On a sunny Wednesday morning last month, dozens of preschoolers filed into a Compleat Kidz autism clinic in Concord, N.C. One wore light-up sneakers. Another had a Spider-Man lunchbox. They settled into tiny green cubicles, each accompanied by a staff member, and started their work.<\/p>\n
A decade ago, this Charlotte suburb had no clinics providing therapy to children with autism. Now it has 12. Inside this one, children buzzed with activity as they worked long sessions with therapists. One 6-year-old girl, exhausted after hours of therapy, fell fast asleep in her therapist\u2019s lap.<\/p>\n
Soon, a supervisor, Stephen Schroeder, intervened.<\/p>\n
\u201cHow long?\u201d Mr. Schroeder asked Courtney Evans, the therapist.<\/p>\n
\u201cI set the timer for 7. We\u2019re almost done,\u201d Ms. Evans said. A couple of minutes later, she nudged the child awake. The girl cried.<\/p>\n
At Compleat Kidz, a fast-growing chain of autism clinics based in North Carolina, the policy is firm: Naps cannot be longer than seven minutes before children are awakened to resume therapy. The company says this is necessary to prevent fraud since clinics can be paid only when children are awake and getting services. But it also allows the clinic to bill insurers or Medicaid for more hours.<\/p>\n
Across the United States, where treatment for autistic children was once fairly rare, thousands of clinics have sprung up, turning a once obscure therapy into a multibillion-dollar industry. The growth has been fueled by rising autism diagnoses, state insurance mandates and a federal requirement that Medicaid cover the therapy. Private equity investors have rushed into the business, buying up chains and opening new clinics.<\/p>\n
A New York Times investigation has found that this rapid expansion has played out with little regulatory oversight and brought allegations of children being harmed by profit-motivated practices. In interviews, dozens of current and former clinic workers described how clinics frequently overprescribe hours \u2014 even recommending that some families remove children from school so they can receive more therapy.<\/p>\n
Marquisha Richards worked at two private-equity-backed chains in Texas. She said she became disillusioned about how financial considerations repeatedly drove care decisions. \u201cThe science is beautiful, but the industry is very ugly,\u201d she said.<\/p>\n
Nationwide, Medicaid spending on autism therapy nearly tripled between 2020 and 2024. In some states it grew much faster: Colorado Medicaid now spends more on autism therapy than on all emergency department visits. North Carolina, which spent $121 million in 2022, projects it will spend over $1 billion next year.<\/p>\n
Like many clinics, Compleat Kidz has adroitly ridden the funding wave. More than 80 percent of its patients are covered by Medicaid, and the chain has collected about $130 million from the public insurance plan since 2019. The company runs 25 clinics now, with a focus on poor and rural areas of the state. Last summer, a private equity firm invested in the company.<\/p>\n
Compleat Kidz says that it does not overprescribe care, and that its average patient attends 18 hours of therapy a week. Thirty percent graduate each year, which the company describes as a sign children have mastered new skills under its care.<\/p>\n
But The Times spoke to 14 former Compleat Kidz employees, ranging from top executives to those working directly with patients, who said they left the company out of concern that its focus on profit was harming children. Their experiences echo concerns from 15 workers at other chains across the country whom The Times interviewed.<\/p>\n
Compleat Kidz employs in-house psychologists to diagnose children, creating a pipeline of new patients. Some ethics experts view this as a conflict of interest, and North Carolina plans to outlaw the practice<\/a> later this year. Bonuses for salespeople are partly based on the number of hours the children they recruit attend.<\/p>\n \u201cThe motivation to have these kids there was financial,\u201d said Patrick Winham, a regional vice president whose contract was terminated in 2024. \u201cThey wanted to fit in as many kids in a day as they could.\u201d<\/p>\n Two other former executives, who requested anonymity because they have nondisclosure agreements, said they too were concerned about the overemphasis on revenue.<\/p>\n Meredith Menninger, a Compleat Kidz spokeswoman, said all of its policies were \u201cpatient-centric\u201d and \u201cgrounded in peer-reviewed research.\u201d She disputed the notion that the company acted in ways that put earnings ahead of children.<\/p>\n She said Mr. Winham\u2019s characterization was not credible, saying that he sought to rejoin the company last year.<\/p>\n Autism clinics operate with little state oversight. Unlike day care facilities, they are not subject to regular inspections despite young children spending long hours there. <\/p>\n A dozen instances of child abuse at Compleat Kidz facilities have been reported to the police since 2023, according to records The Times reviewed. At least two resulted in criminal charges against employees, and a third is the subject of a lawsuit a parent filed against Compleat Kidz.<\/p>\n North Carolina Medicaid opened an investigation into the chain after The Times shared its findings.<\/p>\n The program is \u201cready to take swift and appropriate action,\u201d said Melanie Bush, North Carolina Medicaid\u2019s director. That could include \u201csuspension of Medicaid payments or termination from the program, if warranted.\u201d<\/p>\n The company has fully cooperated with the police when its employees have faced allegations of child abuse, Ms. Menninger said, adding that it will do the same with the new state inquiry.<\/p>\n \u201cWe have nothing to hide and will cooperate fully,\u201d she said.<\/p>\n Little data exists on child abuse at autism clinics. Seven instances were reported to the police across Charlotte\u2019s 80 clinics since 2023, three at Compleat Kidz, according to records provided by the Charlotte-Mecklenburg Police Department. <\/p>\n Opportunities to Profit<\/p>\n Today\u2019s multibillion-dollar autism therapy industry grew out of a 1980s study<\/a> involving 38 preschool children.<\/p>\n It found that children who spent two years in 40 weekly hours of one-on-one therapy, called applied behavior analysis, or A.B.A., had better behaviors than those treated for 10 hours. The focus of the therapy was providing small rewards when children acted correctly and negative consequences when they did not.<\/p>\n The study was small and children were not randomly assigned into therapy, meaning other factors might explain the difference. It used consequences that would not be considered acceptable today, such as slapping a child on the thigh for bad behavior.<\/p>\n Even so, it was heralded as a breakthrough: It suggested that, with intensive therapy, children with autism could behave differently.<\/p>\n Autism diagnoses have increased since that study, rising to about 3 percent of children under 8, or millions of children. Those children often struggle with communication and social skills, and some are unable to speak.<\/p>\n Modern A.B.A. treatment typically relies on rewarding good behavior rather than punishing unwanted actions. The rewards can include a high-five, a play break or a few minutes of screen time.<\/p>\n Recent studies of A.B.A. therapy have mixed findings. One major evidence review in 2018 found \u201cweak evidence<\/a>\u201d that it reduces autism symptoms. Countries have split on whether the service is worth paying for. Some Canadian provinces cover the therapy. Britain does not.<\/p>\n On the April morning in Concord, Times reporters watched Compleat Kidz patients receive therapy. A 5-year-old girl with purple glasses practiced writing letters, getting high-fives and Cheetos as her rewards. Therapists successfully soothed a 3-year-old boy in a dinosaur shirt, who threw a tantrum because he did not want to use the bathroom.<\/p>\n Some parents describe the therapy as transformative.<\/p>\n \u201cBefore, he used to growl or groan when he was frustrated,\u201d Kayla Belton said of her 4-year-old son, who attends therapy with Compleat Kidz. \u201cNow he can verbalize when he\u2019s upset. We\u2019ve seen improvement in his communication and behavior in just a few months.\u201d<\/p>\n Tijuana Blackwell, the mother of the 6-year-old who was roused from a nap, said her daughter\u2019s therapy was a \u201cgame changer.\u201d<\/p>\n Autism treatment did not become big business until the mid-2010s, after state laws began requiring insurers to cover it. Medicaid soon followed<\/a>, and the industry boomed.<\/p>\n In North Carolina, the number of clinics owned by autism therapy providers grew from 61 in 2019 to 409 in 2026, according to data compiled by Daniel Arnold, a health economist at Brown University.<\/p>\n The clinics are enticing to health care investors: Demand is high and payment rates far exceed labor costs.<\/p>\n Medicaid often pays about $70 per hour ($83 in North Carolina) for therapy largely provided by workers with high school diplomas who earn around $20. <\/p>\n Private equity firms have acquired<\/a> at least 500 clinics over the past decade. \u201cThere\u2019s just huge opportunities to grow these businesses and help increase access to care,\u201d said Jon Krieger, a managing partner at Calex, a financial firm that assists with autism clinic mergers and acquisitions. He estimates the market could grow to $90 billion.<\/p>\n The facilities have a double appeal for many parents: Along with promising better behavior, they can amount to free child care because Medicaid pays all the costs. <\/p>\n Adi Khindaria, the chief executive of Compleat Kidz, said scale is crucial to making the clinics successful and able to help more children.<\/p>\n \u201cI personally believe in the fact that, you know, profit is like oxygen,\u201d he said. \u201cWithout oxygen, you can\u2019t live. But the purpose of living is not breathing oxygen, right? The purpose of living is to do something useful.\u201d<\/p>\n 40 Hours a Week<\/p>\n Kim Lambert enrolled her son, Rhett, in 30 hours of weekly therapy after a preschool kicked him out. She kept him out of school for five years at the advice of multiple clinics (none owned by Compleat Kidz) in rural North Carolina.<\/p>\n After several negative experiences, including one where, she said, a worker hit Rhett after he broke a toy, she decided to try public school last fall, enrolling him in fourth grade at age 11. She said he has adjusted easily. But he was placed two years below grade level because of his academic deficit.<\/p>\n \u201cWe were sold this story, if you bring him to us all the time it\u2019s going to be fine,\u201d Ms. Lambert said. She credits Rhett\u2019s progress to an in-home therapist who she said made larger gains in fewer hours each week.<\/p>\n Advising families not to send their children to school is one common practice that current and former workers at clinics across the country described as increasing profits at children\u2019s expense.<\/p>\n Another is telling families they will not enroll their children unless they agree to 25, 30 or sometimes 40 hours of therapy a week.<\/p>\n Emily Jiminez, who worked in executive positions at private-equity owned clinics in Texas and Arkansas, said prescription of therapy was often based on children\u2019s availability rather than their needs.<\/p>\n \u201cIt was more like, this kid is 3 years old, they have the time to be here 40 hours,\u201d said Ms. Jiminez, who now works at a small autism therapy business in North Carolina. \u201cLet\u2019s just prescribe them that.\u201d<\/p>\n Nationally, clinic visits have grown longer since private equity entered the business, from a median of four hours in 2019 to 5.5 hours in 2024, according to an analysis of 34 million Medicaid claims by the health data firm Trilliant.<\/p>\n Visits eight hours or longer have become more common, rising from 9 percent of appointments in 2019 to 16 percent in 2024.<\/p>\n Four former therapists from Action Behavior Centers, a national chain of more than 300 clinics, described having extra hours tacked onto their patient treatment plans without justification.<\/p>\n Charna Mintz, the company\u2019s chief clinical officer, said hours could be added only if \u201ca clinical leader with more experience recommends a change\u201d and the therapist agrees.<\/p>\n Turnover is high across the industry among the behavioral technicians who work one on one with the children. The work is challenging and the pay is similar to working in retail or fast food.<\/p>\n A few weeks after Shana Bridges started a job as a behavioral technician at Compleat Kidz last June, she said, a 7-year-old boy flew into a rage that nobody seemed to know how to handle. \u201cHe was knocking over bookshelves, throwing toys, attempting to hit,\u201d said Ms. Bridges, who left the job after three months. \u201cThe other kids are in the corner, hiding.\u201d<\/p>\n Ms. Bridges and three other technicians said they were given too few tasks to fill the hours . They repeated activities that children had already mastered. The job often felt like babysitting.<\/p>\n Ms. Menninger said these workers \u201cmay not have understood the clinical rationale behind the programming.\u201d<\/p>\n Less Oversight Than Day Care<\/p>\n Two years ago, Zach Wallace had his 3-year-old evaluated for autism at a Compleat Kidz clinic, after the boy\u2019s day care teachers said he was slow to talk and preferred playing alone.<\/p>\n Compleat Kidz diagnosed him with autism, and enrolled him in 25 hours of weekly therapy. A year into treatment, his mother noticed a red mark on his genitals while giving him a bath.<\/p>\n The boy began to cry and said his therapist had told him to \u201ckeep it a secret,\u201d both parents recalled.<\/p>\n \u201cWe don\u2019t keep secrets from Mommy and Daddy,\u201d they said they told him. The boy then said his therapist had been touching him in the bathroom.<\/p>\n The parents told the police, according to a police report. They said they did not pursue charges because their son was uncomfortable talking to the police, who closed the case as \u201cunfounded.\u201d<\/p>\n Ms. Menninger said the clinic reviewed video footage from that day and \u201cfound no evidence to substantiate the allegations.\u201d<\/p>\n Six months later, the parents had their son re-evaluated for developmental delays through their school district. The new round of testing found that he did not have autism, they said. He now attends a regular preschool, and his parents describe him as a normally developing child.<\/p>\n North Carolina inspects day cares annually, posts the results and rates the facilities on a five-star scale. There is no such system for autism clinics.<\/p>\n Compleat Kidz has allowed behavior technicians to begin treating children before finishing background checks, according to three former managers and two former technicians. Several workers were fired after the background check discovered a problem, they said.<\/p>\n Ms. Menninger disputed this account, saying that background checks are always completed before therapists \u201cwork directly with children.\u201d<\/p>\n The Times uncovered 12 reports of child abuse at Compleat Kidz clinics since 2023 by filing records requests with police departments.<\/p>\n Ms. Menninger said only one of the employees involved still works there, after the police found their charges to be \u201cunfounded.\u201d<\/p>\n One 4-year-old girl came out of a clinic in Charlotte with what appeared to be a circular bite mark on her arm last June, according to court records . \u201cTeacher bit me,\u201d the girl told her mother. The worker initially blamed another child for the bite but, after police investigators reviewed video footage, pleaded guilty to assaulting a child.<\/p>\n In January, a Compleat Kidz worker in Winston-Salem was charged with child abuse after he allegedly broke the arm of a 6-year-old boy he was treating. He is awaiting trial.<\/p>\n \u201cWe do not tolerate misconduct toward children,\u201d Ms. Menninger said, \u201cand our response in each instance was immediate termination and full cooperation with authorities.\u201d<\/p>\n Former employees described additional incidents they witnessed. Suhaely Arroyo-Esquivel, a former vice president, recalled seeing children restrained in inappropriate ways. In one instance, a child was pinned to the wall with a table. In another, a boy\u2019s shirt was put on backward with the sleeves tied behind him to restrain his arms.<\/p>\n Those restraints, Ms. Menninger said, \u201cdo not reflect Compleat Kidz\u2019s approved protocols or policies.\u201d She noted that Ms. Arroyo-Esquivel applied for a new job at the company last year.<\/p>\n Allegations of child abuse have occurred at A.B.A. clinics elsewhere. In 2024, parents sued a Texas clinic<\/a> after reviewing video footage they say shows their 7-year-old son being thrown against a wall. This February, a Florida technician was caught on tape<\/a> hitting a 5-year-old with a shoe. Both children were nonverbal.<\/p>\n \u2018A Freshly Stocked Pond\u2019<\/p>\n Last October, North Carolina\u2019s Medicaid program tried to rein in its A.B.A. spending. By December, it had failed.<\/p>\n The state proposed cutting payments to clinics by 10 percent, part of a larger set of reductions to offset a state budget crunch.<\/p>\n