A Comparative Review of ABA and ESDM Cost-Effectiveness Across Treatment Intensities

Abstract

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition associated with significant impairments in social functioning, communication, and behavior. Applied Behavior Analysis (ABA) is the most extensively researched and widely implemented ASD intervention. The Early Start Denver Model (ESDM) combines ABA techniques with an early, developmental approach for young children typically aged 12 to 48 months. Both ABA and ESDM carry a high financial burden, coupled with required treatment intensity fluctuations by child; parents often have difficulty navigating treatment options. No existing framework has comprehensively evaluated the cost-effectiveness of ABA and ESDM or identified the treatment intensity that maximizes outcomes relative to cost. Current economic evaluations are scarce and inconsistent. UK modeling in 2020 estimated ABA’s incremental cost per quality-adjusted life year to range from £46,768-£189,122, while Ontario-based analyses found ESDM cost-saving relative to standard care using disability-free life years. The present study is a comparative review of the effectiveness and cost-effectiveness of ABA and ESDM interventions. Treatment intensity, duration, quantitative outcomes, and costs were extracted from prior studies and synthesized to compare treatment pathways across varying intervention intensities to identify the optimal treatment intensity that balances outcomes and costs. Results indicate that greater treatment intensity did not consistently produce greater annual outcome gains, suggesting that maximizing treatment intensity may not maximize cost-effectiveness. This process aims to support the development of autism digital twins capable of simulating individualized treatment pathways to optimize intensity and cost for children with ASD.