies for BCBAs®

Until or unless funding for ABA services change dramatically, BCBAs® must find ways to navigate medical necessity requirements while ensuring that their practice remains affirming and ethical. While the constraints of the medical model are real, there are concrete strategies to balance insurance compliance with neurodiversity-affirming care.

Meeting Insurance Requirements While Prioritizing Affirming Care

Insurance companies require treatment plans to emphasize medical necessity, which often leads to a deficit-based approach. However, BCBAs® can shift their language and intervention strategies to justify services without reinforcing harmful narratives.

Writing Treatment Plans That Justify Services Without Reinforcing Deficit Narratives

• Frame goals in terms of functional skill-building rather than deficit reduction. For example:

  • Instead of “Decrease impulsivity and increase compliance with safety instructions,” try “Increase independent use of self-regulation strategies to navigate community environments safely.”

• Justify services by emphasizing skill development and autonomy rather than merely correcting behaviors.

  • Example: Instead of documenting “Client displays deficits in social communication that interfere with peer interactions,” consider “Client is working on expanding communication strategies to enhance meaningful peer relationships.”

• Align language with self-determination theory, which emphasizes motivation, autonomy, and competence in learning new skills.

Educating Caregivers and RBTs on Neurodiversity-Affirming Approaches

BIPOC and neurodivergent individuals often experience heightened stigma when interventions prioritize conformity over authenticity. As part of a more affirming approach, BCBAs® should educate caregivers and RBTs on the importance of:

• Respecting individual communication styles (e.g., allowing for alternative forms of engagement rather than enforcing eye contact).

• Valuing self-stimulatory behaviors that provide regulation rather than attempting to extinguish them.

• Shifting away from compliance-based intervention models and instead fostering decision-making and advocacy skills.

• Recognizing the impact of language and how the way we discuss goals influences perceptions of autism.

By equipping caregivers and RBTs with a neurodiversity-affirming lens, we can extend these best practices beyond formal treatment sessions and into the daily lives of the individuals we serve.

Advocating for Systemic Change

While individual practitioners can make meaningful shifts, lasting change requires systemic action. The medical model that underpins ABA reimbursement is deeply ingrained, but small steps taken collectively can push for a more ethical, affirming framework.

What Can ABA Learn from Policy Changes in Education?

Policy shifts in education have led to more flexible and individualized service models. For example, schools have moved away from rigid IQ-based eligibility criteria for special education, instead emphasizing functional assessments and individualized supports (Fletcher et al., 2019). Similarly, the broader adoption of strengths-based learning plans and universal design for learning (UDL) has helped shift education away from purely deficit-based models (Rao & Meo, 2016). While insurance policies have yet to fully reflect these changes, similar reforms could allow for more affirming, accessible support systems for autistic individuals.

Small Steps BCBAs® Can Take to Influence Policy

• Advocate within professional organizations (e.g., APBA, BACB) for changes in how medical necessity is defined.

• Participate in insurance advisory boards or provide input on policy revisions.

• Engage in public education efforts that shift the conversation from deficit-based treatment to strengths-based support.

• Support alternative funding models (e.g., waiver programs, grants) that do not require a medical model framework.

• Collect outcome data on affirming practices to demonstrate their effectiveness for both insurance providers and policymakers.

Moving Toward a More Ethical Future

The medical model may define how ABA is funded, but it does not have to define how ABA is practiced. By making intentional shifts in treatment planning, caregiver education, and policy advocacy, BCBAs® can ensure that their work aligns with both ethical best practices and client well-being—without compromising access to necessary services.

While systemic change takes time, every small step toward affirming, client-centered care brings the field closer to a future where autistic individuals are supported for who they are, not just how well they fit neurotypical norms.

Redefining ABA: A Call to Action for BCBAs®

ABA is at a turning point. The medical model has long dictated how we justify services, forcing a deficit-based approach that often conflicts with ethical, affirming care. But we don’t have to accept this as the only way forward.

By shifting our language, rethinking goal setting, and advocating for systemic change, we can ensure that ABA truly supports, rather than pathologizes, neurodivergent individuals. This isn’t just about working around insurance requirements—it’s about reshaping our field to align with the values of autonomy, self-advocacy, and meaningful skill development.

Be Part of the Change

• Reevaluate how you frame treatment goals. Are they strengths-based and functional?

• Educate those around you. Help caregivers and RBTs adopt a more affirming perspective.

• Advocate for better policies. Push for insurance models that prioritize individualized support over deficit reduction.

ABA doesn’t have to reinforce outdated models. The future of this field is in our hands—let’s ensure it reflects the dignity, strengths, and autonomy of the people we serve.

🎧 Continue the conversation by listening to our podcast episode. Earn 0.5 CEU while exploring practical strategies for making ABA more affirming. Listen now.

References

Fletcher, J. M., Lyon, G. R., Fuchs, L. S., & Barnes, M. A. (2019). Learning disabilities: From identification to intervention. Guilford Press.

Hwang, Y. I., Foley, K. R., & Trollor, J. N. (2023). "He Sees his Autism as a Strength, Not a Deficit Now": A Repeated Cross-Sectional Study of Strengths-Based Programs for Autistic Adolescents. Frontiers in Psychology, 14, 1122334. https://doi.org/10.3389/fpsyg.2023.1122334

Lee, E. A. L., Scott, M., Black, M. H., D'Arcy, E., Tan, T., Sheehy, L., Bölte, S., & Girdler, S. (2024). "He Sees his Autism as a Strength, Not a Deficit Now": A Repeated Cross-Sectional Study Investigating the Impact of Strengths-Based Programs on Autistic Adolescents. Journal of autism and developmental disorders, 54(5), 1656–1671. https://doi.org/10.1007/s10803-022-05881-9

Mathur, S. K., Renz, E., & Tarbox, J. (2024). Affirming neurodiversity within applied behavior analysis. Behavior Analysis in Practice, 17, 471–485. https://doi.org/10.1007/s40617-024-00907-3

Rao, K., & Meo, G. (2016). Universal design for learning in the classroom: Principles and practice. Guilford Press.

U.S. Department of Education. (2020). Individuals with Disabilities Education Act (IDEA). Retrieved from https://sites.ed.gov/idea

Zaks, Z. (2020). Nurture the Love of Learning with a Strengths-Based Approach to Autism Interventions. Learn Play Thrive. https://learnplaythrive.com/nurture-the-love-of-learning-with-a-strengths-based-approach-to-autism-interventions/