The Comprehensive Autism Care Demonstration: Solutions for Military Families (2025)
Chapter: Front Matter
Consensus Study Report
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This activity was supported by a contract between the National Academy of Sciences and the Department of Defense’s Defense Health Agency (HT940223C0003). 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.
International Standard Book Number-13: 978-0-309-99314-2
Digital Object Identifier: https://doi.org/10.17226/29139
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. The Comprehensive Autism Care Demonstration: Solutions for Military Families. Washington, DC: National Academies Press. https://doi.org/10.17226/29139.
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COMMITTEE ON AN INDEPENDENT ANALYSIS OF DEPARTMENT OF DEFENSE’S COMPREHENSIVE AUTISM CARE DEMONSTRATION PROGRAM
GEORGE W. RUTHERFORD (Chair), 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, Uniformed Services University of the Health Sciences and University of Washington
PATRICK J. 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
JOSE 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
RUTH E.K. STEIN, Albert Einstein College of Medicine and Children’s Hospital at Montefiore
ALLYSA N. WARE, Family Voices
ZACHARY J. WILLIAMS, University of California, Los Angeles
Study Staff
JULIE ANNE SCHUCK, Study Director
MARC MEISNERE, Senior Program Officer
ADAM K. JONES, Research Associate
ELONAY KEFLEZGHI, Senior Program Assistant
EMILY P. BACKES, Deputy Board Director
Westat Consultants
JACK DAVIS
JENNIFER EDWARDS
ANNE ROUBAL
ELIZABETH TAYLOR
BOARD ON CHILDREN, YOUTH, AND FAMILIES
JONATHAN TODRES (Chair), Georgia State University College of Law
TAMMY CHANG, University of Michigan
DEBRA FURR-HOLDEN, New York University
ANDREA GONZALEZ, McMaster University
NIA HEARD-GARRIS, Northwestern University Feinberg School of Medicine
NANCY E. HILL, Harvard University
CHARLES HOMER, Economic Mobility Pathways
MARGARET KUKLINSKI, University of Washington
MICHAEL C. LU, University of California, Berkeley School of Public Health
STEPHEN W. PATRICK, Emory University
JENNY S. RADESKY, University of Michigan Medical School
STEPHEN T. RUSSELL, The University of Texas at Austin
JANE WALDFOGEL, Columbia University School of Social Work
JOANNA L. WILLIAMS, Search Institute
Staff
NATACHA BLAIN, Senior Board Director
EMILY P. BACKES, Deputy Board Director
BOARD ON HEALTH CARE SERVICES
DONALD M. BERWICK (Chair), Harvard Medical School
ANDREW B. BINDMAN, Kaiser Permanente
PAUL CHUNG, Kaiser Permanente
MARTHA DAVIGLUS, University of Illinois at Chicago
LEE A. FLEISHER, University of Pennsylvania
COLLEEN GALAMBOS, University of Wisconsin-Milwaukee
EMILY GEE, Center for American Progress
GARY L. GOTTLIEB, Harvard Medical School
ELMER E. HUERTA, George Washington School of Medicine
LAUREN S. HUGHES, University of Colorado
SHARON K. INOUYE, Marcus Institute for Aging Research
MARK S. JOHNSON, Howard University
JOHN R. LUMPKIN, Blue Cross and Blue Shield of North Carolina Foundation
FAITH MITCHELL, Urban Institute
JULIE ROBISON, University of Connecticut School of Medicine
LINDA D. SCOTT, University of Wisconsin-Madison School of Nursing
HARDEEP SINGH, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine
HEMI TEWARSON, National Academy for State Health Policy
KEEGAN WARREN, Texas A&M University
LAURIE ZEPHYRIN, Commonwealth Fund
MICHAEL ZUBKOFF, The Tuck School of Business at Dartmouth
Staff
SHARYL NASS, Senior Board Director
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Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
JENNIFER BITTNER, Exceptional Families of the Military
GERALDINE DAWSON, Duke Center for Autism and Brain Development, Duke University School of Medicine
KAREN DRISCOLL, spouse of retired military and mother of child with autism
THOMAS W. FRAZIER, John Carroll University and Autism Speaks
JOY F. JOHNSON, Spectrum Support
LUKE KALB, Kennedy Krieger Institute and Johns Hopkins Bloomberg School of Public Health
ALICE KUO, University of California, Los Angeles Medicine-Pediatrics and Preventive Medicine and Autism Intervention Research Network on Physical Health
CATHERINE L. LORD, University of California, Los Angeles Semel Institute of Neuroscience and Human Behavior
DAVID MANDELL, University of Pennsylvania, Perelman School of Medicine
ARI NE’EMAN, Harvard T.H. Chan School of Public Health
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by KENNETH W. KIZER, Atlas Research, and RICHARD G. FRANK, The Brookings Institution. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Acknowledgments
This report would not have been possible without the contributions of many people. First, we thank the sponsor of this study—the Defense Health Agency—and acknowledge the tireless efforts of Krystyna Bienia, clinical lead for the Comprehensive Autism Care Demonstration, who provided substantial background and documentation on the demonstration for the committee’s review, responded to the committee’s questions, and helped facilitate negotiations for the data sharing agreement and request for data from the Military Health System data repository and the demonstration’s data records.
We would also like to thank the following organizations and individuals for their support of the Board on Children, Youth, and Families’ mission: The Burke Foundation, The New Venture Fund, The Renaissance Charitable/RCF Giving Fund, The Robert Wood Johnson Foundation, David V. B. Britt, Tammy Chang, Greg J. Duncan, Sherry Glied, Andrea Gonzalez, Nia Heard-Garris, Nancy Hill, Charles J. Homer, Kay Johnson, Margaret Kuklinski, Michael Lu, Daniel Menelly, Linda A. Nelson, Stephen Patrick, Jenny Radesky, Stephen Russell, Nisha Sachdev, Jonathan Todres, Jane Waldfogel, Joanna Williams, and Barbara L. Wolfe.
The data request and analyses conducted for this report would not have been possible without the guidance, patience, and analytical expertise of the Westat team: Jack Davis, Anne Roubal, Elizabeth Taylor, and Jennifer Edwards. We also thank the researchers who prepared commissioned papers for the committee: Brian Reichow, University of Connecticut, Center for Excellence in Developmental Disabilities, and Gina Green, independent consultant and doctoral-level Board Certified Behavior Analyst.
Many individuals volunteered significant time and effort to address and educate the committee during our public information gathering sessions. Their willingness to share their perspectives, research, and personal experiences was essential to the committee’s work. We thank Tomeshia Barnes, Office of Special Needs; Somer Bishop, University of California, San Francisco; Kristi Cabiao, Mission Alpha Advocacy; Mari Cerda, Lighthouse Learning Center; Ira L. Cohen, Consultant; Karen Driscoll, Child Advocate; Erick Dubuque, Autism Commission on Quality; Nanette Elster, Loyola University Chicago Stritch School of Medicine; Thomas W. Frazier, John Carroll University; Gina Green, Consultant; Emily Hotez, University of California, Los Angeles; Brooke Ingersoll, Michigan State University Autism Lab; Rebecca McNally Keehn, Indiana University School of Medicine; Young Shin Kim, University of California, San Francisco; Matthew Lerner, Drexel Autism Institute; Michelle A. Linn, Alpine Autism Center; Molli Luke, Behavior Analyst Certification Board; Matthew J. Maenner, Centers for Disease Control and Prevention; Sneha Mathur, University of Southern California; Elizabeth O’Nions, University College London; Hoangmai H. Pham, Institute for Exceptional Care; Adithyan Rajaraman, Vanderbilt University Medical Center; Greg Robinson, Autistic Self Advocacy Network; Lisa Ruble, Ball State University; Hanna Rue, LEARN Behavioral; Doreen Samelson, Catalight Foundation; Britt Sims, Integrated Behavior Solutions; Pawan Sinha, Massachusetts Institute of Technology; Holly A. Taylor, National Institutes of Health; Jocelyn Thompson, LEARN Behavioral; Daniel Unumb, Autism Legal Resource Center; Chanti F. Waters, ABS Kids; Diane L. Williams, Penn State University; Nicole M. Williams, Congressionally Directed Medical Research Programs; and Rebecca Womack, RAW Consulting Solutions. We also want to thank military families, healthcare providers, and the general public for their feedback and input throughout the study.
The committee thanks the National Academies staff for their support over the study process. We thank the staff members who worked directly with the committee: Julie Schuck, Emily Backes, Marc Meisnere, Adam Jones, and Elonay Keflezghi. Throughout the project, Natacha Blain, director of the Board on Children, Youth, and Families; Carlotta Arthur, executive director of the Division of Behavioral and Social Sciences and Education; and Amy Stephens, associate executive director of the Division of Behavioral and Social Sciences and Education provided valuable oversight and guidance. Megan Snair and Erin Forstag also provided writing assistance, serving as rapporteurs for the three proceedings in brief released during the study to document presentations at the committee’s public sessions.
The committee is also grateful for project support from the Division of Behavioral and Social Sciences and Education and other units of the National Academies. Javed Kahn, Elise Mialou, Pamella Atayi, Faye Hillman, and
Lisa Alston provided administrative and financial assistance on this project. From the Office of Reports and Communication, Kirsten Sampson Snyder, Bea Porter, Douglas Sprunger, and Kimberly Halperin shepherded the report through the review and the production process and assisted with its communication and dissemination. Clair Woolley of the National Academies Press, and Sandra McDermin of the Office of Congressional and Government Affairs were instrumental in the release and promotion of the report.
Finally, special thanks go to the members of the committee, who dedicated extensive time, expertise, and energy to drafting the report, and to the committee chair, George W. Rutherford, for his expert leadership in guiding the committee.
August 2025
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COMPLEMENTARY AND ALTERNATIVE THERAPIES
3 History of ABA Services in the Military Health System
Timeline of Coverage of ABA Services
Statutes and Regulations Relevant to Delivery of ABA
COVERAGE OF ABA SERVICES PRIOR TO THE ACD
2001: Program for Persons with Disabilities
2008: ECHO Enhanced Access to Autism Services Demonstration
Berge vs. United States Class Action Lawsuit Regarding ABA Coverage
2013: Initiation of One-Year ABA Pilot Program
INITIAL STEPS TO PARTICIPATE IN THE ACD
Participation in ECHO and EFMP
Assignment to an Autism Services Navigator
Completion of Baseline Measures and the Initial Treatment Plan
4 ABA Industry Guidelines and Standards of Care
GENERALLY ACCEPTED STANDARDS OF CARE
Health Care Provider Taxonomy Codes
Current Procedural Terminology Codes
Commercial and Public Insurance Coverage for ABA Services
INDUSTRY GUIDELINES FOR KEY ASPECTS OF ABA
Determination of Medical Necessity
Treatment Plans and Delivery of ABA Services
Billing and Reimbursement Exclusions
Caregiver Engagement and Training
5 Evidence Base for Applied Behavior Analysis
DEFINITION AND DIMENSIONS OF APPLIED BEHAVIOR ANALYSIS
APPLIED BEHAVIOR ANALYSIS AND AUTISM
Research Methodology and Evidence Standards
Applied Behavior Programs and Practices
Commissioned Paper on State of Evidence for Comprehensive ABA Services for Autism
Umbrella Review of EIBI and Other ABA Comprehensive Programs
State of Evidence for ABA Focused Intervention Practices
Meeting TRICARE Hierarchy of Reliable Evidence Standard
Viewing ABA Intervention and Services from an Implementation Science Perspective
6 Characteristics of ACD Participants
Descriptive Analysis of ACD Participation
Descriptive Analysis of Assessments
7 Keeping Pace with Autism and ABA Developments
AUTISM DIAGNOSIS AND INTERVENTIONS
DEVELOPMENTS IN THE ABA INDUSTRY
Best Practices for Individual Assessment of Progress with ABA
Assessment Tools (aka “Outcome Measures”)
Appendix A Committee and Staff Biosketches
Appendix B Public Meeting Agendas
Appendix C Questions to the Defense Health Agency and Responses
Appendix D Methodology for the Committee’s Data Analyses
Appendix E Legislation, Statutes, Regulations, and Federal Register Notices Relevant to the ACD
Appendix F Positions on Applied Behavior Analysis of Professional Health Organizations
Appendix G Comparison of Commercial Insurance Coverage for ABA
Boxes, Figures, and Tables
BOXES
S-1 DoD Criteria for Reliable Evidence of Proven Medical Effectiveness
1-1 DoD Criteria for Reliable Evidence of Proven Medical Effectiveness
1-2 Federal Demonstration Authorities
3-1 TMA’s 2013 Interim Analysis of ABA Services
3-2 Current Required Assessments under the ACD
3-3 Impacts of the COVID-19 Pandemic on the ACD
3-4 Perspectives—DSM-5 Diagnostic Checklist
3-5 Illustrative Example of Family Experience with the ACD
3-6 Family Perspectives—Permanent Changes of Station
4-1 Mental Health Parity and Addiction Equity Act
4-3 Perspectives on Activities of Daily Living
FIGURES
2-1 DHA-approved DSM-5 autism Diagnostic Checklist
3-1 Phased implementation timeline
3-2 Steps for participation in EFMP and ECHO
4-3 ABA authorization requirements comparison
5-2 Levels of evidence hierarchy
5-3 Harvest plot depiction of magnitude of effect for primary outcomes
5-4 Harvest plot depiction of magnitude of effect for secondary outcomes
5-5 Implementation science systems model
6-1 Historical ACD participants and government expenditures
6-2 TRICARE-eligible children with autism 2018–2023 and ACD participation
6-3 Age breakdown of ACD participants and non-participants 2018–2023
6-5 Average amount of ABA (hours/week) of ACD participants by age 2018–2023
6-6 Histogram of amount of ABA (hours/week) for ACD participants 2018–2023 (continuous ABA users)
6-7 Histogram of baseline teacher PDDBI composite (N = 14,934)
TABLES
4-1 Adoption of Key Standards and Public Policies
4-2 Comparison of Criteria for ABA Services (CASP Guidelines, Commercial Insurance, ACD Policies)
5-1 Focused Intervention Practice Definitions, Number of Meta-analyses, and Type of Outcome
6-1 Clinical Characteristics for Total Sample by Participation Groups
6-2 Clinical Characteristics for Ages 0 to 2 years old
6-3 Clinical Characteristics for Ages 12 to 18 Years Old
6-4 Clinical Characteristics by Amount of ABA (Hours per Week)
6-5 Summary of Availability of Assessment Scores for ACD Participants (N = 36,420)
D-1 Sample Table for Demographic Characteristics Examined for Ages 0–2
D-2 Clinical Characteristic Fields
D-3 Clinical Characteristics among Ages 0–2
D-4 Clinical Characteristics among Age 3
D-5 Clinical Characteristics among Age 4
D-6 Clinical Characteristics among Age 5
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Acronyms and Abbreviations
| AAC | augmentative and alternative communication |
| AAP | American Academy of Pediatrics |
| ABA | applied behavior analysis |
| ABAI | Association for Behavior Analysis International |
| ACD | Comprehensive Autism Care Demonstration |
| ADDM | Autism and Developmental Disabilities Monitoring |
| ADFM | active-duty family member |
| ADHD | attention-deficit/hyperactivity disorder |
| ADI-R | Autism Diagnostic Interview–Revised |
| ADLs | activities of daily living |
| ADOS-2 | Autism Diagnostic Observation Schedule, Second Edition |
| AMA | American Medical Association |
| APA | American Psychiatric Association |
| ASN | Autism Services Navigator |
| BACB | Behavior Analyst Certification Board |
| BCaBA | Board Certified Assistant Behavior Analyst |
| BCBA | Board Certified Behavior Analyst |
| BCBA-D | Board Certified Behavior Analyst-Doctoral |
| CAPER | Comprehensive Ambulatory/Provider Encounter Record |
| CARS-2 | Childhood Autism Rating Scale, Second Edition |
| CASP | Council of Autism Service Providers |
| CCP | comprehensive care plan |
| CDC | Centers for Disease Control and Prevention |
| CMS | Centers for Medicare & Medicaid Services |
| CPI | Crisis Prevention Institute |
| CPT | Current Procedural Terminology |
| DEERS | Defense Enrollment Eligibility Reporting System |
| DHA | Defense Health Agency |
| DoD | Department of Defense |
| DSM | Diagnostic and Statistical Manual of Mental Disorders |
| DTT | Discrete Trial Teaching |
| EBM | evidence-based medicine |
| ECHO | Extended Care Health Option |
| EFMP | Exceptional Family Member Program |
| EHRs | electronic health records |
| EIBI | early intensive behavioral intervention |
| EPSDT | Early and Periodic Screening, Diagnostic, and Treatment |
| ERISA | Employee Retirement Income Security Act |
| ESDM | Early Start Denver Model |
| FCT | functional communication training |
| FEHB | Federal Employees Health Benefits |
| GAO | U.S. Government Accountability Office |
| GARS-3 | Gilliam Autism Rating Scale, Third Edition |
| GASC | generally accepted standards of care |
| HNFS | HealthNet Federal Services |
| ICD | International Classification of Diseases |
| IEP | individualized education plan |
| IRB | Institutional Review Board |
| M-CHAT | Modified Checklist for Autism in Toddlers |
| MD | mean difference |
| MHPA | Mental Health Parity Act |
| MHPAEA | Mental Health Parity and Addiction Equity Act |
| NADFM | non-active duty family member |
| NCAEP | National Clearinghouse on Autism Evidence and Practice |
| NCCA | National Commission for Certifying Agencies |
| NDAA | National Defense Authorization Act |
| NDBI | naturalistic developmental behavioral intervention |
| NDD | neurodevelopmental disorder |
| NPI | National Provider Identification |
| NQTLs | nonquantitative treatment limitations |
| NSCH | National Survey of Children’s Health |
| OCD | obsessive–compulsive disorder |
| OT | occupational therapy |
| PACS | parent-reported composite score |
| PCS | permanent change of station |
| PDDBI | Pervasive Developmental Disorder Behavior Inventory |
| PDD-NOS | Pervasive Developmental Disorder–Not Otherwise Specified |
| PDTS | Pharmacy Data Transaction Service |
| PECS | Picture Exchange Communication System |
| PFPWD | Program for Persons with Disabilities |
| PRT | Pivotal Response Treatment |
| PSI-SF | Parenting Stress Index–Short Form |
| PT | physical therapy |
| QTLs | quantitative treatment limitations |
| RBT | Registered Behavior Technician |
| RCT | randomized controlled trial |
| RITA-T | Rapid Interactive Screening Test for Autism in Toddlers |
| SCD | single-case design |
| SIDR | Standard Inpatient Data Record |
| SIPA | Stress Index for Parents of Adolescents |
| SLP | speech and language pathology |
| SMD | standardized mean difference |
| SRS | Social Responsiveness Scale |
| STAT | Screening Tool for Autism in Toddlers & Young Children |
| TED-I | TRICARE Encounter Data–Institutional |
| TED-NI | TRICARE Encounter Data–Non-Institutional |
| TMA | TRICARE Management Activity |
| TOM | TRICARE Operations Manual |
| TONI-4 | Test of Non-Verbal Intelligence Scale, Fourth Edition |
| USMC | United States Marine Corps |
| Vineland-3 | Vineland Adaptive Behavior Scales, Third Edition |
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