Applied Behavior Analysis within the Department of Defense’s Comprehensive Autism Care Demonstration

Proceedings of a Workshop—in Brief

Upon Congressional request, the National Academies of Sciences, Engineering, and Medicine appointed a committee to conduct an Independent Analysis of Department of Defense’s (DoD’s) Autism Care Demonstration (ACD), including specifically addressing nine areas identified in Section 737 of Public Law 117-81, National Defense Authorization Act for Fiscal Year 2022. The ACD covers applied behavior analysis (ABA) services to military families as TRICARE¹ beneficiaries. To inform the committee, the National Academies hosted a public workshop on January 11–12, 2024, to examine what is known about ABA and assessment methods in the treatment of autism spectrum disorder (ASD). Workshop discussions included the current state of the field in ABA, historical progression of policies influencing the ACD and effects on families, and first-person experiences of ABA providers. This Proceedings of a Workshop—in Brief summarizes the presentations and discussions expressed during the first day public session aimed at understanding the field of ABA and should not be seen as a consensus of the workshop participants, the committee, or the National Academies.² Suggestions for the ACD made by individual speakers are included in Box 2 at the end of this document.

CURRENT STATE OF THE FIELD: ABA

Speakers provided background on ABA history and research, emerging standards from the industry that are followed by many ABA providers, and the current workforce and business model to best deliver ABA services.

ABA: Research, Standards of Care, and Health Insurance Coverage

Behavior analysis is the science of behavior interacting with environmental events, said Gina Green, doctoral-level Board Certified Behavioral Analyst and consultant. It has a distinct set of research methods, with its own professional organizations, journals, and university training programs and a large body of research evidence. The applied branch of the field began as early as the 1950s and the features of ABA have been defined since 1968. Generally, ABA has stressed positive reinforcement to build important skills in people with and without specific diagnoses. ABA interventions are highly individualized, flexible, and dynamic, she emphasized. Since 1998, requirements for credentialing of ABA practitioners have been developed and revised by the national nonprofit Behavior Analyst Certification Board (BACB) in accordance with well-established standards

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and procedures. The BACB issues two professional-level certifications—the Board Certified Behavior Analyst® (BCBA®) and Board Certified Assistant Behavior Analyst® (BCaBA®)—as well as a credential for paraprofessionals, the Registered Behavior Technician® (RBT®). Those paraprofessionals deliver direct services to clients under the supervision of professional behavior analysts. States have adopted laws to license behavior analysts only since about 2009, she explained, but 37 states now have such laws.

Shifting to behavior analytic research methods, Green said they are distinct from methods used in social sciences. They include several single case research designs (SCRDs), in which each individual experiences both the control (or no treatment) and the treatment phases. Phases are replicated across time, behaviors, participants, settings, or other dimensions. They are true experimental designs, and studies using SCRDs should not be confused with uncontrolled case reports. In ABA research, the emphasis is on clinically important changes in individual behavior relative to baseline or no treatment. Data from multiple studies using SCRDs can be aggregated and analyzed to produce statistics on the overall effects of an intervention on large numbers of participants, and other elements of SCRDs can be combined with elements of between-groups research designs. A number of published reviews of evidence on ABA interventions have excluded all research involving SCRDs on the false assumption, according to Green, that they are merely descriptive case reports. Most studies of the intensive, comprehensive model of ABA treatment for ASD have involved young children (under age 8 when they entered treatment) and used between-groups research designs, with one group of children receiving ABA and one or more groups of similar children receiving another type of treatment or typical services.

Green explained, the behavior analyst assesses each child’s strengths and weaknesses in multiple skill domains (cognitive, communication, social, self-help, maladaptive behaviors, etc.), as well as the preferences and circumstances of the child and their family. Skills that need to be developed are broken down into small components. The behavior analyst develops written protocols for paraprofessionals and caregivers to follow to help the child develop each skill, with training and supervision from the behavior analyst. Small component skills are systematically built into more complex repertoires. The protocols are designed to afford many opportunities for the child to learn and practice each skill each day, which requires a large number of hours of intervention per week for an extended period of time (the typical definition of “intensive”). The behavior analyst trains paraprofessionals and caregivers to implement certain treatment procedures, monitors their implementation, reviews data on the child’s progress frequently, and adjusts treatment protocols as needed. According to Green, there is reasonable agreement on the importance of early intervention for children with developmental delays, with the goal being to accelerate each child’s developmental trajectory so as to make up gaps between their skills and age-appropriate skills. In general, research shows that skill development is most likely to occur when the child starts intervention at a young age, said Green.

Research on the early intensive, comprehensive model of ABA treatment is quite extensive, said Green, with findings generally indicating that it is more likely to produce moderate to large improvements in key skill domains for most children than lower-intensity ABA, eclectic intervention, or standard services (e.g., see meta-analyses by Eldevik et al., 2010; Klintwall et al., 2015). However, she cautioned that some meta-analyses of research on early intervention for ASD have conflated ABA and non-behavior analytic interventions, and many have focused only on studies using randomized clinical trials, excluding studies using other types of research designs that can yield credible evidence about the effects of interventions on clinically meaningful endpoints. Additionally, Green referenced many scores of controlled studies and meta-analyses of the effects of many focused ABA treatments, which typically address a small number of adaptive skills and/or maladaptive behaviors.

Lastly, highlighting insurance coverage Green noted that all 50 states have adopted laws or have guidance requiring certain commercial health plans to cover ABA and other services for people diagnosed with ASD. All Federal Employees Health Benefit plans have been required to cover ABA services for ASD since 2017. As of 2018, 45

percent of self-insured companies with more than 500 employees included coverage for ABA services for their beneficiaries with ASD. She also highlighted the significance of the American Medical Association CPT® Editorial Panel having issued Category I Current Procedural Terminology® (CPT®) codes for ABA services that went into effect in 2019. The application for those codes, of which Green was a co-author, required extensive documentation of research demonstrating the efficacy of the services that met the American Medical Association’s rigorous evidence hierarchy.

Industry Standards

Erick Dubuque, Director of the Autism Commission on Quality, defined industry standards as guidelines within a specific sector that define acceptable quality, safety, interoperability, or performance expectations designed to promote consistency, reliability, and compatibility in products, services, or processes. While compliance is often voluntary, guidelines can be essential for ensuring quality, regulatory adherence, and trust among stakeholders. Within health care, industry standards may include clinical practice guidelines, quality and safety standards, and ethical codes of conduct. Within ABA, industry standards can be used to address many of the barriers preventing families from accessing services they need. The general process in developing standards includes multiple steps: first identifying the need, forming a committee, drafting and testing standards, soliciting public feedback, revising and then publishing the final version. From there, he noted, the standards are adopted and recognized, maintained, and updated—moving forward, compliance is enforced and monitored. Industry standards should come from trusted sources, Dubuque emphasized, such as mission driven nonprofits, with several in the field setting various standards related to ABA (see Figure 1).

Despite the existence and periodic updates of these established ABA guidelines, there are important areas where “the [DHA’s] ACD policy does not align with industry standards in ways that may prevent TRICARE beneficiaries from accessing quality services,” Dubuque noted. He highlighted four key areas for improvement:

1. Concurrent billing limitations: The current ACD policy contradicts the language in the ABA Coding Coalition’s model coverage policy³ and suggests a fundamental misunderstanding of how ABA services are delivered.
2. Caregiver participation requirements: While industry standards make it very clear that caregiver involvement is critical and should be heavily encouraged, services should not be dependent on caregiver participation in ABA services, and patients should not be penalized for nonparticipation by caregivers (ABA Coding Coalition, 2022; Defense Health Agency, 2023).

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3. Treatment setting limitations: The ACD policy saying ABA services cannot be delivered in school and community settings by behavior technicians does not align with industry guidelines that state ABA treatment must not be restricted to specific settings (Defense Health Agency, 2023).
4. Clinical outcome requirements: While providers should demonstrate effectiveness of their treatment, given that ABA services are highly individualized, using pre-selected assessment tools does not align with industry standards, which support the use of assessment decisions that are individualized to each patient based on need.

State of the Workforce

Molli Luke, the Chief Certification and Learning Officer at the Behavior Analyst Certification Board (BACB), explained that her organization acts like a licensing board, certifying those who are providing ABA services. While most of the people they certify are working in the ASD field, the services can apply to other conditions. She shared the common treatment service structure for ABA autism treatment, the tiered service model (see Figure 2).

All of the requirements for certification include levels of education, training, experience, examination, adherence to an ethics code, and in some cases ongoing supervision. The BACB certifications include a RBT®, BcaBA®, or BCBA®. As of the end of 2023, she said they had more than 66,000 BCBAs, more than 5,600 BcaBAs®, and more than 163,000 RBTs®, with the vast majority located in the United States. Luke shared a graph demonstrating the tremendous growth in certificants across the three areas, especially since 2014 (see Figure 3). This is likely due to rapidly available funding, leading to business development and more university focused training. She also highlighted the various ABA subspecialties for their certificants, with more than 70 percent working in ASD. Finally, she noted the significant increase in demand for BCBAs that has been seen recently, with nearly 58,000 job postings asking for BCBA certification in 2022, compared to just 2,903 postings in 2014.

POLICIES AFFECTING THE ACD AND ACCESS TO ABA

Speakers in this section provide background on ASD and how access to ABA services can affect military families, as well as the various impacts that policies have had on ABA access and issues that families encounter.

Autism and Effects on Military Families

Karen Driscoll, child advocate, shared her experience as a mother, military wife, and user of the TRICARE program. TRICARE was created as a robust set of benefits to ensure and protect combat readiness and retention of the force, she said. Family readiness is combat readiness, as family problems can interfere with the ability of service members to deploy, and having services such as ABA available to military families improves the quality of life and can impact willingness to stay in the military, said Driscoll. She emphasized that ABA is seen as medical care in the civilian sector, meaning that it is covered by other insurance carriers, and she called for alignment of TRICARE benefits as well.

Given that military families are so mobile, often moving every few years, becoming established with new ABA providers in different locations becomes the norm, said Driscoll. However, most state-run programs as well as Medicaid have very long wait lists providing little support, with many gaps in access to specialty care such as ABA. For example, her family waited more than 10 years for access to Medicaid-related services during her husband’s last duty station. In May 2023, DHA reported that across all states the average wait time from referral date to first ABA appointment ranged from 0–68 days (Department of Defense, 2023). Barriers to care included things like inadequate provider network, low reimbursement rates, services contingent on assessments, and restrictions on where services are delivered. Making these assessments mandatory and contingent for services goes against best practices, said Driscoll. The restrictions on who can diagnose and refer patients to ABA are sometimes limited to a clinical psychologist only. Enrollment in the Exceptional Family Member Program (EFMP) and Extended Care Health Option (ECHO) programs is also required to access ongoing services, she explained, which places an additional burden on the parents. Additionally, she said, excluding ABA from the TRICARE medical benefit allows TRICARE to exclude ABA from mental health parity review. Limiting ABA to only beneficiaries with autism also excludes other patient populations that would benefit from behavioral health services, she noted. Driscoll concluded by reiterating her perspective that ABA is a widely accepted medical therapy with reliable evidence standards. Additional first-person experiences with seeking ABA services through the ACD can be found in Box 1.

Policy Perspectives on the ACD

Rebecca Womack, Consultant at RAW Consulting Solutions, remarked that it is critical to understand how services are authorized in the ACD. She first clarified that the practice guidelines, developed in 2014 under the Board Analyst Certification Board moved to be under the Council of Autism Service Providers (CASP) in 2020. Additionally, in 2019, a clarification on these guidelines stated that “authorizations for services to the client should not be predicated on requirements for parents or other caregivers to participate in training” (Board Analyst Certfication Board/Association for Professional Behavior Analysts, 2019). She focused on two key points related to the committee’s task: evaluating the efficacy of ABA services and the treatment of ASD, as well as reviewing guidelines and industry standards of care. To level set the discussion, she also emphasized that medical necessity is a demonstration of a legitimate clinical need that is proportionate to requested treatment (Adams & Grieder, 2014). ABA services should include delivery of the intervention, documentation, and insurance claims, with measured results, Womack recommended.

Walking through the ACD policy timeline, Womack noted the beginning of TRICARE policy requirements in 2015, when there was no restriction on place of services and concurrent billing was excluded. Then in 2017, the Office of the Inspector General (OIG) conducted an audit oversight of benefits in the TRICARE south region. Results showed improper payments extrapolated to be around $1.9 million as well as a lack of adherence to standards of documentation for services, so OIG recommended closer oversight and taking action when problems are identified (Office of the Inspector General, 2017). In 2018, there was another audit in the TRICARE north region. She said, the audit extrapolated that $81.2 million of costs were improper payments, however this extrapolation was done using only a handful of providers (Office of the Inspector General, 2018). At the same time, TRICARE policy require-

ments increased to include additional outcome measures, and services conducted in school had to be contingent on parents submitting the child’s individual education plan to oversight in the region. In 2019, she continued, Category I CPT® codes defined distinct clinical activities, but the policy still did not restrict the place of setting. However, in 2021, policy changes were made, including restrictions on settings and designating that activities of daily living (ADLs) as a skill could only be taught via caregivers through the BCBA, she emphasized. Thinking about the purpose of the ACD what is currently being measured as part of the benefit is just a portion of CASP practice guidelines, not all of them. In closing, she said that the ACD only achieves in part how ABA services should be delivered and does not promote ABA service delivery in accordance with generally accepted standards of care.

Mental Health Parity

Dan Unumb, Autism Legal Resource Center, provided an overview of the ACD policy and mental health parity on a broad level, looking back to the statute that implements medical care in the DoD (10 U.S.C. § 1071). From this he drew two basic propositions: (1) Military beneficiaries should receive services of at least the same quality and comprehensiveness as civilian counterparts, and (2) Program administration should be geared toward promoting service member retention, readiness, and productivity. Shifting to ABA services, he commented that ABA, delivered through the tiered delivery model, is the standard accepted treatment for ASD across all civilian funding streams and institutions, including commercial insurance, employer sponsored health plans, Medicaid, and federal civilian employee health benefits. Since the

2014 initiation of the ACD, all states have now mandated coverage of ABA as medical treatment, he added, and the Department of Labor has uniformly rejected attempts by health plans to exclude coverage of ABA as experimental treatment⁴ (Department of Labor, 2022). Medicaid programs across all states also now cover ABA as “medical assistance”, and experimental or investigative treatments would not fall under this category. He also reiterated that Category 1 CPT® codes for ABA were adopted in 2019, and these codes can only be promulgated for treatments that are safe, effective, and consistent with current medical practice.

Reviewing access to services of the same scope and quality of civilians, Unumb said there should not be a priori limitations on age, range of symptoms treated, or settings where treatment occurs. He noted that children with autism can have different behaviors based on the setting they are in and translating skills across settings is not easily generalized, and sometimes community settings can be the most challenging. The Mental Health Parity and Addiction Equity Act (29 U.S.C. § 1185a; MHPAEA)⁵ says treatment limitations applicable to mental health benefits such as coverage of ABA for ASD are to be no more restrictive than the predominant treatment limitations applied to substantially all benefits covered by the plan. Additionally, because ASD is defined as a mental health disorder, benefits for the treatment of and services for ASD, such as with ABA, are subject to mental health parity protections, said Unumb.

Under MHPAEA, no treatment limit can be applied only to mental health or a specific mental health condition (i.e., ABA for ASD), Unumb said. Under mental health parity, if a treatment limitation is not applied to any medical condition or surgical condition, it cannot be applied to mental health coverage, including ABA for ASD. Additionally, quantitative treatment limits (QTLs) cannot be applied unless the limitation is applied to substantially all medical outpatient services. Generally, dollar caps, visit limits, or cap limitations on treatment hours are prohibited QTL violations. Limits on a particular service or CPT® code is also likely to be a violation, he said, which can sometimes be seen in limits on assessments under CPT® Code 97151. MHPAEA also prohibits nonquantitative treatment limitations (NQTLs) that limit the scope or duration of a mental health treatment benefit unless they are also applied no more restrictively to outpatient medical/surgical benefits. Examples include prior authorization, medical necessity criteria, and progress standards. Specific to ABA, NQTLs may include location exclusions, limitations on treatment targets, symptoms treated, etc. He summarized a number of examples of program restrictions inconsistent with generally accepted standards of care for ABA and/or MHPAEA.

Unumb emphasized that because of frequent relocation, a robust provider network is critical for servicemembers’ families. Servicemembers have identified a number of program administration issues negatively impacting their families including program restrictions resulting in their children not receiving the same care as civilian counterparts even when being served by the same provider. He shared other issues such as disincentives for providers to be part of the TRICARE program. Disparate and onerous administrative burdens on documentation requirements and payment delays have led to providers discontinuing partnership with TRICARE, he noted. These restrictions and procedures that are inconsistent with industry standards for ABA contribute to this departure of providers from the network, reducing the available pool of providers, limiting care, and negatively impacting military readiness and operations, Unumb suggested.

LIMITATIONS OF THE CURRENT ACD POLICY

In response to a question on limitations on behavior targets for ABA services, Womack said that her interpretation of the policy is that it limits the direct addressing of ADLs by the ABA provider. So, providers would need to train caregivers to be the implementers of the goals to address ADLs. The policy is very specific, saying that goals can only target specific core deficits of autism. Umumb added that this is a restriction on medically necessary care, which is inconsistent with how ABA providers would typically handle medical coverage. These kinds of skills are critical for morale and family life, he argued.

Several questions related to the tiered service model were raised. Implementation of ABA services is constrained,

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Womack responded, because formerly under the ACD, behavior technicians were allowed to implement 1:1 services in community settings where the behavior occurred. However, now only the behavior analyst can implement that direct service in a school setting contingent on authorization. Families are unable to have services in a community setting, for example at a shared playground, where problematic behaviors might occur, because DHA has defined this as an exclusion, said Womack. Driscoll added that TRICARE has said they cannot authorize these services from non-master’s level professionals, but that is how services are delivered in the marketplace, often through behavioral technicians. Technicians have their own ethical requirements and work under supervision of a board certified professional. Unumb emphasized that this becomes an access issue, since there is a small number of behavioral analysts and without the extension of the technician, it is challenging to meet the current demand. Several studies have shown effectiveness with a tiered model using technicians, he added.

EXPERIENCES OF ABA PROVIDERS

Britt Sims, Integrated Behavior Solutions, introduced himself as an ABA provider with TRICARE clients. As a military spouse, he also understands the importance of supporting families and the impact on combat readiness. He serves clients across ranges of autism from the ages of 2–17, and initially started with an overwhelming majority (90%) TRICARE clients, using only certified professionals, said Sims. However, in 2013, the program changes disrupted access and forced the company to change service models. This led to many denials and delays in authorization and resulted in them expanding to patients with other insurance. In 2021, with the update to the TRICARE Operations Manual, there was a significant impact to ABA access due to increased and unclear provider requirements. Overall, it was “mass chaos” for providers, he said, with many new guidelines and regulations. Sims agreed that some of the 2021 changes were necessary but implementing them has proved challenging for ABA providers. Then in 2023, he said, there were additional revisions of the operations manual, which resulted in added confusion and time to process the new revisions. The perception of limited technical assistance and communication has made these changes incredibly difficult and confusing for providers, said Sims.

Sharing measures of effectiveness of treatment outcomes, he explained, is difficult. The industry standards of care come from CASP guidelines, and include indirect assessment, direct assessment, parent goals and training, and individualized treatment goals. But ACD guidelines restrict the access to socially significant domains (e.g., ADLs, pre-academics) and settings that are critical for independent living. When it comes to measures required by the ACD, he said, they are norm based and cannot capture all the nuances of individual progress (see Figure 4). Assessment of the services is better reflected in the ongoing direct data captured by ABA providers, he argued.

Michelle A. Linn, Alpine Autism Center, shared her experience as a military spouse and mother of two boys with profound autism. Without the ABA benefit within TRICARE, she said they would not have been able to continue their service as a military family. She reviewed the services offered by Alpine Autism Center and highlighted a point in 2008. She said it was a wonderful experience working with TRICARE’s west region contractor at the time (TriWest) to help military families. Then in 2013, TriWest lost the contract and United Health took over, which led to an “abysmal bureaucratic and administrative nightmare,” commented Linn. As a provider, she was not paid for months, and Alpine Autism Center needed to secure a business loan to stay open. In 2021, they went through an audit, and even though they were delivering good clinical care, they had to defer services to TRICARE clients because again, they were not receiving payments for months. Now in 2024, their client base is less than one third TRICARE, she said.

Linn reviewed some of the recent changes, including outcome measures, such as the requirement of the Social Responsiveness Scale completed initially and annually, and the Parenting Stress Index completed every six months. She disagreed with the benefit of these assessments, saying her company collects a wealth of objective data that could be used to show progress, addressing up to 30 different targets at a time. The assessments do not add additional value on top of that, she said. Additionally, ABA services in school settings by behavior technicians became excluded, restrictions were placed on services in community settings, and minimums were set for parent training sessions every six months. Military families need to obtain extra documentation from their doctors, she said, which adds stress on both parties. She shared a table of the additional burdens that arose related to TRICARE’s plan compared to others (see Figure 5).

“Why would a military member deal with frequent moves, long work hours, and deployments when they know their family could be better taken care of by other insurance carrier plans,” Linn posited. TRICARE payment rates are competitive on paper, but when you look at the additional administrative burden and other challenges that come with it, she said, the benefit is not as worthwhile. In closing, she emphasized the effectiveness of ABA, and shared a video of one of her TRICARE clients who went from being nonverbal and whose family reported poor quality of life prior to ABA, to a much happier child using full sentences and making friends.

Additional suggestions for the ACD from speakers throughout the workshop are highlighted in Box 2.

REFERENCES

ABA Coding Coalition. (2022). Model Coverage Policy for adaptive Behavior Services (2nd ed.). https://abacodes.org/wp-content/uploads/2022/01/Model-Coverage-Policy-for-ABA-01.25.2022.pdf

Adams, N., & Grieder, D. M. (2014). Treatment planning for person-centered care: Shared decision making for whole health (2nd ed.). Elsevier Academic Press.

Board Analyst Certfication Board/Association for Professional Behavior Analysts. (2019). Clarifications regarding applied behavior analysis treatment of autism spectrum disorder: Practice guidelines for healthcare funders and managers (2nd ed.). Behavior Analyst Certification Board and Association of Professional Behavior Analysts.

Defense Health Agency. (2023). TRICARE Operations Manual 6010.59-M, Chapter 18, Section 4. Revision: C-121. U.S. Department of Defense.

Department of Defense. (2023). Report to the Committees on Armed Services of the Senate and the House of Representatives: TRICARE Comprehensive Autism Care Demonstration Program (Third Quarter, Fiscal Year 2022).

Department of Labor. (2022). Realizing parity, reducing stigma, and raising awareness: Increasing access to mental health and substance use disorder coverage. MHPAEA Report to Congress. https://www.dol.gov/sites/dolgov/files/EBSA/lawsand-regulations/laws/mental-health-parity/report-to-congress-2022-realizing-parity-reducing-stigma-and-raising-awareness.pdf?_ga=2.212325789.803053475.1712755288441501262.1711659816

Eldevik, S., Hastings, R. P., Hughes, J. C., Jahr, E., Eikeseth, S., & Cross, S. (2010). Using participant data to extend the evidence base for intensive behavioral intervention for children with autism. American Journal on Intellectual and Developmental Disabilities, 115(5), 381–405. https://doi.org/10.1352/1944-7558-115.5.381

Klintwall, L., Eldevik, S., & Eikeseth, S. (2015). Narrowing the gap: Effects of intervention on developmental trajectories in autism. Autism, 19(1), 53–63.

Medical and Dental Care, 10 U.S.C. § 1071-1085 Suppl. 2. (1970). https://www.loc.gov/item/uscode1970-017010055/

Mental Health Parity and Addiction Equity Act, 29 U.S.C. § 1185a. (2008). https://www.congress.gov/bill/110th-congress/house-bill/6983

Office of the Inspector General. (2017). The Defense Health Agency improperly paid for autism-related services to selected companies in the TRICARE South Region (DODIG-2017-064). https://www.dodig.mil/reports.html/Article/1189569/the-defense-health-agency-improperly-paid-for-autism-related-services-to-select/

___. (2018). TRICARE North Region payments for applied behavior analysis services for the treatment of autism spectrum disorder (DODIG-2018-084). https://www.dodig.mil/reports.html/Article/1468277/tricare-north-region-payments-for-applied-behavior-analysis-services-for-the-tr/#:~:text=Finding%3A,performed%20in%202015%20and%202016

DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by Megan Snair as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the committee; or the National Academies of Sciences, Engineering, and Medicine.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Eileen Huck, National Military Family Association. We also thank staff member Lida Beninson for reading and providing helpful comments on this manuscript. Kirsten Sampson Snyder, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

COMMITTEE MEMBERS George W. Rutherford, University of California San Francisco; Brian A. Boyd, University of North Carolina at Chapel Hill; Wendy K. Chung, Boston Children’s Hospital; Lauren Erickson, Institute for Exceptional Care; Eric M. Flake, University of Washington; Patrick Heagerty, University of Washington; A. Pablo Juárez, Vanderbilt University Medical Center; Samuel L. Odom, University of North Carolina at Chapel Hill; Jennifer E. Penhale, Colorado Developmental Disabilities Council; José E. Rodriguez, University of Utah Health; Andy Shih, Autism Speaks; Kristin Sohl, University of Missouri School of Medicine; Aubyn C. Stahmer, University of California Davis Mind Institute; Ruth E. Stein, Children’s Hospital at Montefiore; Allysa N. Ware, Family Voices; and Zachary J. “Zack” Williams, Vanderbilt University Medical Center.

SPONSORS This workshop was supported by contracts between the National Academy of Sciences and the Department of Defense’s Defense Health Agency (HT940223C000). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

For additional information regarding the workshop, visit: https://www.nationalacademies.org/our-work/independent-analysis-of-department-of-defenses-comprehensive-autism-care-demonstration-program.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2024. Applied Behavior Analysis within the Department of Defense’s Comprehensive Autism Care Demonstration: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/27800.