Supporting the Adult Population as a Board-Certified Behavior Analyst (BCBA)
Tip #113: Diagnosis ≠ Daily Needs: Rethinking ABA Care
I’ve supported individuals whose teeth were actively decaying due to persistent resistance to brushing and attending dental appointments. Through direct observation, it was clear the behavior was maintained by a combination of sensory (automatic) aversion and escape/avoidance.
As a behavior analyst, I could clinically identify the function and potential intervention strategies. However, due to insurance limitations and medical necessity criteria, these concerns did not qualify for billable ABA services. As a result, I was unable to formally include targeted strategies in the treatment plan—despite the clear impact on the individual’s health and quality of life.
Similarly, I’ve worked with individuals who refuse to engage in physical activity, leading to gradual health decline and increased long-term risk. Yet under Medicaid waiver services, these behaviors may not align with what is considered “medically necessary” for ABA billing. This creates a gap where meaningful, preventative support cannot always be formally addressed within the plan.
Let's Consider This...
In adult services, ABA is rapidly shifting toward an insurance-driven medical model. Utilization has increased significantly, with services now closely tied to billing structures and medical necessity. While this expansion improves access, it also presents a challenge: services are often approved based on diagnosis, not always on what the individual truly needs in their daily life.
As behavior analysts, our responsibility is to ensure interventions remain function-based, meaningful, and ethically sound within these constraints. This directly aligns with Ethics Code 2.01 (Providing Effective Treatment) and Ethics Code 3.01 (Responsibility to Clients)—prioritizing outcomes that reduce harm and improve quality of life.
In practice, this means identifying the function of behavior (e.g., escape), recognizing that activities of daily living (ADLs) can serve as antecedent triggers, and implementing proactive, preventative strategies. For example, if toothbrushing is experienced as aversive, early precursor behaviors may escalate into escape-maintained behavior such as elopement. In this context, supporting toothbrushing is not simply teaching a life skill—it is a function-based intervention to prevent vulnerable distress behavior.
It is critical that this approach is not misunderstood as relabeling ADLs for approval. Instead, interventions must be grounded in functional relationships, focused on risk reduction, and designed to support dignity and access. Rather than broadly stating “teaching independence,” clinicians should use precise, function-based language such as reducing escape during hygiene routines, increasing tolerance for non-preferred tasks, and teaching replacement behaviors (e.g., requesting a break or withdrawing assent). Ultimately, strong clinical practice is demonstrated by how clearly interventions are anchored to FBA results, including antecedents and precursor behaviors.
Looking ahead, even when we align our practice within the system, system-level limitations remain. This is where advocacy becomes essential. When ADLs are functionally related to behavior and risk, they should be recognized within treatment planning. Expanding how medical necessity is defined is critical to ensuring that quality of life, safety, and interdependence are fully addressed in adult services.
Looking ahead: Advocacy matters
While we can align clinically within the current system, long-term change requires advocacy.
When ADLs are functionally related to challenging behavior, they can and should be incorporated as proactive, antecedent-based strategies. At the same time, this highlights the need to expand how medical necessity is defined so that quality of life and interdependence are fully recognized in adult services.
1. Engage in State Medicaid & Policy Processes
Participate in public comment periods
Join advisory boards or task forces
Submit recommendations during waiver or policy updates
👉 Use real clinical examples to demonstrate how ADLs relate to risk and behavior
2. Partner with Advocacy Organizations
Collaborate with The Arc or Autism Society of America
Join local coalitions and family networks
Present concerns alongside caregivers and self-advocates
👉 Collective voices create stronger impact
3. Educate Lawmakers & Decision-Makers
Meet with state representatives or policy staff
Clearly explain:
The functional relationship between ADLs and behavior
The risks of service limitations (e.g., escalation, hospitalization)
Offer actionable solutions (e.g., expanding definitions of medical necessity)
👉 Keep messaging simple, practical, and human-centered
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From the one and only... Shanda J Your BCBA
Author Credit: Meme and article modified and enhanced with support from my AI tool ChatGpt aka Gem.
Final References (APA 7th Edition)
Behavior Analyst Certification Board. (2022). Ethics code for behavior analysts. https://www.bacb.com/ethics
Behavior Analyst Certification Board. (2023). BCBA/BCaBA test content outline (6th ed.). Behavior Analyst Certification Board.
Trilliant Health. (2025). ABA therapy utilization grew nearly 300%, driven by increases in Medicaid. https://www.
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