By Matt Harrington, BCBA · Behaviorist Book Club · Research-backed answers for behavior analysts
Informed consent is a formal, legal process in which a competent individual or their legal guardian receives information about a proposed treatment, understands the risks and benefits, and voluntarily agrees to proceed. It typically occurs at specific decision points. Assent is the ongoing, moment-to-moment behavioral expression of willingness to participate in treatment. It is not a legal process but an ethical and clinical one. For clients who cannot provide informed consent independently, assent represents the primary way their preferences and autonomy are respected during treatment. Both are required for ethical practice.
For non-vocal clients, assent and withdrawal indicators must be identified through careful observation and collaboration with caregivers who know the individual well. Common indicators of assent include approach behavior, reaching for materials, sustained engagement with tasks, relaxed body posture, and smiling. Common withdrawal indicators include moving away, turning away, pushing materials, covering eyes or ears, physical tension, crying, and aggression. These indicators should be operationally defined, validated with people who know the client, and tested for reliability across observers before being used for clinical decision-making.
This represents a genuine ethical dilemma requiring careful analysis. First, explore whether the intervention can be modified to gain assent, such as changing the pace, providing more reinforcement, or altering the context. Second, investigate alternative approaches that might achieve the same therapeutic goal with less client resistance. Third, consult with the interdisciplinary team and caregivers. If proceeding without assent is truly necessary for safety, document the clinical rationale, implement the least restrictive approach possible, and continue working toward obtaining assent through gradual exposure and choice-building. Never treat overriding assent as a routine practice.
In a concurrent chains arrangement, the client is presented with two or more options and allowed to choose between them. Practically, this might look like offering a choice board with a treatment activity and a preferred activity, then allowing the client to select. The key requirements are that both options must be genuinely available, the consequences of each choice must be consistently delivered, and the client must understand what each option involves. Over time, the practitioner records the client's choices and uses this data to evaluate treatment acceptability. If the client consistently avoids a specific treatment activity, this data should drive treatment modifications.
No. Assent-based practice does not mean that clients never encounter demands or challenges. It means that their responses to those demands are monitored and respected, and that treatment is designed to maximize willing participation rather than relying on compliance. Many clients will engage with challenging tasks when they have genuine alternatives, adequate reinforcement, and a history of having their boundaries respected. The goal is to build a therapeutic relationship and treatment context in which the client chooses to participate because the experience is positive and meaningful, not because they have no alternative.
Degrees of freedom analysis evaluates how much genuine choice a client has within their treatment plan. To conduct one, list every component of the client's daily treatment routine, including activities, transitions, breaks, and routines. For each component, assess whether the client has choices about what happens, when it happens, where it happens, how it is done, and with whom. Calculate the proportion of components that include at least one choice opportunity. If the proportion is low, identify specific points where choice can be added without compromising treatment objectives. This analysis should be repeated periodically as treatment plans evolve.
Technician training should include explicit instruction on the conceptual distinction between assent and compliance, practice identifying the specific assent and withdrawal indicators defined for each client, role-play scenarios for responding to assent withdrawal, instruction on implementing concurrent chains arrangements, and training on recording assent data accurately. Many technicians trained in compliance-based models will need support in understanding that honoring assent withdrawal is clinically appropriate and not permissiveness. Ongoing supervision should include observation and feedback on assent-related practices.
Frame the conversation around outcomes that caregivers value. Explain that research shows clients who have genuine choice in their treatment tend to be more engaged, learn faster in contexts they choose, and develop fewer treatment-evoked challenging behaviors. Emphasize that assent-based practice does not mean the child controls everything, but rather that their communication about their experience is respected and used to design better treatment. Use concrete examples to illustrate how honoring assent withdrawal in the moment actually builds cooperation over time. Address concerns directly and validate that this approach may feel counterintuitive at first.
Decision rules should be individualized, but a common framework includes tiered responses based on frequency and pattern. For example: if assent withdrawal occurs in a single session, the technician pauses, offers alternatives, and documents. If withdrawal occurs in more than 30 percent of sessions with a specific activity over two weeks, the supervisor reviews and modifies the activity. If withdrawal persists after modification, the team convenes for a formal treatment plan review. The specific thresholds should be set based on the client's baseline rates, the nature of the treatment goals, and the severity of the withdrawal behavior.
Yes, and doing so demonstrates comprehensive clinical practice. Assent data can be framed in progress reports as treatment acceptability measures that inform clinical decision-making. Many funding sources are receptive to documentation showing that treatment is client-centered and that the practitioner monitors the client's experience alongside behavioral outcomes. Including assent data alongside skill acquisition and behavior reduction data paints a more complete picture of treatment quality. If a funding source is unfamiliar with assent measurement, a brief explanation in the report can educate them about this dimension of ethical practice.
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All behavior-analytic intervention is individualized. The information on this page is for educational purposes and does not constitute clinical advice. Treatment decisions should be informed by the best available published research, individualized assessment, and obtained with the informed consent of the client or their legal guardian. Behavior analysts are responsible for practicing within the boundaries of their competence and adhering to the BACB Ethics Code for Behavior Analysts.