These answers draw in part from “Supporting Clinicians in Promoting Patient Assent” by Karen Nohelty, M.Ed., BCBA (BehaviorLive), and extend it with peer-reviewed research from our library of 27,900+ ABA research articles. Clinical framing, BACB ethics code references, and cross-links below are synthesized by Behaviorist Book Club.
View the original presentation →Informed consent is a legal process in which a person with decision-making authority, typically a parent or legal guardian, agrees to treatment after receiving information about the nature of services, potential risks and benefits, alternatives, and their right to withdraw. Assent refers to the behavioral indicators that the client themselves, who may not have the legal capacity to provide consent, is willing to participate. A parent may consent to ABA services for their child, but the child's willingness to engage in specific activities during sessions, expressed through approach behaviors, positive affect, or verbal agreement, constitutes assent. Both are ethically required, and the absence of one does not excuse the absence of the other.
Patients with limited communication express dissent through behavior. Common behavioral indicators include turning away from materials or the clinician, pushing items away, moving to a different area of the room, crying or whimpering, increasing self-stimulatory behavior, becoming rigid or still, engaging in self-injurious behavior, or showing changes in facial expression or vocalization patterns. Each patient's indicators will be unique, and it is the clinician's responsibility to learn and document the specific behaviors that indicate dissent for each individual. Collaborate with families and other team members who know the patient well to identify these indicators accurately.
When a patient dissents from a clinically important activity, conduct a risk-benefit analysis. Consider the clinical importance of the specific activity, the potential consequences of pausing or postponing it, whether alternative approaches could achieve the same goal, and what the patient's dissent might be communicating about their needs or experience. If the activity is not immediately critical, honor the dissent and return to the activity later under modified conditions. If the activity is immediately critical, such as a safety-related skill, minimize the aversiveness as much as possible, provide additional support, and document the decision and rationale. In all cases, examine whether the intervention design can be modified to reduce future dissent.
Honoring dissent does not mean avoiding all challenging activities. Learning new skills inherently involves some effort and initial discomfort. The key distinction is between productive challenge, where the patient is working hard but remaining engaged, and non-productive distress, where the patient is communicating that the activity exceeds their current capacity to cope. Promoting assent means structuring difficult activities so that the patient has support, choices, and the ability to take breaks. It means building toward difficult tasks gradually rather than imposing them abruptly. And it means paying attention to whether the patient's dissent is diminishing over time as they develop competence and confidence, or persisting and intensifying, suggesting that the approach needs modification.
Teaching assent and dissent communication uses the same behavioral procedures as any communication training. Identify a response form appropriate for the patient's current repertoire: vocal speech, sign language, picture exchange, augmentative communication device, or simple gesture. Teach the patient to use this response to communicate yes/continue, no/stop, want something different, and need a break. Create opportunities during sessions for the patient to practice these responses, and consistently honor the patient's communication by pausing, modifying, or discontinuing activities in response to their expressed preferences. Reinforce the use of communication by responding promptly and genuinely. Over time, the patient learns that their communication has power and is valued.
Parents sometimes expect that their child will comply with all therapeutic activities without resistance, and they may express concern if they see the clinician modifying or pausing activities in response to their child's dissent. Address this by educating parents about the importance of assent, its relationship to long-term outcomes, and the difference between accommodation and avoidance. Explain that honoring dissent is not the same as letting the child opt out of treatment; it is a clinical strategy that builds trust, teaches communication, and produces more sustainable behavior change. Share data showing that sessions incorporating assent monitoring produce better engagement and learning outcomes. Most parents, when they understand the rationale, are supportive of assent-based practices.
A risk-benefit analysis in the context of assent is a structured clinical decision-making process used when a patient dissents from a treatment activity. The clinician weighs the benefits of continuing the activity, such as progress toward a treatment goal or prevention of a safety risk, against the costs of overriding the patient's expressed preference, such as damage to the therapeutic relationship, increased emotional distress, reduced future willingness to participate, and undermining the patient's developing self-advocacy skills. Karen Nohelty's course provides a framework for conducting this analysis that considers both immediate and long-term consequences. The analysis is not a formula that produces a single correct answer; it is a systematic way of thinking through a complex decision.
Yes, assent considerations should be explicitly documented in the treatment plan. Documentation should include the individualized operational definitions of assent and dissent behaviors for the patient, the procedures clinicians will follow to monitor assent during sessions, the decision-making framework for responding to dissent, and any assent-related treatment goals such as teaching the patient to communicate preferences. Documentation creates accountability, ensures consistency across team members, and provides a record of the clinical rationale for assent-related decisions. It also communicates to families and payers that assent is a central component of the treatment approach rather than an afterthought.
Assent and the least restrictive environment principle are philosophically aligned. Both prioritize the individual's autonomy and seek to minimize the degree to which external control is exerted over the person's behavior. The least restrictive environment principle, drawn from disability rights and special education law, holds that services should be provided in the setting that imposes the fewest restrictions on the individual's freedom and participation. Assent extends this principle to the clinical interaction itself: not only should the environment be minimally restrictive, but the interaction between clinician and patient should respect the patient's right to participate willingly. When assent is promoted, the clinical environment becomes less restrictive because the patient has genuine influence over what happens.
Assent-based practice can and should be implemented in group settings, though it requires additional planning. In groups, individual patients may assent to some activities and dissent from others, and the clinician must balance multiple patients' preferences simultaneously. Strategies include building choice into group activities so that patients can select from options, establishing individual assent signals and dissent protocols for each group member, training group facilitators to monitor all participants for signs of dissent, and having alternative activities available for patients who dissent from the primary group activity. Group settings also provide natural opportunities to practice assent-related skills such as making choices, expressing preferences, and negotiating with peers.
Changes in assent during a session are normal and expected. When a patient withdraws assent during an activity, the clinician should pause, acknowledge the patient's communication, and assess the situation. Check for environmental factors such as fatigue, hunger, sensory overload, or confusion about the task. Offer modifications such as a break, a change in materials, a reduction in task difficulty, or a switch to a preferred activity. If the patient re-engages after the modification, note what change was effective and incorporate it into future sessions. If the patient does not re-engage, honor their decision and transition to a different activity. Document the change in assent, the modifications attempted, and the outcome to inform future session planning.
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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.