Mental health outcomes associated with applied behavior analysis in a US national sample of privately insured autistic youth

Applied behavior analysis is a widely used intervention for autistic youth, though its mental health impacts remain under-researched. This study aims to investigate the association between applied behavior analysis therapy and post-traumatic stress disorder, suicidality, mental health hospitalization rates, and length of mental health hospitalizations using a national database of privately insured youth under 18. We matched 17,120 autistic youth who received applied behavior analysis with a control group of autistic youth with no record of applied behavior analysis and clustered them into four applied behavior analysis dose groups using two-stage bisecting k-medians clustering. Then, we used negative binomial regression and logistic regression to compare outcomes for the applied behavior analysis and non-applied behavior analysis groups. Overall, applied behavior analysis receipt was associated with 30% higher odds of experiencing a mental health hospitalization (odds ratio = 1.30, p < 0.001) and a 32% higher incidence rate of these hospitalizations (incidence rate ratio = 1.32, p < 0.001). Our analysis found no relationship between applied behavior analysis dosing and the other tracked mental health outcomes. These results indicate the need for more quantitative analysis with more comprehensive records of applied behavior analysis receipt to fully investigate claims of ABA resulting in adverse adult mental health outcomes. Lay abstract Autistic youth often receive applied behavior analysis (ABA) therapy, but some autistic adults who had ABA as youth say it harmed their mental health as adults. We looked at the relationship between ABA and post-traumatic stress disorder (PTSD), suicidality, mental health hospitalization rates, and length of mental health hospitalizations among autistic youth. We used private health insurance claims data to look at how ABA receipt was related to those mental health outcomes. We divided autistic youth into groups based on how much ABA they received, so we could see if different amounts of ABA had different associations with mental health. There were 17,120 autistic youth in the group that did not receive ABA, and 17,120 autistic youth in the group that did receive ABA. In this sample, ABA therapy was associated with a greater use of acute mental health services; autistic youth in the ABA group had an overall risk that was 30% higher for mental health hospitalizations; and a 32% greater frequency of mental health hospitalizations. These results suggest that there may be a relationship between mental health hospitalizations and getting ABA. However, more work is needed to fully understand the impact of ABA therapy on mental health outcomes.