By Matt Harrington, BCBA · Behaviorist Book Club · Research-backed answers for behavior analysts
Informed consent is a legal and ethical process in which a competent individual or their legal representative agrees to treatment after receiving information about the nature, risks, benefits, and alternatives. Assent is the voluntary agreement of an individual who may lack the legal capacity for informed consent but can still express preferences and participate in decisions. In ABA practice, informed consent is typically obtained from parents, guardians, or legal representatives, while assent is sought from the individuals receiving services. Under Code 2.11, behavior analysts should pursue both informed consent from responsible parties and assent from the client to the greatest extent possible, recognizing that assent is an ongoing process rather than a one-time event.
For nonverbal clients, assent must be assessed through behavioral indicators rather than verbal responses. Key indicators of assent include voluntary approach toward materials or the task area, relaxed body posture, neutral or positive affect, cooperative motor responses such as extending limbs when prompted during dressing, and sustained engagement with the task. Indicators of withdrawal include turning away, pushing materials or people away, tense or rigid body, crying or other distressed vocalizations, and escalation of challenging behavior. Develop an individualized assent profile for each client by consulting caregivers and observing patterns across daily living activities. This profile should specify which behaviors indicate assent and which indicate withdrawal for that specific individual.
When assent is withdrawn during a medically necessary task, first pause the activity. Provide comfort and acknowledge the individual's distress. Assess whether the task can be briefly delayed without health or safety consequences. If delay is possible, honor the withdrawal and revisit with modifications later. If the task is truly time-sensitive, attempt modifications such as changing the approach, offering choices within the task, providing additional support, or altering the environment. If you must proceed despite withdrawal, do so with the minimum necessary intervention, document the rationale, and immediately develop a plan to prevent future conflicts. Consult with the treatment team about proactive strategies that reduce the likelihood of forced compliance in the future.
No. Assent-based practice does not mean unlimited avoidance of nonpreferred activities. Many daily living tasks are necessary for health, hygiene, and community participation, and helping individuals develop these skills serves their long-term interests. Assent-based practice means maximizing choice and control within necessary activities, using the least intrusive teaching methods, pausing when distress is high, modifying approaches that consistently evoke resistance, and ensuring that the individual's perspective is considered in treatment planning. The goal is a collaborative approach where individuals are active participants in their daily routines rather than passive recipients of care imposed without regard for their preferences.
Choices can be embedded across multiple dimensions of daily living tasks. Offer choices about what (which task to complete first), when (before or after another activity), how (which method or tool to use), where (bathroom versus bedroom for dressing), and with whom (which staff member provides support). Even within non-negotiable tasks, choices exist. During tooth brushing, the individual can choose the toothpaste flavor, the order of brushing, and the rinse cup color. During bathing, they can choose water temperature, soap scent, and music to play. These choices may seem small but they communicate respect and preserve a sense of agency that is fundamentally important to human dignity.
Assent data can be collected using a simple coding system during daily living task sessions. Categories might include enthusiastic participation, cooperative participation, passive tolerance, mild resistance, and active withdrawal. Record the category that best describes the client's response during each task or task component. Analyze these data alongside skill acquisition data to identify tasks or procedures that consistently evoke resistance, times of day or contexts where assent is higher or lower, the effects of modifications on assent levels, and trends over time. When assent data show persistent resistance, this should trigger a clinical review to determine whether goals, procedures, or environmental conditions need adjustment.
Communication supports are essential for enabling individuals to express assent and withdrawal. Visual schedules help individuals anticipate upcoming activities, reducing anxiety associated with unpredictability. Choice boards allow individuals to select between options using pictures or symbols. Augmentative and alternative communication (AAC) devices can include programmed options for expressing agreement, refusal, requesting a break, or asking for modifications. Teaching functional communication responses specifically related to daily living activities, such as requesting help, requesting a pause, or indicating readiness, directly supports the individual's capacity to participate in assent processes. Under Code 2.01, investing in communication supports that enhance assent capacity serves the client's interests.
Training should include didactic instruction on the concept and importance of assent, modeling of assent-based practices during actual daily living routines, guided practice with feedback, and ongoing supervision. Key training targets include recognizing the individual client's behavioral indicators of assent and withdrawal, offering choices naturally within routines, using least-intrusive prompting hierarchies, pausing and problem-solving when withdrawal is observed rather than forcing compliance, and documenting assent data. Use behavioral skills training with role play to practice responding to withdrawal scenarios. Emphasize that honoring assent withdrawal is not permissiveness but rather a clinical response that builds trust and long-term cooperation.
Many individuals with disabilities have experienced trauma, including trauma related to previous service delivery that involved coercion, restraint, or disregard for personal boundaries. Trauma-informed daily living support recognizes that personal care tasks can be triggering, especially when they involve touch, undressing, or invasion of personal space. Assent-based practices serve as a protective factor by establishing predictable routines with advance notice, providing control and choice that counter the helplessness associated with trauma, responding to distress signals rather than pushing through resistance, and building trust through consistent respect for boundaries. For clients with known trauma histories, assent protocols should be developed with particular sensitivity to potential triggers.
In the short term, honoring assent withdrawal may mean that some sessions yield fewer completed trials or practice opportunities. However, research and clinical experience suggest that assent-based approaches produce better long-term outcomes. When individuals experience daily living interventions as collaborative rather than coercive, they develop more positive associations with the activities, which increases willing participation over time. Forced compliance, conversely, can create learned aversion that increases resistance and slows progress in the long run. Additionally, assent-based practice develops skills in choice-making, self-advocacy, and emotional regulation that generalize beyond daily living contexts. Under Code 2.01, effective treatment must be evaluated over the long term, not just by immediate session productivity.
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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.