Connecting with Children During Difficult Moments: Honoring Assent and Assent Withdrawal in ABA

Overview & Clinical Significance

The concept of assent in applied behavior analysis has gained significant attention as the field grapples with its ethical obligations to the children and individuals it serves. While consent is a legal concept typically exercised by parents or guardians, assent refers to the learner's ongoing willingness to participate in therapeutic activities. Assent withdrawal, the behavioral indication that a learner no longer wishes to continue, represents one of the most challenging clinical scenarios practitioners face daily.

Every ABA session involves moments where children encounter demands, transitions, or activities they find challenging or aversive. How practitioners respond in these moments shapes the therapeutic relationship, affects the learner's willingness to participate in future sessions, and determines whether the clinical environment is one of safety and respect or one of coercion and compliance.

Traditionally, ABA practice has sometimes prioritized session productivity and program completion over the learner's moment-to-moment experience. When a child protests, turns away, cries, or attempts to leave during a session, the practitioner faces a decision with significant ethical and clinical implications. Following through with the demand teaches persistence and maintains instructional control, but it also risks overriding the child's communication about their experience. Honoring the withdrawal respects the child's autonomy and communication, but it also risks reinforcing escape behavior. This tension is real and does not have a simple resolution.

Assent-centered tools represent a middle path that takes both concerns seriously. Rather than choosing between compliance and capitulation, these tools provide practitioners with strategies for connecting with the child during difficult moments, acknowledging their communication, and finding ways to continue the therapeutic process while maintaining the child's sense of safety and agency.

The clinical significance extends beyond individual sessions to the broader therapeutic trajectory. Children who experience ABA as respectful and responsive are more likely to engage willingly in future sessions, tolerate increasingly challenging demands over time, develop trusting relationships with practitioners, and generalize skills learned in therapy to natural environments. Conversely, children who experience ABA as coercive may develop escape and avoidance patterns that persist across settings and practitioners, ultimately undermining the very goals the therapy was designed to achieve.

For the profession, the assent conversation represents an opportunity to demonstrate that behavior analysis can be both effective and humane. Addressing this topic thoughtfully strengthens the field's credibility with families, other professionals, and the disability community.

Background & Context

The current emphasis on assent in ABA practice has emerged from multiple converging forces, including ethical code revisions, advocacy from the autistic community, and evolving understanding of the therapeutic relationship in behavioral services.

The BACB Ethics Code (2022) introduced more explicit language around assent than previous versions. While earlier iterations of the code focused primarily on informed consent from guardians, the current code recognizes the learner as a stakeholder whose preferences and communication must be considered in service delivery. This shift reflects broader trends in disability rights that emphasize self-determination, autonomy, and the right to refuse services.

The autistic self-advocacy movement has been particularly influential in bringing attention to the learner's experience during ABA sessions. Adult autistic individuals who received ABA services as children have described experiences ranging from positive and empowering to traumatic and dehumanizing. A common thread in negative reports is the feeling that their communication, including protests, distress signals, and attempts to disengage, was systematically overridden in service of compliance-based goals. These accounts have prompted the profession to examine its practices and develop approaches that center the learner's experience.

The concept of assent withdrawal draws on the broader informed consent literature but adapts it for individuals who may not be able to provide verbal consent. For young children, individuals with intellectual disabilities, and others with limited verbal repertoires, assent is communicated behaviorally through approach and avoidance, engagement and disengagement, comfort and distress signals. Recognizing these behavioral communications as meaningful and worthy of response is the foundation of assent-centered practice.

Historically, behavior-analytic practice has distinguished between escape-maintained behavior that should be addressed through extinction or other procedures and genuine distress that warrants a compassionate response. The assent literature complicates this distinction by suggesting that even behavior that functions as escape from demands may simultaneously communicate something important about the learner's experience. The practitioner's task is not simply to identify the function but to consider the full meaning and context of the behavior.

The tools for connecting with children during difficult moments have been developed to address the practical challenge of implementing assent-centered practices in real clinical contexts. These are not abstract philosophical guidelines but concrete strategies that practitioners can use when a child is distressed, resistant, or attempting to disengage from a therapeutic activity.

Clinical Implications

Implementing assent-centered practices has significant implications for session structure, instructional strategies, data collection, and the therapeutic relationship.

Session structure must be designed to support assent from the outset. This includes beginning sessions with preferred activities to establish a positive rapport before introducing demands, providing choices throughout the session so that the learner experiences agency, building in regular breaks that are not contingent on compliance, and using visual schedules or other supports to make the session predictable and transparent. When a child knows what to expect and has some control over their experience, the probability of assent withdrawal decreases and the quality of engagement increases.

Instructional strategies should incorporate scaffolding that helps children succeed during challenging tasks rather than relying on escape extinction to push through resistance. If a learner is showing signs of distress during a demand, the practitioner can modify the demand by reducing its difficulty or duration, offer a choice between two acceptable task options, provide additional support such as modeling or partial prompts, intersperse easy and preferred tasks to maintain motivation, and acknowledge the difficulty verbally while providing encouragement. These strategies maintain the therapeutic flow while respecting the learner's limits.

When assent withdrawal occurs, the practitioner's response is critical. The first step is to recognize the behavioral indicators of assent withdrawal, which may include turning away, pushing materials away, crying, saying no or stop, attempting to leave the area, going limp, covering ears or eyes, or engaging in self-stimulatory behavior at increased intensity. These behaviors communicate something about the learner's experience, and the practitioner's first obligation is to acknowledge that communication.

The second step is to provide a brief pause that creates space for the child to regulate. This is not the same as providing escape contingent on challenging behavior. It is a compassionate response to a communication of distress that maintains the therapeutic relationship. During the pause, the practitioner can offer comfort if the child is receptive, provide a calming activity or sensory support, and wait for signs that the child is ready to re-engage.

The third step is to reconnect and, when appropriate, return to the therapeutic activity in a modified form. The modification might involve reducing the demand, offering more support, changing the materials while maintaining the same learning target, or moving to a different activity altogether.

Data collection should capture both the learning targets and the assent-related interactions. Track the frequency of assent withdrawal episodes, the practitioner's response, and the outcome of the response. Over time, this data can reveal patterns that inform proactive strategies. If assent withdrawal consistently occurs during a particular type of demand or at a particular point in the session, the practitioner can modify the session structure to address the pattern.

Ethical Considerations

Honoring assent and assent withdrawal is directly supported by multiple provisions of the BACB Ethics Code (2022), and the ethical case for assent-centered practice is strong.

Code 2.11 (Obtaining Informed Consent) explicitly addresses assent. The code requires behavior analysts to obtain the assent of the client, to the extent possible, in addition to informed consent from the legally authorized representative. This means that assent is not optional or aspirational but a required component of ethical practice. Practitioners who systematically override assent withdrawal without attempting to address the learner's concerns are not meeting this ethical standard.

Code 2.01 (Providing Effective Treatment) might seem to conflict with assent-centered practices if effectiveness is defined solely as skill acquisition rate. However, effectiveness encompasses the learner's overall wellbeing, the sustainability of engagement, and the long-term outcomes of the therapeutic relationship. An approach that produces rapid skill acquisition at the cost of the learner's willingness to participate in future services is not truly effective.

Code 2.15 (Minimizing Risk of Behavior-Change Interventions) applies because overriding assent withdrawal carries risks including emotional harm, damage to the therapeutic relationship, the development of generalized avoidance of therapy, and in extreme cases, psychological trauma. Practitioners must weigh these risks against the risks of honoring assent withdrawal, which may include slower skill acquisition and the potential for escape behavior to be reinforced.

Code 1.01 (Being Truthful) and Code 1.02 (Conforming with Legal and Professional Requirements) support the practitioner's obligation to communicate honestly with families about the assent framework. Families should understand that the practitioner will respect their child's communications, that this may sometimes mean pausing or modifying activities, and that this approach supports better long-term outcomes.

Code 2.09 (Involving Clients and Stakeholders) requires that the learner's preferences be considered in service delivery. For nonverbal or minimally verbal learners, behavioral indicators of preference and distress are the primary channel for this involvement. Honoring assent withdrawal is a concrete expression of involving the client in their own treatment.

The ethical tension between honoring assent and addressing escape-maintained behavior is real and requires nuanced clinical judgment. Not every instance of resistance constitutes assent withdrawal, and not every demand should be withdrawn when the learner protests. The skilled practitioner distinguishes between momentary preference for escape that can be addressed through motivation and scaffolding and genuine distress that warrants a change in approach. This distinction cannot be made by following a rigid protocol but requires ongoing clinical judgment informed by knowledge of the individual learner.

Assessment & Decision-Making

Making real-time decisions about assent during clinical sessions is one of the most challenging aspects of behavior-analytic practice. A systematic decision-making framework helps practitioners navigate these moments thoughtfully rather than reactively.

The first step is to establish individualized indicators of assent and assent withdrawal for each learner. Because learners communicate assent behaviorally, the indicators will vary from one individual to another. For one learner, assent might look like approach behavior, eye contact, reaching for materials, and relaxed body posture. Assent withdrawal might look like turning away, pushing materials, and increased vocal protests. For another learner, the indicators may be subtler. Establish these indicators collaboratively with the family and document them in the treatment plan so that all team members can recognize and respond consistently.

The second step is to develop a graduated response protocol for different levels of resistance. Not all instances of resistance require the same response. A learner who makes a mild verbal protest but continues engaging with the task may simply be expressing preference, and acknowledgment plus encouragement may be sufficient. A learner who becomes visibly distressed, attempts to leave, or engages in self-injury requires an immediate change in approach. Having a graduated protocol prevents both over-reaction to mild resistance and under-reaction to genuine distress.

The third step involves distinguishing between assent withdrawal and escape-maintained behavior that can be addressed through clinical strategies. This distinction is the most challenging aspect of assent-centered practice and cannot be reduced to a simple algorithm. Factors to consider include the intensity and duration of the resistance, whether the resistance is specific to one demand or generalized across activities, the learner's history with the specific demand, whether the learner shows signs of physiological distress such as elevated heart rate or flushed skin, and whether the resistance escalates when the demand is maintained versus when it is withdrawn.

The fourth step is to analyze patterns over time. Single instances of resistance provide limited information, but patterns across sessions reveal important clinical data. If a learner consistently shows distress during a particular program, the appropriate response may be to modify the program rather than to continue pushing through. If resistance occurs only during certain times of day or with certain practitioners, setting events and relationship factors may be contributing.

Data-based decision rules should specify when to persist with supportive scaffolding, when to modify the demand, and when to withdraw the demand entirely. These rules should be individualized, documented in the treatment plan, reviewed regularly, and updated based on accumulating data. The goal is to provide practitioners with guidance that supports both the learner's autonomy and continued therapeutic progress.

What This Means for Your Practice

Integrating assent-centered practices into your daily clinical work requires both a philosophical commitment and a practical skill set. The good news is that these practices do not require abandoning effective instruction but rather enriching it with respect for the learner's experience.

Start by examining your default response to resistance. When a child pushes materials away, do you reflexively re-present the demand? When a child says no, do you immediately redirect? These habitual responses may not be the most therapeutically productive ones in every situation. Building a brief pause between the learner's communication and your response creates space for clinical judgment.

Develop your ability to read the learner's behavioral state in real time. This skill goes beyond identifying the function of behavior and requires attending to the learner's emotional tone, physiological indicators, and overall engagement level. A learner who is calmly pushing materials away is in a different state than a learner who is crying and attempting to flee. Your response should differ accordingly.

Build a repertoire of connection strategies that you can deploy during difficult moments. These might include getting down to the learner's physical level, offering a preferred item or activity, using a calm and warm tone of voice, providing physical comfort if the learner is receptive, labeling the learner's emotion in simple language, and offering a genuine choice about what happens next. These strategies are not reinforcing escape; they are maintaining the therapeutic relationship through a difficult moment.

Communicate with families about your approach to assent. Many families appreciate knowing that their child's communications will be respected during sessions. Some families may have concerns about whether honoring assent withdrawal will slow their child's progress. Address these concerns honestly, explaining that a child who feels safe and respected in therapy is more likely to engage fully and make durable progress over time.