Questions about Assent- Part 2

An Assent filled Coffee Date- Part 2

Bryan arrives early for his meeting with Sia. It has been a busy week; with two re-auths and a behavior plan due, he hasn’t had time to think about his questions since his coffee date with himself. 

After getting his Americano—triple shot, extra hot, black—he finds a quiet table in the corner. He pulls out his notebook and reviews his questions. 

1. What are our organization’s rules for assessing assent? 
2. Given most researchers do not mention assent procedures (Morris et al., 2021) and there are no standard recommendations for obtaining assent in research or practice, where do we even start? 
3. Under what conditions do we need or not need to obtain assent?
4. If researchers ever do develop models for obtaining assent in research, how would those models be translated to a comprehensive treatment setting, where sessions times are longer and there are a variety of goals to work on? 
5. What does assent entail? How often do we assess for it? 
6. Is any instance of challenging behavior a withdrawal of assent? Does it depend on the circumstances? For instance, if I am teaching a client to count money, tact 2-D items, or imitate and the client engages in challenging behavior, is that a withdrawal of assent to participate in the teaching procedures as designed? At that moment, should I cease instructional trials? 
7. If I cease instruction (service delivery) for some period of time, will it have implications for billing/reimbursement from the client’s insurance company? 
8. Do you know of any good trainings for designing treatments with assent front and center?

Whoa—did he write these? He had forgotten how many questions he had! They only have an hour to chat, so he might have to reduce or condense these questions somehow.

He looks up to see Sia waving and making a gesture that says, “I’m going to order before joining you.” He gives a thumbs up and sips his coffee while he waits. He starts to feel that thought-spinning feeling he had last time he was here, so he closes his eyes and focuses on the sensations of coffee consumption: The fragrant aroma, the smooth and complex tastes, the warmth in his hands, mouth, and throat. He has found that his thoughts (covert verbal behavior) cannot “spin” (occur rapidly) if he’s engaged in topographically incompatible behavior. 

He opens his eyes when he hears Sia pull out the chair across from him. 

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Sia sets their things down and smiles broadly. 

Bryan: Thanks for meeting with me, Sia. 

Sia: You’re welcome! I’m happy to chat, especially about the hot topic of assent! 

Bryan: Assent is hotter than my coffee! He chuckles at his own joke. Sia smiles. So, like I mentioned, I saw a few talks at ABAI about consent and assent in research, but I have not come across anything about consent and assent in practice. A couple of weeks ago, I made a coffee date with myself to learn more on my own. That’s when I found the article I sent you—Morris et al., 2021—and refreshed myself on the BACB’s Ethics Code. I also came up with a list of questions for you. 

Sia nods and blows on their still-too-hot holiday-spiced coffee. 

Bryan: I know that, at our organization, caregivers give consent for their child to receive our services—and I’m fairly sure that happens once, at intake—but I don’t know if we have procedures for getting assent from our learners at all, let alone on an ongoing basis, and…

Bryan trails off for a second. The caffeine is kicking in, and he’s starting to ramble. Sia takes the opportunity to interject. 

Sia: Sorry to interrupt, but I have a point of order, so to speak. 

Bryan: Oh, no apologies! Please… He gestures for them to continue. 

Sia: Yes, as far as I know, consent is provided one time by caregivers at intake, prior to service delivery, but let’s put a pin in that. Right now, we’re talking about assent—that is, verbal (vocal or nonvocal) agreement from our learners (who are not legally able to provide their own consent) to participate or continue participating in ABA service delivery. Correct? 

Bryan nods emphatically. 

Sia: OK, cool beans. Or hot beans…coffee jokes! Anyway, back to my point of order: You said “getting assent.” Recently, I heard Dr. Tyra Sellers (as in Sellers and LeBlanc, authors of the supervision book we use, and the incoming CEO of APBA) suggest that, instead of saying “get assent,” we say something like, “give opportunities for providing assent.” She suggested that changing the verbal frame could change how we approach it. If we say “I’m getting assent,” it sounds like the function is to walk away with assent, whereas, if we say, “I’m giving this learner opportunities to provide assent,” it sounds like the function is to see whether they want to continue or not. 

Bryan is pensive, so Sia continues. 

Sia: For instance, I’m enjoying this new nutmeg creamer in my coffee so much that I think everyone should try it. Of course, I’m not going to pour it into your coffee without permission. Before I ask if you’d like some, I could think to myself, “I’m going to get his assent to put cream in his coffee.” Saying it that way sounds like I’m going to get a “yes,” and it might make it difficult to accept “no.” Alternatively, I could think, “I’m going to provide him with the opportunity to assent to cream in his coffee.” Saying it that way sounds like it could go either way, which might make it easier to accept “no.” 

Bryan and Sia laugh. Sia shrugs. 

Sia: Okay, that was a silly example, but maybe it makes the point. 

Bryan: I like that! Framing it as an opportunity requires a few extra words, and it might take some practice – and occasional error correction – but it makes sense. And, no, thank you, I don’t want cream in my coffee. I like it black. 

Sia chuckles. 

Sia: Good thing I provided an opportunity for you to say no! Asking permission before doing something to or for another person seems like simple human decency, right? Sometimes it is more complicated than it seems though. And, yes, the “opportunity” frame might take some getting used to, but changing our verbal behavior is a powerful tool for changing other behavior. 

Bryan: Right on. I was doing that a few minutes ago with a coffee meditation. Sia looks inquisitive, but Bryan knows he better stay on topic. I’ll tell you later. Can I pepper you with more questions about assent? 

Sia: Consider me a lemon chicken! Shoot! 

Bryan chuckles at Sia’s bad pun. He appreciates her – oops, Sia’s preferred pronoun is  ‘their’ – sharp but cheesy sense of humor. Sharp cheese…Sia would have a field day with that.

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Bryan: OK! First, does our organization have standards for getting—ahem, providing opportunities for assent?  

Sia: Good catch, and that is a great question! The short answer is no, we do not have standard procedures for how or how often we should provide assent opportunities or measurement thereof. Each BCBA® is responsible for designing programs that meet our Ethical Code’s standards, but this is a situation where some guidance from Margot, our Clinical Director, might be warranted. 

Bryan: I can bring it up as a discussion point during our next group data review meeting! 

Sia: Love the eagerness, but, given the importance of assent, maybe we should go ahead and email Margot. We can tell her that we’ve been discussing assent; that we would appreciate her guidance in the absence of standard, company-wide policies; and that we would be happy to help develop those policies if needed. Would you like to take the lead on the email? 

Bryan: Sure, I can do that. I’ll copy you on the email, of course.

Sia smiles and gestures “okay” as they sip their coffee. Byan makes a note to email Margot. 

Bryan: OK, next question. The Morris et al. (2021) article I sent you discussed assent in research. Sia nods. They found that most behavior analyst researchers have not mentioned their assent procedures in publications. If there are no standard recommendations for obtaining assent in research or practice, where do we start? 

Sia: Another great question! Sia pauses, then continues. Like Morris et al. pointed out, the absence of assent procedures in research papers does not mean that researchers are not providing opportunities for assent. I’d guess that most researchers provide participants with opportunities for assent, even if they don’t report how they do it. After all, journal space is limited, and it seems like, most of the time, the details reported are limited to those necessary for replication. Hopefully, those researchers will come to the rescue quite soon and start making their assent procedures public. And, now that Morris et al. shined a light on a dark area, maybe more editors will begin requiring descriptions of consent and/or assent procedures in the supplementary information. Sia shakes their fist in the air playfully. Their audience demands it! 

Bryan looks as if he’s about to interject, but he’s currently biting into a scrumptious-looking muffin, so Sia continues. 

Sia: I bet you were about to ask, “Shouldn’t we replicate the assent process as well?” 

Bryan nods while chewing; he’s balancing his muffin and pencil in one hand and piping hot coffee in the other. For Sia, a quintessential klutz, that would be a disaster waiting to happen. 

Sia: Not necessarily. The opportunities for assent—and the responses indicative of assent—will vary on an individual basis. Sometimes, it might be as simple as asking, “Do you want to do X, Y, and Z?” and the participant (or, in our case, learner) saying or signing “yes.” But, as you know, whether a learner is able to do that or not depends on their learning history. So, what the opportunities for assent (and topographies of assent responses) look like will vary based on the individual—and they could be different across contexts for the same individual, too. But, let’s get back to the heart of your question: You wanted to know, in the absence of “divine research guidance,” how do we, clinicians, go about assessing assent? 

Bryan: Yes, exactly. 

Sia: I can’t give a definitive answer, but, to use your metaphor, I’ll pepper you with thoughts. For one, I don’t think assent is a one-time thing: I think it is something that needs to be evaluated continuously because assent withdrawal should always be possible, even when a formal opportunity is not provided. Come to think of it, this might be one way the process could be slightly different in research than in practice: In research, they are usually doing one “thing” or procedure, right? So, they might provide an opportunity to assent prior to the start of the research session and, throughout the session, provide opportunities for an escape response (assent withdrawal), using, say, a concurrent-choice arrangement. For instance, they could teach the participant that touching a card (which would always be available) would produce escape from the session or for some period of time. They could make that card available during the sessions and always honor the request (assent withdrawal). For us, given our “sessions” are much longer than typical research “sessions,” we might implement the concurrent-choice model (always have an escape card, or whatever, available) the whole time the learner is in our care. 

Bryan: That’s interesting. Now that I think about it, teaching an escape response—like a tap out in Jiu Jitsu—is probably an important first step in any behavioral treatment. 

Sia: Great point! I didn’t know you were a martial artist. 

Bryan: Ha! I’m not so much an artist as a perpetual student. 

Sia: Don’t sneak up on Bryan—noted! And aren’t we all? 

Bryan smiles and nods. 

Sia: Yeah, we should absolutely teach and honor “I don’t want to do this” responses. It also seems important for us to provide many opportunities for learners to provide or withdraw their assent and to regularly document (measure) assent and assent withdrawal. Like I said, what those opportunities look like might vary on a case-by-case or procedure-by-procedure basis. As an organization, we might benefit from rules regarding when, how, and how often to provide opportunities for assent behavior to occur or be observed. We might even make templates for assessing assent, like we have for behavior plans. Of course, even with templates, we’d develop individualized definitions of assent and assent withdrawal (with examples and non-examples) and backup plans in the event that assent is withdrawn. 

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Bryan: That last thing you said about backup plans leads into another question on my list: What do we do if the learner withdraws assent? Does that have implications for billing if we cease service delivery? 

Sia: Gosh, you have great questions! I think that’s a one for Margot, but I’d guess that we should always have alternatives at the ready. We don’t want to cease service delivery: We want to find methods of service delivery that are socially valid to the learner. (I think that’s also true of goals, but that’s another topic.) In the moment, assent withdrawal should function as an S-delta for the technician to continue what they’re doing. It will be up to us to provide our technicians with SDs to pivot to different activities or programs (after obtaining assent, of course). If assent is withdrawn for a given program on a regular basis, that might trigger an internal audit of sorts, where the BCBA® examines the technician’s treatment integrity, the procedures themselves, whether something else is going on (like a medical problem), etc. Assent withdrawal isn’t inherently a bad thing: It’s an opportunity for us to reflect and reconsider what we’re doing or not doing.

Bryan takes a deep breath and mumbles a breathy agreement before collecting himself. 

Bryan: OK, wow. This is a lot to take in. We have a lot to discuss with Margot. 

Sia: We sure do! I’m not sure if everything I’m telling you is “right” – I just know there is a lot to consider when it comes to assent, and it is a very important topic. I’m so glad you’ve sparked this fire!

Bryan smiles, pleased with himself. He looks at his watch. Time really flies when you’re learning something new! He better hurry this conversation along. 

Bryan: OK, looking over my list of questions, I see you’ve touched on many of them. 

Sia: Great minds!

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Bryan chuckles and lands on another question. 

Bryan: You mentioned that assent procedures in research might look different than those in practice. If researchers ever do develop models for obtaining assent in research, how would those models be translated to a comprehensive treatment setting, where sessions times are longer and there are a variety of goals to work on? 

Sia: Another fantastic question! Well, I think the Morris et al. (2021) review identified a few papers that did report their assent procedures, and they provided a model, correct? 

Bryan nods. 

Sia: So, there are procedures available to us now. It’s not like we’re going at it blind, which is somewhat comforting. I think more research on assent is inevitable, and, hopefully, comprehensive care and extended session durations will be taken into consideration when guidance  is offered. As far as specifics, I don’t know. I assume assent practices in research will follow a path like preference assessments. 

Bryan tilts his head in a way that reminds Sia of their 2-year-old Shar Pei, which evokes a guttural laugh. 

Bryan: Why are you laughing?

Sia: Ah…no offense, but your head tilt reminded me of Bijou! 

Bryan: Aww, none taken. I’m in good company. Love that guy! 

Sia: He’s a hound. Anyway, you know how there are like 5 million variations and names for preference assessments? I’m exaggerating, of course, but still…

Bryan: Yeah, I sure do! SSPA, PSPA, MSW, MSWO, SSPA, SIPA, RRPA, FOPA, ROPA…

Sia: ROPA? I should brush up. My point is that there are a lot of ways we can systematically assess preference. I assume that, eventually, there will be a lot of ways to assess assent. Hopefully, there won’t be a million and one new acronyms to remember! Sia puts her palms together. Magical mand unto the universe of journal editors! 

Bryan: Indeed! This was such a great conversation, Sia. I have one more question for you. 

Sia: My literal cup is empty, but my metaphorical cup is full enough for one more…  

Bryan: Do you know of any good trainings for designing treatments with assent front and center?

Sia: Oh, do I ever! Here are a few!

• This one by the Behaviorist Bookclub covers assent from a practitioner perspective.
• This one covers it within the PFA & SBT approach (From PFA and SBT Community (thinkific.com); not sponsored)
• And there are a bunch in the DoBetter Collective! (From the DoBetter Collective, not sponsored)

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Written and edited by Dr. Jennifer N. Haddock, BCBA-D

Jennifer is currently an Adjunct Professor at the University of Kansas, where she teaches in the online master’s program in the Department of Applied Behavioral Science. She began working with neurodivergent populations when studying at the University of North Carolina, Chapel Hill, but she was not introduced to behavior analysis until after graduating, in 2005. It was love at first play-based procedure, and she never looked back. In the 17 years since, she studied at North Carolina Central University; the Florida Institute of Technology; California State University, Los Angeles; and the University of Florida, where she obtained her Ph.D. She completed a Postdoctoral Fellowship at the Kennedy Krieger Institute and was an Assistant Professor at McNeese State University before moving to her home state of North Carolina to care for her aging father. She is unfathomably grateful for all of the learning, teaching, and life-improving opportunities that have and continue to come her way. These days, you can find her teaching online courses in behavior analysis; consulting with ABA companies; guest reviewing for behavioral journals; driving between North Carolina and Georgia; spending time with her family and dog, Risley; teaching and practicing yoga and meditation; gardening; and/or writing for Everyday Behaviorist, her Facebook blog.