We all know that we must get informed consent from parents or caregivers to provide treatment, but are you getting assent from the learner as well? In the BACB’s Code of Ethics updated for 2022, the BACB requires BCBAs to obtain assent as a part of obtaining informed consent (2.11 Obtaining Informed Consent-see below).
“2.11 Obtaining Informed Consent Behavior analysts are responsible for knowing about and complying with all conditions under which they are required to obtain informed consent from clients, stakeholders, and research participants (e.g., before initial implementation of assessments or behavior-change interventions, when making substantial changes to interventions, when exchanging or releasing confidential information or records). They are responsible for explaining, obtaining, reobtaining, and documenting required informed consent. They are responsible for obtaining assent from clients when applicable.”Ethics Code for Behavior Analysts~Behavior Analyst Certification Board
The BACB included a caveat that says “when applicable,” but many would argue that assent is always applicable. Assent is the approval of treatment by the learner themselves. All children, even those who can’t speak, should have a say in their own treatment.
Why the Need for Assent?
Acquiring assent for treatment or as it’s often referred to, assent-based learning, is one part of “Today’s ABA” (a term used by Dr. Greg Hanley) or “Better ABA,” a push toward a kinder, more compassionate way to apply the science taught in master’s degree programs for BCBAs. For years, autistics and parents of autistics have been speaking out against the harsh traditional ABA methods that seek to eliminate autistic traits and include extinction and aversive procedures.
Historically, ABA evolved from a belief that autistics were not complete humans. In a famous interview with Psychology Today in 1974, Lovaas compared helping autistics to constructing a person.
“You see, you start pretty much from scratch when you work with an autistic child. You have a person in the physical sense – they have hair, a nose and a mouth – but they are not people in the psychological sense. One way to look at the job of helping autistic kids is to see it as a matter of constructing a person. You have the raw materials, but you have to build the person.”~Lovaas, 1974Wilson, 2020
While this is not the viewpoint of today’s professional, the field can’t shake this association. Education for BCBAs includes an emphasis on provoking and measuring maladaptive behavior while using functional analysis (FA) and functional behavior assessment (FBA) to identify the environmental variables that control behavior. BCBAs then learn to manipulate these variables to change behavior.
This provides BCBAs with a great power to influence the lives of a vulnerable population. These strategies have been used to change behaviors such as eye contact and stereotypies which are now recognized as ways autistics moderate their sensory input. Practitioners of ABA changed behaviors for the convenience of others without realizing the impact that has on the learner.
As Voltaire said, “with great power comes great responsibility.” It is our duty in the field to adapt our practice to information as it becomes available. Incorporating assent into our practice demonstrates a respect for our learners and gives them the right to choose, or not choose, treatment.
While practitioners seek to establish independence and a high quality of life for their learners, many do so using means that remove power from the learner. Using traditional methodologies that learners may find undesirable, aversive or even manipulative strips the learner’s autonomy. Obtaining assent for treatment builds that autonomy and teaches self-advocacy.
What is Assent?
Assent occurs when a learner verbally or nonverbally agrees to participate in treatment. Vocal communication, and even functional communication, is not needed.
Obtaining assent requires anyone working with the learner, including RBTs, BCBAs, parents, and non-certified professionals, to vigilantly watch for signs of assent. Pay attention to the learner’s body language, facial expressions and vocalizations. How the learner engages with the practitioner determines whether or not s/he is providing assent.
Behaviors that demonstrate assent include:
- Looking toward the instructor or materials (eye contact is not required as a sign of assent)
- Active engagement and participation
- Reaching for the practitioner
- Ready cooperation
- Affirmative statements when asked to participate
When learners demonstrate these behaviors, practitioners can feel confident that they have assent and proceed with treatment activities. This is not where assent ends. Assent is ongoing and can be withdrawn at any time.
Learners show assent withdrawal through a wide variety of verbal and nonverbal behaviors. As ABA practitioners, we must continually monitor our leaners for assent withdrawal. Assent is not a one-time deal. Learners may give assent at one point in time and withdraw assent at another.
At any time during treatment, a learner may withdraw assent. Assent withdrawal might include maladaptive behavior such as:
Alternatively, assent withdrawal might look a lot more subtle and include:
- Turning away
- Complaints or grumbling
- Pushing materials away
Watch your learner’s behavior. Which side of the table below does the behavior fall under? Is your learner giving assent to your treatment?
|Reaching for the instructor||Turning away from the instructor|
|Looking toward the instructor or materials||Inattention|
|Affirmative statements||Complaints, saying “no,” or saying “I don’t want to”|
|Ready cooperation without coercion||Pushing materials away|
|Active engagement||Crying, putting head down|
Make sure your staff know how to recognize assent. Download the infographic below.
Implementing Assent-Based Learning
There are 3 main components to implementing assent-based learning:
- Functional Communication Training (FCT): teaching self-advocacy statements
- Reinforcement of escape-maintained behavior: these behaviors are always reinforced and honored as though it were communication
- Adapting the learning environment and contingencies: changing the environment and contingencies to elicit more assent behaviors
When a learner engages in any of the assent withdrawal behaviors listed above, honor their withdrawal by allowing them to end the activity and then reassess the situation. At this point, you’re probably thinking, “won’t that reinforce the maladaptive behavior?”
The simple answer is yes, it will. What you want when using this model is to establish trust with your learner. You want the learner to know that you respect them and will listen to them, even when they aren’t speaking. Ideally, you want to end activities at the first sign of assent withdrawal, reinforcing the lower-level behaviors before the learner feels the need to escalate to the higher-level, potentially dangerous behaviors.
Over time, you will use FCT to teach your learner to communicate their assent withdrawal using words, sign language or other alternative form of communication. Assent withdrawal provides an opportunity to teach self-advocacy. Self-advocacy statements might include:
- I need help
- I don’t want to do this right now
- I don’t like the way you’re teaching me
- I want to do it my way
Next identify what specifically in the environment, your teaching strategy, your relationship with the learner, or the available contingencies that evoked the assent withdrawal. Consider:
- What is the learner responding to?
- Why don’t they want to participate?
- Is the learning environment not fun? Is it boring?
- Has the learner been sitting too long?
- Is the task too hard?
- Do you need to work on rapport building?
As you identify what evoked the assent withdrawal, consider ways to make changes to evoke assent. Adapt the learning environment by changing the:
- Teaching style (i.e. DTT vs NET vs fluency)
- Programs or targets
Once you adapt your approach or the environment, check again for assent. How often you check for assent will depend on your learner. Some learners will assent after only a few minutes if you make appropriate adjustments. Other learners might need a day or more before they assent to intervention.
Changing Current Practices to Include Assent
This flies in the face of traditional ABA practices and, at times, feels like it violates much of our training. That being said, eliminating situations where your learner is likely to engage in severe problem behavior is freeing.
Consider your current practices and interventions. Are you confident that your learners would provide informed consent to your treatment the way it’s currently implemented? You base your treatment on your education and experience, what science has told us is effective. How much does your learner care about all this?
What would your treatment and the learner’s progress look like if the learner was excited to participate in treatment? Where do you start?
- Data collection-identify what the learner is withdrawing assent from. Does he run from the therapist? Are there specific tasks he finds aversive? Is there something in the environment itself that creates a problem for him?
- Develop rapport-this goes far beyond pairing yourself with reinforcement. The learner must be excited to see you and the entire treatment team. Many learners know when someone likes them, or when they don’t. Spend time engaged in the learners special interests, not with an ulterior motive, but to show the learner you think he’s valuable.
- Make learning fun-often where we go wrong as ABA professionals is when we introduce “work” to our learners. Remember that your learners are children. Children learn through play. Piaget knew back in 1951 that “play is the work of childhood.”
- Pile on the reinforcement-but remember that not all reinforcement is artificial or tangible. Some learners rely, at least initially, on tangible reinforcers, but as you build rapport and incorporate their areas of special interest in learning activities, you find they need less tangible and artificial reinforcement.
Dr. Greg Hanley recommends considering the “televisability” of your interventions. In other words, if your interventions would trigger outrage if shown on television, you shouldn’t use it behind closed doors. Rise above the history of ABA. Demonstrate respect for autistics as individuals with the right to choose to participate, or not, in treatment.
For a comprehensive training that goes beyond the use of assent, check out the training Practical Functional Assessment and Skill Based Treatment offered by Dr. Greg Hanley through FTF Behavioral Consulting.
Ready to join a community of caring professionals who want to continue to move the field toward using assent-based learning? Learn more about ABLE Support for BCBAs and be part of the solution!
References and related reading
Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts.
Littleton, CO: Author.
Hanley, Greg. “A Perspective on Today’s ABA from Dr. Hanley.” Practical Functional Assessment, 19 Oct. 2021, https://practicalfunctionalassessment.com/2021/09/09/a-perspective-on-todays-aba-by-dr-greg-hanley/.
Morris, C., Detrick, J. J., & Peterson, S. M. (2021). Participant assent in behavior analytic research: Considerations for participants with autism and developmental disabilities. Journal of Applied Behavior Analysis.
Wilson, Brittany. “Who Was Dr. Ole Ivar Loovas?” Applied Behavior Analysis Programs Guide, 10 Sept. 2020, https://www.appliedbehavioranalysisprograms.com/faq/dr-ole-ivar-loovas/.