By Matt Harrington, BCBA · Behaviorist Book Club · Research-backed answers for behavior analysts
Consent is a legal process whereby a person with the authority to make decisions, typically a parent or guardian, agrees to proposed treatment after being informed of its nature, risks, benefits, and alternatives. Assent is the client's own expression, verbal or nonverbal, that they are willing to participate in treatment. A child cannot legally consent to ABA services, but they can assent or withdraw assent during sessions through their behavior. Consent happens at intake and is updated periodically. Assent is monitored continuously throughout every treatment session. Both are ethically required: Code 2.11 of the Ethics Code addresses informed consent, while the broader ethical framework supports attending to the client's ongoing willingness to participate.
Nonverbal withdrawal of assent can take many forms and must be assessed individually for each client. Common indicators include moving away from the therapist or materials, pushing materials away, turning their body or face away, tensing their body, crying or whimpering, becoming passive and unresponsive where they were previously engaged, engaging in self-injurious or other challenging behavior, and exhibiting escape-maintained responses. Consult with the client's family and long-term caregivers, who often have the most nuanced understanding of the client's communicative behavior. Document the specific behaviors that indicate assent and withdrawal for each client in their treatment plan so all staff respond consistently.
No. Assent-based practice does not mean that clients never encounter effortful tasks or that all demands are removed. It means that practitioners monitor the client's willingness to participate, respond with respect when assent is withdrawn, and modify treatment to reduce unnecessary aversiveness. When a client withdraws assent, the practitioner might offer a brief break, modify the demand, provide additional support, or switch to a different activity. The goal is to make participation more reinforcing while still working toward meaningful clinical outcomes. In situations involving safety, such as dangerous behavior, the obligation to protect the client takes precedence, but these should be rare exceptions documented in the treatment plan.
This is one of the most common clinical challenges in assent-based practice. The key is to avoid a binary framework where every refusal is either pure assent or pure escape. Instead, consider that escape-maintained behavior often communicates something meaningful: the demand may be too difficult, the reinforcement may be insufficient, the session may be too long, or the teaching procedure may be more aversive than necessary. Honoring the communication by providing a brief break or modifying the demand does not reinforce escape in the way that unlimited avoidance would. Instead, it provides information about how to make the treatment context more effective. Over time, as the client learns that their communication is respected, the need for intense escape behavior often decreases.
Yes, particularly for clients who currently lack reliable means of communicating their preferences. Teaching a client to use a break card, say no, or indicate preferences through an augmentative communication system should be treated as a foundational goal. These skills enable all future treatment to be conducted with the client's active participation rather than passive compliance. Code 2.14 of the Ethics Code supports prioritizing skills that increase client autonomy and reduce the need for restrictive procedures. From a practical standpoint, clients who can communicate their preferences are less likely to use challenging behavior to escape aversive situations, which benefits both the client and the treatment environment.
Include a section in each client's treatment plan that specifies the client's identified assent and withdrawal behaviors, the protocol for responding to assent withdrawal, and any goals related to teaching assent and refusal skills. In session notes, document instances of assent withdrawal, the context in which they occurred, the staff response, and the outcome. Track assent data quantitatively by recording the frequency of withdrawals per session and the activities or contexts associated with them. This documentation serves multiple purposes: it ensures staff consistency, provides clinical data for treatment planning, demonstrates ethical practice, and creates accountability for assent-based procedures.
This situation requires clear communication grounded in ethical obligations. Explain to the parent or funder that assent-based practice is required by the Ethics Code and that it produces better long-term outcomes than compliance-based approaches. Share data showing that clients who are willing participants in treatment learn more efficiently, maintain gains better, and develop fewer treatment-interfering behaviors. If the pressure comes from a funder's utilization requirements, document the ethical conflict and advocate for policies that allow practitioners to honor assent. Code 2.16 requires identifying conditions necessary for program effectiveness, which includes a treatment context where client preferences are respected. Ultimately, your ethical obligations to the client supersede external pressures.
Assent remains relevant even when clients engage in severe challenging behavior, though the implementation may look different. Safety must always be maintained, and there will be moments when intervening to prevent harm takes precedence over honoring refusal. However, these moments should be minimized through proactive treatment planning that addresses the conditions giving rise to challenging behavior. Between episodes, assent-based practice applies fully: the client's preferences about daily activities, therapy structure, and engagement should be honored. Crisis procedures should be documented as exceptions to standard assent protocols, with clear criteria for when they apply. After any instance where assent was overridden for safety, the treatment plan should be reviewed to identify ways to reduce the need for such overrides in the future.
Training should include didactic instruction on the concept of assent, the ethical basis for assent-based practice, and the specific indicators of assent and withdrawal for each client on their caseload. Role-playing scenarios where the technician practices responding to assent withdrawal are particularly effective. During supervision observations, provide specific feedback on the technician's responsiveness to client communication, including both praise for appropriate responses and corrective feedback when withdrawal indicators are missed. Create written protocols for each client that specify the assent indicators, the response to withdrawal, and any relevant exceptions. Discuss the difference between assent-based and compliance-based practice explicitly, as many technicians may default to prioritizing task completion.
Yes, though it requires additional planning. In group settings, practitioners must monitor assent for multiple clients simultaneously, which demands clear protocols and sufficient staffing. Strategies include building choice into group activities so all participants can express preferences, having a designated space where clients can take a break if they withdraw assent, using visual supports such as choice boards or break cards that facilitate communication in a group context, and training all staff in the group to recognize and respond to individual clients' assent indicators. Group activities should be designed with natural pauses and transitions that provide opportunities for clients to communicate their preferences. Data collection on assent in group settings may require modified systems such as interval recording rather than continuous measurement.
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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.