Ralston has spent 25 years in ABA, from the days of VHS tapes and Scantron exams to the private equity consolidation wave. Now she’s CEO of a PE-backed provider, and she has opinions about what the industry is getting wrong.
Amanda “Mandy” Ralston has been a behavior analyst since 1999, before the RBT credential existed, before insurance covered autism services, before most of the infrastructure the industry now takes for granted. She built a company over twelve years and sold it to a large ABA provider in 2019. She took a detour into health-tech. And now she’s back running a provider, this time as CEO of KidsChoice, an Oklahoma-based ABA company that just received a majority investment from Aquitaine Capital, a women-owned private equity firm.
Ralston passed her BCaBA exam in 2002 with a number two pencil and a Scantron machine. She learned clinical skills by mailing VHS tapes to a behavioral psychologist, talking through cases on a landline phone. And after passing her BCBA in 2014 and watching the industry she helped build become dominated by private equity, she has strong opinions about what it’s getting wrong.
The False Choice
KidsChoice offers ABA, speech therapy, and occupational therapy to children and families across Oklahoma, including clinics in rural areas like Elk City in the western part of the state. The company has emphasized individualized, outcomes-driven care, though specific details about its current footprint and patient volume were not disclosed. The deal marks Aquitaine’s first platform investment in applied behavior analysis.
As part of the transaction, Nic Newton and Sierra Harrington will serve as co-presidents under Ralston. The board includes Dr. Joseph Cunningham, former president of Blue Cross and Blue Shield of Oklahoma, and Kathleen Stengel, a BCBA with more than two decades of leadership experience in pediatric behavioral health.
“We want KidsChoice to be one of the best therapy providers in Oklahoma,” Elizabeth Broomfield, managing partner of Aquitaine Capital, said in a statement. “That means supporting clinicians, investing in quality and consistency, and ensuring families can count on ethical care as the company grows.”
In a LinkedIn post following the announcement, Stengel wrote that Aquitaine is “investing not just in expansion, but in systems, leadership, infrastructure,” and emphasized “outcomes over optics, sustainability over speed.”
The Rollup
The deal arrives at a moment of continued consolidation in the ABA industry, though the pace and character of dealmaking has shifted since the frenzied years of 2017 to 2022, when private equity firms completed 85 percent of all mergers and acquisitions in autism services, according to a report from the Center for Economic and Policy Research. That rate was not found in any other healthcare segment.
The results have been mixed. Some PE-backed companies have delivered on promises of operational efficiency and expanded access, while others have faced scrutiny over staffing ratios, clinical quality, and the sustainability of their growth models. The language Aquitaine and its board members are using signals an awareness of that track record and an attempt to differentiate.
Ralston has lived that history. She was part of the consolidation wave, and she’s watched what came after.
Seven Families in Lexington
Ralston learned about autism in 1999 while writing a research paper for a psychology course at Centre College in Kentucky. Her textbook gave the condition two paragraphs and cited a prevalence of one in 10,000. Today that figure is closer to one in 31, according to CDC data released in 2025.
“I found seven families in Lexington, Kentucky that were flying a consultant out from California once a quarter to cobble together ABA programs,” Ralston recalled. She began following Dr. Vincent Carbone, a behavioral psychologist who was traveling the country teaching new approaches to autism treatment. “I basically started lightly stalking him,” she said. She completed a 90-hour certification bootcamp in Jacksonville, Florida, then spent a year under Carbone’s mentorship.
In the years since, Ralston has been on nearly every side of ABA’s evolution. She co-founded her first organization in 1999 with three other women and became its CEO by 25. She founded Verbal Behavior Consulting in 2007 and built it over twelve years before selling to BlueSprig, a multi-state ABA platform, in 2019.
“That’s How They’ve Always Done It”
Inside BlueSprig, Ralston saw the problem she, alongside their leadership team, would spend the next several years trying to solve. “I can get 100 BCBAs in a room together, put one kid with autism in front of them, and say, ‘How are you going to approach treatment for this person?'” she said. “They’ll all have completely different approaches, and most of the reason they do it that way is because that’s how they’ve always done it.”
The lack of clinical standardization became her focus as Director of Clinical Intelligence at The Cedar Group, BlueSprig’s subsidiary. She then went on to found NonBinary Solutions, a health-tech company that developed Knowetic, a clinical decision support and care navigation platform for BCBAs. The company is still operating but paused development to focus on securing additional funding. Ralston left it in the hands of her leadership team when she took the KidsChoice role.
The opportunity emerged last October at the Oklahoma Association for Behavior Analysis conference, where Ralston delivered a keynote and joined a panel on private equity in ABA. There she met Broomfield and reconnected with Stengel.
“They bring the brain trust and the resources to allow KidsChoice to grow thoughtfully and ethically at the same time,” Ralston said of Aquitaine. “It’s not a binary. You can have both operational excellence and clinical quality.”
What Families Actually Ask
Ralston is candid about the field’s problems. The number of first-time BCBA examination candidates has increased by over 500 percent since 2010, according to BACB data, and over half of practitioners now have relatively limited experience. “Can you imagine if half of the oncologists in the medical community had less than three years of experience and they didn’t have any kind of standardization in their training?” she asked. “What would that mean for quality of care?”
She is critical of providers who prescribe treatment hours based on operational convenience rather than clinical judgment. “That is not a clinical decision,” she said of blanket policies assigning 20 or 40 hours a week regardless of individual need. “That is an operational decision. That is taking the analysis part out of applied behavior analysis.”
And she wants to redefine what the industry means by outcomes. “Having a certain score on an assessment or a standardized evaluation is not an outcome,” she said. “Having a kid who is toilet trained is an outcome. Having an individual who can get their teeth cleaned without general anesthesia is an outcome. Having somebody who can sleep in their own bed at a regular interval is an outcome.”
These are the questions families actually ask, she said, drawing on years of conducting intake interviews: Can you get him to eat more than five foods? Can you get him to sleep in his own bed? Can you get him toilet trained?
Nowhere to Turn
Ralston grew up in a town of 3,000 people in West Virginia, the kind of place where specialized care meant driving hours to somewhere else. “I’m very aware of the limitations of rural areas and the ability to access care,” she said.
Earlier this year, she visited the KidsChoice clinic in Elk City, a small city in western Oklahoma surrounded by farmland and oil fields, more than 100 miles from Oklahoma City. Staff told her that teachers and families in the area still don’t know what ABA is. Some children, they suspect, remain undiagnosed entirely.
It reminded her of Kentucky in 1999, when she found those seven families flying in a consultant from California because no one nearby knew how to help their kids. She plans to do what she did then: go on a talking tour, offering free workshops on autism and ABA to teachers, pediatricians, and anyone else who will listen. Physical clinics in places like Elk City do more than provide therapy, she said. They create jobs and bring services to families who otherwise have nowhere to turn.
The Three-Legged Stool
Longer term, Ralston wants to move the industry toward value-based reimbursement, a model where outcomes, not hours billed, determine payment. She describes it as a three-legged stool: the interests of the payer, the provider, and the patient must all be balanced. The current fee-for-service model, she argues, tips that stool toward operational decisions that may not serve families.
“If we can reach consensus on what meaningful outcomes are and how to measure them, and producing meaningful outcomes equates to a better rate, then I think we’re going to see real change in the industry,” she said.
Whether this approach will lead to sustained, long-term stability for the organization remains to be seen.
“I’m looking forward to helping lead KidsChoice into being one of the best providers in the nation,” she said.
