Children as Revenue Sources: The Anthropological Crisis Behind the ABA-Medicaid Scandal

A four-year-old spends more than 40 hours a week in an Applied Behavior Analysis clinic. His parents were told this intensity was medically necessary. His diagnosis may have been inflated or fabricated to justify the hours. The adults working with him are paid near minimum wage and cycle through his case with little continuity. His developmental needs are real; the system billing Medicaid on his behalf has organized itself around something else entirely.

The New York Times reported in May 2026 that this pattern is not anomalous. Across the ABA industry, financial incentives have produced false diagnoses, excessive service hours, undertrained staff, and documented harm to children too young to report it themselves. State Medicaid budgets are strained. Oversight is thin. The children at the center of this system are, in a meaningful structural sense, the means by which money moves from government accounts to clinic operators.

The secular press correctly frames this as a regulatory failure. But the regulatory frame cannot reach the root of the problem, because the root is not a billing code. It is an account of the child — implicit, unexamined, and wrong — that made this kind of system possible in the first place.

The child as line item

Medicaid reimbursement structures pay per hour of documented service. When clinic survival depends on volume, the child's actual developmental state becomes an administrative variable rather than a clinical signal. A child who is dysregulated, exhausted, or present only in body is still a billable unit if the documentation can be made to say the right things. The documented cases of false and inflated diagnoses follow the same logic: an autism diagnosis at the right severity level unlocks a reimbursement tier, and the child's actual presentation is secondary to the revenue calculus.

Aquinas, writing on justice in the Summa Theologiae, distinguishes between what is owed to a person by reason of their nature and what is owed by reason of contract or convention. The child in the ABA clinic is owed something prior to any Medicaid contract: recognition as a being whose body and soul form a genuine unity, whose development unfolds through real relationship, and whose suffering cannot be abstracted into a revenue cycle without moral consequence. Vitz, Nordling, and Titus argue in their Catholic Christian Meta-Model of the Person that the body's state is never a secondary variable in human development. Treating a child's neurological condition as a billing opportunity — rather than as a call to attuned accompaniment — is not merely fraud. It is a category error about what the child is.

Forty hours a week and the developing person

The reported cases of children spending 40 or more hours weekly in ABA are not simply a matter of excessive billing. They represent a developmental intervention conducted at an intensity that can itself cause harm, particularly when the staff delivering it are undertrained, underpaid, and subject to high turnover.

Bruce Perry's Neurosequential Model insists that effective intervention with young children must match the child's neurological state at each moment of encounter. A dysregulated or exhausted child cannot process behavioral contingency. Perry's work demonstrates that the therapeutic relationship — not the technique applied over it — is the primary vehicle of neurological reorganization in early childhood. Forty hours a week of contact with rotating, undertrained staff is not forty hours of therapy. It is, in many cases, forty hours of managed dysregulation.

The CCMMP's sensory-perceptual-cognitive premise identifies what Suazo, drawing on Aquinas, calls the cogitative sense — the child's evaluative faculty by which perception, memory, and imagination are integrated into a coherent sense of safety or threat. This faculty develops through repeated, attuned encounters with a responsive other. Clinics that treat throughput as the primary variable are not merely inefficient; they train the cogitative sense toward patterns of disconnection. The harm is not only that too many hours were billed. The harm is that the developmental architecture being formed in those hours was shaped by an environment organized around institutional convenience rather than the child's actual good.

Nordling's child-centered play therapy research shows what genuine therapeutic encounter with young children looks like: a progression from cautious testing of the therapist's reliability, through limit-setting, to cooperative and nurturing play. This arc requires time, consistency, and a therapist whose attention is not divided between the child and the documentation dashboard. High staff turnover — endemic in a low-wage, high-volume model — structurally prevents this arc from completing. The child who needs continuity most gets the least of it.

False diagnoses and the corruption of care

The reports of inflated and fabricated autism diagnoses represent the sharpest edge of the scandal. A diagnosis is not a bureaucratic category. It is a judgment about a child's nature and needs, and it carries weight in how the child is seen — by parents, by schools, by the child herself as she grows into the identity the diagnosis confers. To issue a false diagnosis in order to unlock a billing tier is not only fraud against Medicaid. It is a particular kind of violence against the child's developing self-understanding.

The CCMMP's account of the Fallen state is precise here. Concupiscence, in the Thomistic account, is not wickedness but disordered appetite — desire that has slipped its rational ordering and now pursues its object without reference to the good of the whole. Applied Behavior Analysis has a legitimate evidence base for specific autism-related outcomes. The industry the Times describes has replicated, at institutional scale, exactly the structure Aquinas names: a good appetite, disordered by an incentive environment that removed the natural checks on excess. Gabor Maté observes that social environments shape desire — that systems develop their own appetites, and that individuals within those systems find their judgments gradually bent toward the system's reward structure.[^1] A clinician working in a high-volume ABA clinic who begins to adjust diagnoses slightly upward to maintain authorization hours is not, in most cases, a calculating fraudster. She is a person whose practical judgment has been eroded by sustained immersion in a disordered incentive structure.

This does not excuse the conduct. It locates it within a recognizable account of how moral failure spreads through institutions.

Proxy parenting and the relational void

One of the most troubling patterns in the Times reporting is what might be called the proxy-parenting dynamic: young children spending the majority of their waking hours in clinic settings, cared for by a rotating cast of undertrained behavioral technicians, while parents — often working, often themselves in need of support — are structurally excluded from the therapeutic relationship.

Ignatius of Loyola, in the Spiritual Exercises, locates discernment in attention to actual interior movements — the lived experience of consolation and desolation — rather than to the plausible surface of a proposed action. A parent who notices that her child returns from the clinic withdrawn, exhausted, or more dysregulated than when he left has been given data. The question is whether the system has built any channel through which that data can arrive and change anything. In a model organized around documentation of billable events, the parent's observation of her child's state is structurally invisible. Her voice is not silenced by malice; it is silenced by design.

The child's primary attachment relationships — with parents, with consistent caregivers — are the developmental substrate on which all other learning depends. Bowlby's attachment theory and Perry's neurodevelopmental work converge on this point. A care model that displaces rather than supports those relationships, regardless of its technique, is working against the child's most fundamental developmental need. The high-hour, high-turnover ABA clinic does not merely fail to support attachment. In many cases, it actively competes with it.

What prudence requires of institutions

Prudence, in the Thomistic account, is not caution about consequences. It is the faculty of perceiving the genuine good in a concrete situation and ordering action toward it. An institution that has lost this faculty — that can no longer register a distressed child as a signal requiring a clinical response rather than a documentation workaround — cannot recover it through compliance training or fraud detection software alone.

The correction Aquinas proposes is formation of the faculty that governs desire. For institutions, this means embedding the question of the child's actual good into the decision architecture at every level: intake criteria, diagnostic review, staffing ratios, session length, parental involvement, and staff formation. It means hiring clinicians with the developmental formation to recognize when a child needs fewer hours, not more. It means building documentation systems that make the child's lived state legible rather than obscuring it behind billing categories.

Jonathan Haidt has written about the feedback loops that amplify harmful social patterns when prestige and reward flow toward visible suffering rather than genuine recovery.[^2] The ABA-Medicaid system has generated its own version of this dynamic: the children with the most severe profiles, held in the most intensive programs, generate the highest reimbursements, and the system's reward structure flows accordingly. Breaking that loop requires more than external audit. It requires institutions whose leaders can name the disorder and choose differently.

What genuine accompaniment looks like

A therapeutic system organized around the child's actual good looks structurally different from what the Times describes. Diagnostic processes include independent review and conservative thresholds. Service intensity is calibrated to the child's neurological state, not to a reimbursement tier. Staff are paid, trained, and retained at levels that make continuity of relationship possible. Parents are active participants in the therapeutic process rather than sources of consent signatures. And the documentation system captures the child's lived experience — what she communicated, how she responded, what the clinician observed — rather than recording only the categories needed for billing authorization.

None of this is utopian. Several ABA providers operate on something close to this model. The difference between those providers and the ones the Times describes is not primarily regulatory. It is anthropological. The providers doing this work well begin from a prior conviction that the child in front of them is a person — not a unit of service delivery, not a diagnosis code, not a reimbursement vehicle — and that their task is genuine accompaniment of that person's development.

The CCMMP framework, as Vitz, Nordling, and Titus develop it, names this conviction precisely: the human person is a unity of body and soul, constitutively relational, whose flourishing requires encounters ordered to her genuine good rather than to any institution's financial sustainability. No audit produces that orientation. Only formation in it does.

The children in these clinics are not abstract policy problems. They are persons whose cogitative sense is being shaped, right now, by the environments adults have built around them. The question this scandal presses is whether the adults responsible for those environments will reorganize them around the child's actual dignity — or wait for the next investigative report to force the issue.

[^1]: Gabor Maté, In the Realm of Hungry Ghosts — on how social environments shape desire and gradually bend individual judgment toward a system's reward structure.

[^2]: Jonathan Haidt, The Anxious Generation — on feedback loops that amplify harmful social patterns when prestige and reward flow toward visible suffering rather than genuine recovery.