At first it just looks like play. In fact, the entire place looks and sounds like a child care center in a Chandler strip mall. On a recent Monday afternoon, preschool-age kids are eating lunch in the cafeteria or racing around the indoor gym.
But pay attention and you’ll notice that there’s an adult assigned to each child, and that the adults are focused on the children in a way you don’t see at day care.
This is a clinic entirely devoted to a particular form of therapy called applied behavior analysis, or ABA, commonly used to treat people with autism.
In a well-lit, carpeted room barely larger than a closet, a young woman and a 4-year-old boy are stacking blocks and playing with puzzles. Staff can observe through a window in the door. The woman, Lizbeth Meneses, has worked with this boy for almost a year.
Today he sits with his back against the corner of a small, brightly lit room filled with preschool toys, a sensory-friendly chewable toy dangling from his mouth. Meneses joins him on the floor, and while the two play she models how he should use the communication device she’s holding. The boy is good-natured, if distracted; he engages sporadically.
“Almost my turn! Three, two, one. You ready?” Meneses asks in an animated voice, handing him plastic toys that snap together to make animals.
“My turn ... Legos? Let go! Thanks. Look. OK. Dog. Sheep. Chicken.”
“Put the dog together,” she told the boy. He makes an attempt. “Thanks for trying,” she said. “Good job!”
Meneses applauds. She’s a registered behavior tech, overseen by licensed, board-certified behavior analysts trained specifically in ABA. This particular clinic is run by an out-of-state company called Action Behavior Center.
There are dozens of such clinics around town, quick growth considering 20 years ago, ABA therapy was pretty much non-existent here. Even today, if you’re not close to a person with autism, you might not be familiar.
ABA is the most common form of therapy for autism, a diagnosis that continues to grow. It’s used to develop and reinforce so-called “appropriate” behaviors and skills.
It’s also threatening to become Arizona’s next financial crisis.
ABA is the most popular form of therapy for people on the autism spectrum. And like the Parents as Paid Caregivers program for kids with developmental disabilities that’s made headlines over the past year for spiraling costs, the cost of delivering this form of therapy is quickly spiraling out of control. Providers and insurance companies are fighting as private equity companies buy up clinics. Federal officials are investigating billing practices. And there are serious questions about the quality of care being provided.
KJZZ spent weeks talking to concerned families, advocates, bureaucrats and professionals. Particularly with potential cuts to Medicaid funding looming, many say reforms are overdue.
ABA is very popular. It’s also controversial. Self-advocates in the autism community say it strips people on the spectrum of harmless behaviors that make them unique. Family members of children with autism say ABA is the only thing that’s worked to limit aggression and other behavior that keeps their kids from being a part of the community. There’s also debate within the ABA community about the right way to do therapy — and whether ABA is the best option for everyone. There are less intense alternative methods that are also covered by Medicaid — but they are rarely mentioned.
And ABA is expensive. It’s poised to be the next budget crisis for the state agencies charged with caring for Arizonans with intellectual and developmental disabilities. The increased use is due, in part, to the increase in autism diagnoses, and the fact that families are moving to Arizona to take advantage of a system that’s more generous than in other states. Between 2021 and 2024, the number of people with autism approved for Medicaid services in Arizona more than doubled.
In fiscal year 2025, ABA cost the Arizona Health Care Cost Containment System — the state’s Medicaid system — more than $371 million. That’s up from over $260 million in fiscal year 2024. It comes out to about a 43% increase in just over a year’s time. (Medicaid is a combination of state and federal funds.)
The total cost to the state is likely higher. Families of students with disabilities are spending private school voucher money on ABA. The state does not break out spending on ABA from other therapies, but the amount spent on therapy for Empowerment Scholarship Account recipients with disabilities more than doubled between 2024 and 2025, from $9.5 million to $20.1 million.
ABA is also expensive because it’s time intensive — some kids get a few hours of therapy a week, but there are 2-year-olds spending 40 hours a week in clinics. Some families are using ABA therapy as a substitute for child care. Others are pulling their kids from public school in favor of ABA.
It’s not just the cost that critics say is unsustainable. Arizona does not require ABA clinics to be licensed by the state Department of Health Services, meaning that — among other things — the behavior techs working directly with small children are not required to be fingerprinted.
And KJZZ has confirmed that the federal Office of the Inspector General is investigating billing practices in Arizona. The OIG has already found tens of millions of dollars in fraudulent ABA over-billing in Indiana, Wisconsin and Maine.
None of that matters to parents desperate for help. Shawn Cutting has had her 7-year-old son, Dominic, at ABA clinics since he was 4 — sometimes for up to 35 hours per week.
“It's been amazing for him. We saw progress in communication, in tolerating peers, tolerating outdoor events, loud events ... dance parties, worship at church. We saw him try new foods,” she said. “We still have struggles, but it's definitely helped a lot.”
It hasn’t all been great. She’s taken Dominic to two different clinics.
“The first place was a really good fit for a long time until — I don't know if it was a change of policies but things changed there. And the turnover rate just became really, really high. My son just didn't like it. And we would pull in the parking lot, and his whole demeanor would change and then we would drop him off and he would cry and he would be so upset and it just kept getting worse.
“And in the second place, they didn't allow naps,” Cutting continued. “His aggression and self-injurious behaviors just became so strong that we've never seen before.”
She hasn’t given up on ABA. Cutting is currently trying to get her son into a different clinic. The paperwork and waiting lists are tough.
ABA has been controversial from its earliest days.
During the infancy of the psychology research that would become ABA, the prevailing theory was that behaviors are influenced by the consequences that follow. Reinforcement encourages repeat behaviors, while punishment is a deterrent. ABA therapists often used food as a reward for “good” behavior and corporal punishment for “bad” behavior. A 1966 video shows a therapist yelling at a child – and worse.
By the 1970s, ABA principles were being applied in schools and therapy settings. The practice continued to evolve and for the most part does not look like it once did. In 2009, Arizona passed a law mandating that ABA be covered.
Cynthia Macluskie is director of advocacy for the Autism Society of Greater Phoenix. She and her son, Mark, who is autistic, testified on behalf of Steven’s Law, as it’s known. (Steven was an Arizona child whose parents struggled to pay for ABA therapy out of pocket.)
“Back in 2008, there was six of us moms that ran the autism insurance legislation,” Macluskie said.
At the time, it was a longshot. But they won.
“It was a miracle, really,” Mccluskie said. “And at the time when we passed this, we had one BCBA in our entire state.”
Just 17 years later, there are more than 1,300 board-certified behavior analysts, or BCBAs, in Arizona.
And state spending on ABA has rapidly ballooned.
Families and professionals are concerned about the lack of regulations for ABA clinics. BCBAs, who are often responsible for determining need and planning treatment, go through schooling and national certification. But most direct services are provided by registered behavior technicians who complete 40 hours of training and pass a certification exam. A private company might require a background check – but the state does not.
Dr. Diana Davis-Wilson is a BCBA and chief executive advisor for Aspen Behavioral Consulting. She said parents should know there’s a chance their behavior tech does not have fingerprint clearance because the state does not require ABA clinics to be licensed.
“You can't just sit here and continue to allow for 30, 40, 50 kids to be put in a building where these families are under the impression that the providers … have a facility license. And at a minimum, I think you need to be transparent with the families to make sure they're informed that none of that exists in the place that they're dropping off their child. Because when I drop my child off at a day care or a school, I'm trusting that those are safe places for my children. And don't get me wrong, I'm not saying these ABA providers are not safe places. I'm saying I don't wanna sit around and wait until the worst case scenario happens to figure it out, especially when it's my child,” Davis-Wilson said.
In a statement to KJZZ, Action Behavior Centers said, “ABC’s highest priority is patient safety” and “ABC utilizes a robust industry standard background check process for all team members prior to hire and throughout their employment.” ABC does not require fingerprint clearance but says it will comply if the state ever requires it.
This is only one of the challenges families face when they do get access to clinic-based therapy. There’s concern that some kids are prescribed many more hours than they need.
Jessica Belokas was one of the first BCBAs licensed to practice ABA in Arizona after Steven’s Law passed. She previously served as president of the Arizona Association for Behavior Analysis.
Belokas says she’s seen firsthand that priorities are shifting from serving clients to making money. It got so bad, she says, that after working at several clinics that were bought out by private equity, she started her own.
“What really started happening was a lot of optimization, efficiency pressures in those environments. Unfortunately, I was starting to see some families who were losing out on the opportunity to receive services. Families who maybe didn't feel comfortable with dropping off their 2-year-old at a clinic for 40 hours when they're still napping. Or families who have a really long drive to reach a clinic, or even families who, for that child, [an] intensive program isn't quite necessary,” Belokas said.
Regional Clinical Director Saba Biggar at Action Behavior Centers joined the Chandler clinic tour. She says ABC employees create individualized treatment plans for each child they serve. They say most of their 2- to 6-year-old patients need around 30 hours a week.
“It depends on the needs based off of the clinician who will do an assessment. And we do see a lot of deficits,” Biggar said. But, she added, “It's not always full-time. Sometimes it could be part-time, but since we do see the deficits a lot of times it ends up being more towards higher hours.”
ABA therapy works well for a lot of individuals and families, and there are providers in Arizona who are working to build new ways of implementing ABA principles while incorporating compassion and insights from autistic adults who’ve gone through treatment under older forms of ABA.
Some say ABA is never acceptable. Zoe Gross is director of advocacy at the national Autistic Self Advocacy Network.
“The goal that ABA is normally used to achieve is to make autistic people act like non-autistic people. So things like stopping stimming — repetitive behaviors that autistic people may do to regulate our nervous systems — or forcing eye contact,” she said.
“ABA is not good at teaching skills. It's good at conditioning if/then responses. So if you're using ABA to teach speech, whether that's using a speech device or speaking with your mouth, you're much better off with a speech language pathologist than to try and get that through ABA.”
Others disagree. Daniel Openden is the president and CEO of the Southwest Autism Research & Resource Center (SARRC) in Phoenix. SARRC does not operate clinics; Openden’s therapists work with children in their own homes and out in the community. The argument is that while it’s more expensive to do business that way — gas and travel costs can be steep, it’s not as efficient as a clinic – it provides a better outcome by exposing kids on the spectrum to real life situations.
“We know that good outcomes are possible with an ethical and effective ABA treatment program,” Openden said. “We have seen it at SARRC and really in lots of providers throughout the state that are doing high quality ABA. And kids, teens, adults are benefiting tremendously.”
Openden was instrumental in creating the Autism Commission on Quality, an organization that makes it possible to get accreditation for ABA clinics across the country.
Here in Arizona, pressure from all sides is making for an ecosystem that’s untenable, observers say, especially with potential cuts to Medicaid on the horizon. Officials with AHCCCS and the Office of Gov. Katie Hobbs told KJZZ they plan to release a package of ABA reforms.
When asked about the lack of licensing, including required fingerprint clearance for employees working with children, AHCCCS responded, “... The reforms AHCCCS will be posting for public comment in the coming weeks will include requirements that all providers meet licensure and fingerprint requirements as a condition for AHCCCS provider registration.”
Republican legislators on budget and health committees, including Rep. Matt Gress and Sen. Hildy Angius, declined comment for this story. Rep. David Livingston did not respond to several messages.
Davis-Wilson says accountability is past due.
“I think that we have a really, really, really good infrastructure here. I think the problem is, nobody's using it and nobody's enforcing it. … There's a pathway, it exists. Let's get them all DHS license[d], let's get them fingerprint clearance cards. Let's get all of this set up correctly and give our current system a chance to be the guardrails. Because I think that if we had an enforcement of our current system, we would be in a much different and good place, both from a state budget perspective, but as a BCBA, and as an advocate for sustainable ABA services across the nation.”
Statement from Action Behavior Centers
ABC requires fingerprinting and industry-standard background checks for all our BCBAs. For technicians, it depends on the state and its applicable laws and regulations. In Arizona, in the absence of an ABA facility licensure process, there is no current requirement for technician fingerprinting at this time. However, all ABC new hires undergo thorough background checks, which include an Enhanced Nationwide Criminal Search, County Court Search, FACIS L3, DOJ Sex Offender Search, Extended Global Sanctions, SSN Trace, and Driver's Record. These background checks are completed at onboarding and throughout their employment.
Please note, should AZDHS create an ABA facility license that includes a fingerprinting requirement, ABC would fully participate in both the licensing and fingerprinting process.
Statement from Arizona Health Care Cost Containment System
ABA utilization in Arizona has increased significantly in recent years, as it has across the country. AHCCCS remains committed to program sustainability. As a result, the agency will be publishing significant ABA reforms for public comment in the coming weeks. Program reforms will safeguard access to medically necessary care while ensuring the long-term sustainability of the Medicaid program and continued investment in other essential services for Arizonans and their families ….
In Arizona, individual ABA providers are regulated under state law (A.R.S. Title 32, Chapter 19.1), which requires licensure through the Board of Psychologist Examiners. Licensed behavior analysts must meet Behavior Analyst Certification Board standards, complete fingerprinting, and follow established rules regarding unprofessional conduct. They are also responsible for the clinical supervision of unlicensed technicians and trainees. Certain university personnel and some out-of-state providers are exempt from these requirements.
AHCCCS Managed Care Organizations are required to maintain a standardized credentialing and recredentialing process under AMPM Policy 950. This process includes verifying provider qualifications such as licensure, accreditation, education, practice history, and other indicators used to determine whether a provider meets the standards necessary to deliver covered services. These safeguards help ensure network providers meet consistent quality and safety standards across all AHCCCS contracted plans.
ADHS licenses health care institutions and many ABA provider facilities are already licensed with ADHS. The reforms AHCCCS will be posting for public comment in the coming weeks will include requirements that all providers meet licensure and fingerprint requirements as a condition for AHCCCS provider registration.
EDITOR'S NOTE: This story has been updated to clarify that Jessica Belokas is a previous president of the Arizona Association for Behavior Analysis.
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