What Is Assent in ABA Practice?
Assent refers to a client's ongoing agreement to participate in assessment and treatment procedures. Unlike informed consent, which is typically provided by a parent, guardian, or legally authorized representative, assent comes from the client themselves. In many ABA contexts, clients are children or individuals with developmental disabilities who may not have the legal capacity to provide informed consent. However, they can and do communicate their willingness or unwillingness to participate through their behavior.
Assent-based practice has gained significant attention in the behavior analytic community, driven by growing recognition that respecting client autonomy is both an ethical obligation and a factor that influences treatment effectiveness. The BACB Ethics Code for Behavior Analysts emphasizes the responsibility to respect clients' rights and dignity, and assent-based practice provides a practical framework for meeting this responsibility.
Assent Versus Consent
Understanding the distinction between assent and consent is important for BCBAs:
- Informed consent is a legal and ethical process in which a competent individual (or their legal representative) agrees to a proposed treatment after receiving information about its nature, purpose, risks, benefits, and alternatives. Consent is documented formally and is required before treatment begins.
- Assent is the client's expressed willingness to participate in an activity or procedure. It may be communicated verbally ("yes," "okay"), through gestures (nodding, approaching), or through the absence of withdrawal behaviors. Assent is ongoing and can be withdrawn at any moment.
- Withdrawal of assent occurs when the client communicates unwillingness to continue. This may be expressed through verbal refusal, physical resistance, attempts to leave, crying, or other behaviors that indicate the individual does not want to continue the current activity.
Why Assent Matters
Ethical Foundations
The ethical case for assent-based practice rests on the principle of respecting human dignity. The individuals we serve, regardless of age or disability status, are autonomous beings whose preferences and bodily autonomy deserve respect. When we override a client's clear signals of unwillingness without careful ethical justification, we risk causing harm and violating the trust that effective therapeutic relationships require.
The BACB Ethics Code specifically addresses the importance of client assent. Behavior analysts are expected to obtain assent from clients when possible and to honor withdrawal of assent except in limited circumstances where safety is at immediate risk.
Clinical Outcomes
Beyond ethics, there are practical reasons to attend to assent. Research suggests that treatment procedures implemented over a client's objection may be less effective because resistance creates competing behaviors, because the therapeutic relationship suffers, and because the client may develop conditioned aversion to the treatment setting, the therapist, or learning activities in general. Conversely, when clients are active participants who feel respected and in control, engagement and learning outcomes tend to improve.
Recognizing Assent and Withdrawal of Assent
For verbal clients, assent and withdrawal of assent may be straightforward: the client says "yes" or "no." For nonverbal or minimally verbal clients, behavior analysts must identify behavioral indicators of assent and withdrawal. These indicators should be individualized based on the client's communicative repertoire:
Indicators of Assent
- Approaching the work area or therapist
- Engaging with materials
- Making eye contact and orienting toward the task
- Relaxed body posture
- Using communication devices or signs to indicate "yes" or readiness
- Smiling, vocalizing positively, or showing other signs of engagement
Indicators of Withdrawal of Assent
- Turning away from the therapist or materials
- Pushing materials away
- Attempting to leave the area
- Crying, screaming, or other distress vocalizations
- Physical resistance to guidance or prompts
- Becoming rigid, going limp, or other changes in muscle tone
- Using communication to say "no," "stop," or "all done"
Practical Strategies for Assent-Based Practice
Establishing Assent Protocols
Develop individualized assent protocols that specify how assent and withdrawal will be assessed for each client. Document the specific behaviors that indicate assent and withdrawal based on the client's communicative abilities. Share these protocols with all team members to ensure consistency.
Building in Choice
Incorporate choice opportunities throughout sessions. Allow clients to choose between activities, materials, reinforcers, and break times. Choice functions as an antecedent intervention that reduces the likelihood of problem behavior and increases engagement, and it demonstrates respect for client preferences.
Teaching Communication of Assent and Refusal
Actively teach clients to communicate their preferences, including the ability to say "no" or "stop." This is a critical functional communication skill. Some practitioners worry that teaching refusal will increase noncompliance, but research suggests that individuals who can effectively communicate refusal actually show less problem behavior because they have an appropriate alternative to escape-maintained challenging behavior.
Responding to Withdrawal of Assent
When a client withdraws assent, the default response should be to pause the current activity and provide a brief break. During the break, the therapist can assess whether the withdrawal was specific to a particular demand, a particular stimulus, or a more general state of fatigue or distress. After the break, the therapist can offer the activity again using modified antecedent conditions (reduced demands, added choice, higher reinforcement) to see if assent is re-established.
When Withdrawal of Assent Creates Safety Concerns
There are situations where honoring withdrawal of assent may conflict with safety needs. For example, a client may withdraw assent from a dental procedure that is medically necessary, or from wearing a seatbelt in a vehicle. In these cases, BCBAs must carefully weigh the immediate safety needs against the principle of respecting autonomy. Document the clinical and ethical reasoning for any decision to proceed despite withdrawal of assent, and work to build the client's tolerance and skills so that future instances involve less distress.
Integrating Assent with Other ABA Practices
Assent-based practice does not replace other evidence-based ABA procedures. Rather, it adds a layer of ethical sensitivity to how those procedures are implemented. Discrete trial instruction can incorporate assent checks between trials. Natural environment teaching can follow the client's lead and respond to their interests. Behavior reduction programs can include protocols for responding to withdrawal of assent that balance safety with dignity.
BCBA Exam Relevance
The BCBA exam tests ethical knowledge extensively, and questions about client rights, dignity, and autonomy are common. Understanding assent-based practice demonstrates knowledge of the Ethics Code requirements around informed consent and assent, client dignity, and the least restrictive effective treatment. Be prepared to analyze scenarios where client preferences conflict with treatment recommendations and to identify ethically appropriate responses.