By Matt Harrington, BCBA · Behaviorist Book Club · Research-backed answers for behavior analysts
Consent is a legal process by which a competent adult (typically a parent or guardian in pediatric settings) agrees to treatment after being informed of its nature, risks, benefits, and alternatives. Assent is a developmentally appropriate process through which the child client indicates willingness to participate in treatment activities. While consent authorizes treatment legally, assent ensures that the child's own communication about their comfort and willingness is respected during treatment delivery. Both are important: consent without assent means treatment is legally authorized but may proceed against the child's expressed wishes.
Non-verbal clients communicate assent withdrawal through behavioral signals that may include turning away or physically moving away from the activity, pushing materials away, covering their face or ears, crying or vocalizing distress, going limp or becoming unresponsive, engaging in self-injurious behavior or aggression, or displaying changes in physiological indicators like facial flushing. Identifying these signals requires careful observation across contexts and collaboration with caregivers who know the child's communication patterns. Document each client's individualized withdrawal signals in their assent protocol so all team members can recognize and respond consistently.
This is a common concern, and the answer requires nuanced clinical thinking. While escape from demands can be reinforced through negative reinforcement, treating all withdrawal as escape-maintained behavior risks dismissing genuine client distress. Assent-based practice does not mean abandoning demand-based activities entirely. It means responding to withdrawal signals by pausing, assessing, and modifying the approach rather than simply continuing. You can honor withdrawal in the moment while simultaneously developing desensitization programs, increasing motivation, and building tolerance gradually through ethical, collaborative approaches.
Start by validating parents' goals for their child's skill development. Then explain that research shows clients who feel respected and empowered in therapy tend to make better long-term progress and develop more positive associations with learning. Use concrete examples: describe how you will offer choices, follow the child's lead when appropriate, and pause when the child shows signs of distress. Emphasize that assent-based practice does not mean the child directs the session or avoids all challenges, but rather that you work with the child as a collaborative partner. Share data on how engagement and outcomes improve when assent is incorporated.
A comprehensive assent protocol should include the specific behaviors that indicate assent for this individual client, the specific behaviors that indicate withdrawal of assent, the procedure to follow when assent is given (how to begin and maintain the activity), the procedure to follow when withdrawal is observed (pause, redirect, offer choices, provide break), the timeline for re-presenting the activity after withdrawal, any exceptions for safety-critical activities with documented rationale, the communication strategies to use throughout, and a schedule for reviewing and updating the protocol. The protocol should be written in clear, operational terms that all team members can follow consistently.
Physical prompting requires particular attention through an assent lens because it involves direct physical contact that the client may not welcome. Before using physical prompts, assess whether less intrusive prompting strategies could achieve the same outcome. When physical prompting is used, attend carefully to the client's response. If the client actively resists physical prompts by pulling away, stiffening, or showing signs of distress, this constitutes withdrawal of assent. In such cases, pause the prompting, provide a break, and reassess your approach. Consider whether gestural prompts, visual supports, or modeling could be substituted.
Yes, though the implementation requires adaptation to each individual's communication abilities. Even clients with severe intellectual disabilities communicate preferences through behavioral signals such as approach versus avoidance, relaxed versus tense body posture, positive versus distressed vocalizations, and engagement versus disengagement with materials. The key is identifying and consistently responding to these individualized signals rather than requiring a specific communication modality. For clients with very limited communication, assent protocols may focus primarily on physiological and behavioral indicators of comfort and distress, with lower thresholds for pausing activities when withdrawal signals are observed.
When a therapeutic activity is medically necessary, such as teaching tolerance of medical procedures, the ethical analysis becomes more complex. In these situations, document the medical necessity clearly and develop a desensitization plan that gradually increases the client's tolerance while minimizing distress. Even when the ultimate goal is completing a necessary medical procedure, the approach should maximize client comfort and control throughout the process. Offer choices wherever possible, use visual schedules to increase predictability, and pair medical procedures with preferred items and activities. The goal is to build genuine tolerance rather than forced compliance.
Documentation should include the individualized assent protocol for each client, session-by-session records of assent withdrawal episodes including the activity context, the withdrawal behavior observed, the clinician's response, and the outcome. Treatment plans should reference how assent will be incorporated into each target area. Progress reports should include data on engagement levels and withdrawal frequency alongside traditional skill acquisition data. When assent is overridden for safety or medical necessity, the specific rationale should be thoroughly documented. This documentation supports ethical accountability and provides data for evaluating the effectiveness of assent practices.
RBTs should receive training that covers the conceptual basis for assent including why it matters for client dignity and outcomes, how to identify individualized assent and withdrawal signals for each client on their caseload, the specific procedures to follow when withdrawal is observed, how to offer choices and create opportunities for client agency during sessions, how to document assent-related observations, and when to seek supervisor guidance for complex assent situations. Training should include modeling, role-play, and in-vivo practice with feedback. Ongoing supervision should regularly address assent-related scenarios and reinforce consistent implementation.
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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.