Assent Procedures for Individuals with Communication Difficulties: Practical Approaches for Behavior Analysts

Overview & Clinical Significance

Standard assent procedures in clinical practice and research assume a level of communication ability that many individuals with autism spectrum disorder and related developmental disabilities do not possess. Written assent forms require reading comprehension. Verbal assent discussions require receptive and expressive language skills. Even simplified visual assent tools assume a baseline of symbolic understanding that some individuals have not yet developed. Cody Morris's presentation confronts this problem directly: how do behavior analysts ethically obtain assent from individuals whose communication abilities make conventional assent procedures inadequate?

This question is not hypothetical for most practitioners. A significant proportion of individuals receiving ABA services have limited functional communication. Some communicate through augmentative and alternative communication systems that may be in early stages of development. Others communicate primarily through behavior, including approach and avoidance responses, facial expressions, and changes in engagement. For these individuals, the assent process must be reconceptualized as a behavioral rather than a linguistic event.

The clinical significance of this reconceptualization is profound. When assent procedures are designed for individuals who can speak or read, the individuals who cannot are effectively excluded from the assent process. Their participation in treatment and research becomes something that happens to them rather than something they agree to. This exclusion is not merely a procedural gap; it reflects a power imbalance in which the individuals with the least ability to advocate for themselves receive the least consideration of their preferences.

Cody Morris's presentation introduces assent and its critical components in a way that equips practitioners to adapt their approach to the communication abilities of each individual they serve. The emphasis on adaptation rather than abandonment is important: the goal is not to skip assent for individuals who cannot communicate verbally but to develop alternative methods that respect their right to participate in decisions about their own lives, to the greatest extent possible given their current repertoire.

For behavior analysts specifically, this topic intersects with core professional competencies. Assessment of communicative repertoire, identification of behavioral indicators of preference and avoidance, and design of environmental conditions that support choice-making are all skills within the behavior analyst's scope. The application of these skills to assent procedures represents a natural extension of clinical practice that carries significant ethical weight.

Background & Context

The concept of assent in human services and research has evolved considerably over the past several decades. In biomedical research, the Belmont Report established the principle that respect for persons requires providing individuals with the opportunity to choose whether to participate in research. For individuals who cannot provide legal consent, such as children and individuals with certain cognitive disabilities, assent was introduced as a complementary process through which the individual's agreement to participate is sought within the limits of their capacity.

In clinical practice, assent has gained increasing attention as the disability rights movement and person-centered planning approaches have influenced how services are designed and delivered. The recognition that individuals with disabilities have the right to participate in decisions about their own lives, including treatment decisions, has created an expectation that practitioners will seek and honor assent even when legal consent is provided by a guardian or surrogate.

The challenge arises when the standard methods for seeking assent depend on communication modalities that the individual does not possess. A written assent form is meaningless to an individual who does not read. A verbal explanation of treatment procedures is inaccessible to an individual who does not understand spoken language at the level of complexity required. Even simplified visual supports, such as picture schedules showing what will happen during a session, require a level of symbolic understanding that some individuals are still developing.

For individuals with ASD and related developmental disabilities, communication difficulties are highly variable. Some individuals have fluent speech but struggle with receptive language processing. Others use augmentative communication systems with varying degrees of proficiency. Still others communicate primarily through behavior, including movement toward or away from stimuli, changes in body posture, vocalizations, and facial expressions. This variability means that no single assent procedure will work for all individuals, and practitioners must be prepared to individualize their approach.

The behavior-analytic framework offers tools for this individualization. Preference assessments can identify stimuli and activities that the individual approaches versus avoids. Functional communication training can expand the individual's repertoire for expressing preferences. Choice-making opportunities embedded in daily routines can build the skills needed for meaningful assent. These are not new tools for behavior analysts; they are familiar clinical procedures applied to a new context.

Cody Morris's focus on introducing the critical components of assent, including voluntariness, information, comprehension, and agreement, provides a framework for evaluating whether a given assent procedure adequately addresses each component for a given individual. When a component cannot be fully achieved due to communication limitations, the practitioner must identify the closest achievable approximation and document both the procedure used and the rationale for the adaptation.

Clinical Implications

Adapting assent procedures for individuals with communication difficulties requires a systematic assessment of each individual's current communicative repertoire and the development of an assent protocol tailored to that repertoire. The clinical implications of this process touch every aspect of service delivery.

The first step is assessing the individual's current ability to indicate preference and agreement through whatever communication modality is available to them. For some individuals, this might be a formal communication system such as a speech-generating device or picture exchange system. For others, it might be behavioral indicators such as approaching preferred stimuli, turning away from nonpreferred stimuli, or engaging in specific vocalizations associated with positive or negative affect. The behavior analyst must identify these indicators, operationally define them, and validate them through systematic observation.

Once the individual's assent indicators are identified, the practitioner develops an assent protocol that uses those indicators in a meaningful way. For an individual who uses a picture exchange system, the protocol might involve presenting pictures representing the activities planned for the session and allowing the individual to select which activities to engage in first, or to indicate that they do not want to participate in a particular activity. For an individual who communicates primarily through approach and avoidance behavior, the protocol might involve presenting materials or activity setups and observing whether the individual approaches or moves away.

The clinical implications extend to how sessions are structured. When assent is monitored throughout a session rather than only at the beginning, the practitioner must be attentive to changes in the individual's behavioral indicators. An individual who initially indicated willingness to participate may show signs of withdrawal as the session progresses. Honoring these signs means being willing to modify the session plan in real time, which requires flexibility and clinical judgment.

Documentation of assent procedures becomes more complex when the procedures are individualized and behaviorally based. The treatment plan should include the operational definitions of assent and withdrawal of assent for each individual, the protocol for seeking assent at the beginning of each session, the protocol for monitoring assent during sessions, and the response procedures for when assent is withdrawn. Session notes should document whether assent was obtained, any instances of assent withdrawal, and the actions taken in response.

For research contexts, the implications are equally significant. Institutional review boards require assent procedures for individuals who cannot provide legal consent. When the research population includes individuals with significant communication difficulties, the researcher must describe the adapted assent procedures in the research protocol and demonstrate that these procedures adequately address the core components of assent. Behavior analysts conducting research are well positioned to develop these procedures, but they must articulate the behavioral rationale clearly for reviewers who may not share their background.

The training implications for direct service staff are substantial. RBTs and other implementers need to understand the individual's assent indicators, know how to monitor for withdrawal of assent, and have clear protocols for responding when assent is withdrawn. This training must be specific to each individual, as assent indicators vary from person to person.

Ethical Considerations

The ethical framework for assent with individuals with communication difficulties draws on foundational principles of respect for persons, beneficence, and justice. The Ethics Code for Behavior Analysts addresses these principles through several specific standards.

Code 2.09 requires behavior analysts to involve the client in the treatment process to the extent possible. For individuals with communication difficulties, this means identifying whatever level of involvement is achievable and implementing procedures that support it. The standard does not provide an exception for individuals whose communication limitations make involvement difficult; it requires effort to find ways to involve them.

Code 1.06 addresses nondiscrimination, and the application to assent is clear. Individuals should not be denied the opportunity to participate in decisions about their treatment simply because their communication difficulties make the standard assent process inapplicable. Adapting assent procedures to the individual's communicative repertoire is an expression of nondiscrimination in practice.

Code 2.15 on least restrictive procedures is connected to assent in a fundamental way. When an individual cannot communicate their consent or dissent through conventional means, there is an increased risk that they will be subjected to procedures they find aversive without adequate recognition of their objection. The behavior analyst's duty to use least restrictive procedures is amplified for individuals who cannot easily communicate that a procedure is distressing to them.

The ethical analysis must also address the quality of the adapted assent procedure. There is a risk that simplified assent procedures may become token gestures that look like assent monitoring but do not genuinely capture the individual's preferences. Presenting a choice between two options and then proceeding with the activity regardless of the individual's response, for example, is not meaningful assent. The ethical standard requires that the procedure actually function as a mechanism for the individual to influence what happens to them.

Voluntariness is perhaps the most challenging component of assent to achieve with individuals who have communication difficulties. True voluntariness requires that the individual understands they have the option not to participate and that choosing not to participate will not result in punishment or loss of access to preferred activities. For individuals with limited comprehension, communicating this concept requires creative approaches, such as consistently pairing refusal responses with neutral or positive outcomes over time so that the individual learns through experience that refusal is safe.

The intersection of assent with guardianship is another ethical dimension. A guardian's legal consent authorizes treatment, but this does not eliminate the obligation to seek assent from the individual to the extent possible. When the individual's behavioral indicators suggest they are not willing to participate in a procedure that the guardian has consented to, the behavior analyst faces a tension that requires careful ethical navigation. The resolution typically involves communicating with the guardian about the individual's response, exploring modifications that might increase the individual's willingness to participate, and documenting the ongoing assent monitoring process.

Assessment & Decision-Making

Developing an individualized assent protocol begins with a thorough assessment of the individual's communicative repertoire. This assessment should identify all modalities through which the individual currently communicates, including formal systems such as speech, sign, picture exchange, or speech-generating devices, and informal behavioral indicators such as approach and avoidance, affect changes, vocalizations, gestures, and body language.

For each communication modality, the assessment should determine the individual's proficiency level. Can they use a picture exchange system to request preferred items? Can they use it to protest or refuse nonpreferred items? Can they use it to indicate agreement or disagreement in response to a question? The answers to these questions determine how the assent procedure can be structured for that individual.

Preference assessments provide critical information for developing assent protocols. A systematic preference assessment identifies the stimuli and activities the individual approaches and avoids, which serves as a foundation for understanding their behavioral expressions of agreement and disagreement. Paired stimulus, multiple stimulus, and free operant preference assessment methodologies each contribute different information about the individual's preference hierarchy.

The decision about what level of assent procedure is appropriate for a given individual should be based on a combination of their communicative repertoire, their comprehension level, and the nature of the procedure for which assent is being sought. For a low-risk activity such as a preference assessment, a simple approach-avoidance indicator may be sufficient. For a higher-risk procedure such as a functional analysis involving extinction or a restrictive behavior intervention, the assent standard should be more rigorous, with more opportunities for the individual to indicate refusal and more sensitive monitoring for withdrawal of assent.

Decision-making about how to respond to ambiguous assent indicators is particularly important. When the individual's response does not clearly indicate either agreement or refusal, the default should generally be to pause and reassess rather than to proceed. Proceeding in the absence of clear assent is ethically riskier than pausing, particularly when the activity involves aversive elements.

The assent protocol should be documented in the treatment plan and should be reviewed and updated as the individual's communication skills develop. As an individual acquires new communication abilities, their assent protocol should evolve to reflect their expanded repertoire. A person who could only indicate assent through approach behavior last year may now be able to use a picture exchange system to indicate yes or no, and their assent protocol should be updated accordingly.

Regular team discussion about assent-related observations supports consistent implementation. Treatment team meetings should include a standing agenda item for discussing any instances of unclear or withdrawn assent, the team's response, and any protocol modifications needed. This ensures that assent monitoring remains an active clinical focus rather than a static policy.

What This Means for Your Practice

For every individual on your caseload who has significant communication difficulties, evaluate whether your current assent procedures are meaningful or merely procedural. Can the individual actually influence what happens to them through the assent process, or is the process occurring around them without genuine participation?

Develop written assent protocols for each individual that specify the behavioral indicators of assent and withdrawal of assent, how assent will be sought at the beginning of each session, how assent will be monitored throughout the session, and the response procedure when assent is withdrawn. Include these protocols in the treatment plan and train all staff who work with the individual on the procedures.

If an individual's current communication repertoire does not support any form of assent indication, prioritize teaching a simple refusal or protest response. This might be as basic as pushing an item away, shaking the head, or activating a single switch that communicates a protest message. Building this foundational communication skill serves both the individual's communicative development and their right to participate in decisions about their care.

When you encounter ambiguity in an individual's assent indicators, err on the side of caution. Pausing an activity when you are unsure whether the individual is willing to continue costs very little clinically but demonstrates respect for their autonomy. Over time, careful observation during these pauses will help you refine your understanding of the individual's assent signals.

Finally, recognize that developing meaningful assent procedures for individuals with complex communication needs is a clinical skill that improves with practice and reflection. Each individual teaches you something new about how to recognize and honor preferences expressed through non-conventional means.