Defining Assent in Behavior Analysis
Assent is the expressed agreement of an individual to participate in a procedure or intervention. Unlike consent, which has legal standing and must come from someone with the legal authority to make decisions on behalf of another, assent represents the individual's own willingness to participate. In behavior analysis, this most commonly applies to children and individuals with developmental disabilities who may not have the legal capacity to provide consent but who can and should have a voice in their own treatment.
The 2022 BACB Ethics Code recognizes assent as an important component of ethical practice. The code directs behavior analysts to seek the assent of the individual receiving services, in addition to obtaining informed consent from the legal representative, whenever the individual is capable of providing it.
Why Assent Matters
Seeking assent is about more than simply following the ethics code. It reflects a fundamental commitment to treating every individual with dignity and respect, regardless of their age or ability level. The reasons assent matters include:
- Respecting autonomy: Even individuals who cannot provide legal consent have preferences, opinions, and the right to have those considered in decisions about their own lives
- Improving treatment outcomes: When individuals are willing participants in their treatment, engagement and cooperation tend to be higher, which can lead to better outcomes
- Reducing coercion: The power differential between a behavior analyst and a client (especially a child or an individual with a disability) creates the potential for coercion. Seeking assent helps to counterbalance this dynamic
- Modeling respect: Seeking assent teaches the individual that their voice matters and models appropriate social behavior for caregivers and other team members
- Ethical integrity: Practicing behavior analysis without considering the wishes of the person most affected by the treatment raises serious ethical questions, regardless of whether the individual can provide legal consent
Assent vs. Consent: Key Differences
Understanding the distinction between assent and consent is important for both clinical practice and the BCBA exam:
- Consent is a legal concept. It must be obtained from someone with the legal authority to make decisions (a parent, guardian, or the individual themselves if they are a competent adult).
- Assent is an ethical concept. It represents the individual's own agreement to participate and does not have legal standing. It supplements, but does not replace, informed consent.
- A person can withhold assent even when their guardian has provided consent. In such cases, the behavior analyst must carefully consider how to proceed.
How to Obtain Assent
The process of obtaining assent should be tailored to the individual's developmental level, communication abilities, and understanding. Here are strategies for different populations:
Verbal Individuals
For individuals who can communicate verbally, assent can be obtained through a direct conversation about the proposed activities. Explain what will happen in simple, age-appropriate language, describe what the individual will be asked to do, explain why the activity is being recommended, and ask whether they are willing to participate. Document the individual's response.
Individuals with Limited Verbal Communication
For individuals who use augmentative and alternative communication (AAC) systems, visual supports, or other non-verbal communication methods, assent can be sought through their existing communication system. This might involve presenting visual choices, using communication boards to ask about willingness to participate, or interpreting consistent behavioral responses (such as approaching or avoiding an activity) as indicators of assent or dissent.
Individuals with Significant Cognitive Limitations
For individuals with significant cognitive limitations who may not be able to understand the concept of assent in a traditional sense, behavior analysts should still attend to behavioral indicators of willingness or unwillingness to participate. Signs of distress, consistent avoidance, or escalating challenging behavior during a procedure may indicate that the individual does not assent, even if they cannot verbally express this.
What to Do When Assent Is Withdrawn
One of the most challenging aspects of assent-based practice is knowing how to respond when an individual withdraws assent during a session. This situation requires careful clinical judgment:
- Pause and assess: If the individual shows signs of distress or indicates unwillingness to continue, pause the activity and assess the situation
- Consider the context: Is the withdrawal related to a specific aspect of the procedure? Is the individual fatigued, hungry, or experiencing some other transient condition? Has something in the environment changed?
- Balance welfare with autonomy: In some cases, an individual may resist a procedure that is necessary for their safety or well-being (such as a medical procedure or a crisis intervention). In these situations, the behavior analyst must balance respect for the individual's wishes against the obligation to protect them from harm.
- Modify the approach: If possible, modify the procedure to address the individual's concerns while still achieving the therapeutic goal
- Document and discuss: Record instances of assent withdrawal, your response, and the outcome. Discuss recurring patterns with the treatment team and the individual's guardian.
Assent in the Context of Behavior Reduction Procedures
Assent is particularly important when implementing behavior reduction procedures, which may involve aspects that are uncomfortable or unwanted by the individual. Before implementing a behavior reduction procedure, consider whether the individual has been given an adequate explanation of what will happen and why, whether the individual has expressed willingness to participate, whether there are less aversive alternatives that the individual might prefer, and how you will monitor and respond to signs that the individual is no longer willing to participate.
Assent on the BCBA Exam
The BCBA exam may include questions that test your understanding of the difference between consent and assent, when and how to seek assent from individuals receiving services, how to respond when assent is withdrawn, and the ethical rationale for assent-based practice. Look for answer choices that prioritize the voice and preferences of the individual receiving services while balancing their welfare and safety.
Conclusion
Assent is an evolving concept in behavior analysis that reflects the field's growing commitment to treating every individual with dignity, respect, and autonomy. By actively seeking and honoring the assent of the individuals we serve, behavior analysts can deliver more ethical, person-centered services that truly prioritize the welfare of the client.