Article Club: Assent in ABA- Ethical Considerations and Practical Recommendations

Assent, Informed Consent, and Assent Withdrawal Are Three Different Things

Three terms carry this talk. Informed consent (permission given after hearing the facts) comes first. You explain the service: the steps, the likely gains, and the risks. Then you get an okay from the client or their legal guardian. Assent (agreement to take part) comes from someone who cannot legally consent. Assent withdrawal is the moment that person tells you to stop.

The presenters named a gap right away. Assent gets more attention in our field each year. Real guidance on how to run it is still thin. The group read one article on that problem. The title is "Assent in applied behaviour analysis and positive behaviour support: ethical considerations and practical recommendations." The article has two jobs. It looks at assent through an ethics lens. It also gives steps for building assent into treatment.

Our field has no agreed definition of assent. So the authors looked wider. They read how research, medicine, and behavioral services each define it. Three themes came up again and again. No objection is not a yes. Assent must be free, with no pressure. And assent can be pulled back at any time.

That last theme is easy to miss in daily practice. A yes early in the session is not a yes later on. You check, then check again, for the whole session. Spotting the change is part of the job.

Assent isn't something that we just obtain at the beginning.

From the talk — Pauli Catanese & Sam Mueller

The Ethics Codes Behind Assent, and the "When Applicable" Gap

Assent rests on plain human rights. People with disabilities hold the same rights as everyone else. That includes the right to choose and to shape their own care. The presenters tied that idea to four codes. Code 2.01 covers effective treatment and client rights. Code 2.09 covers involving clients and stakeholders in goals and plans. Code 2.11 covers informed consent. Code 2.14 covers picking and running behavior change plans that fit the client.

Code 2.11 drew the most heat. It says we obtain assent from clients when applicable. Those two words leave a lot open. Each of us gets to decide when assent applies. The article pushes back on that. Build assent in across the board. Do not rank learners by skill and hand choice only to the top.

This is where ableism (bias against disabled people) enters the room. Our read of a learner's skill shapes what we offer. If we think someone cannot choose, we stop offering choices. If we think someone cannot refuse, we miss the refusal. The group called that a heavy burden, and it is. The ethics code also sets four core principles. The second one is to treat others with compassion, dignity, and respect. Choice and self-determination (making your own choices) live inside that principle.

Just because someone needs additional support to communicate their preferences or what they need, what they want, doesn't mean that they shouldn't have opportunities to make choices at all.

From the talk — Pauli Catanese & Sam Mueller

How to Define Assent and Refusal for One Specific Learner

You define assent the way you define any other behavior. Start with topography (what the behavior looks like). Add function (why it happens). Use indirect tools first: interviews with caregivers and others around the client. Then use direct tools and watch the learner in session.

The article's table two splits the signs into vocal and nonvocal. That split matters. A learner does not need speech to say yes or no. Assent may look like saying yes. It may also look like walking over or reaching for the markers. Refusal may be no or stop. It may also be turning away, pushing materials aside, or leaving the area.

The group filled that table with their own cases. One learner reaches for a marker to start work and drops it to stop. One taps a pencil and sighs when a worksheet is too hard. One makes an X with two fingers. One goes quiet instead of speaking up. A learner who talks all day can still refuse without words. For some learners, a hard look is the whole message. Quiet refusal often gets read as distraction. That is a costly mistake.

These signs also drift. One team had to update a learner's definitions every few weeks. So put the definitions where staff will see them. Session notes and program sheets beat a plan nobody opens.

Ask What the Learner Is Actually Refusing

Here is the sharpest idea in the hour. Assent is not one yes to a whole activity. The learner may be agreeing, or refusing, at a much smaller level. The article points at four conditions. The demands you place. The prompts you use. The reward rules in play, meaning how rewards are earned. And how the room is set up.

Take the marker example from the talk. The learner drops the marker. Wait a beat, hold it out again, and the work starts back up. So what was refused? Maybe not the worksheet. Maybe the prompt, or how long the prompting ran.

Full refusal of the task looked different for that learner. It showed up as leaving the seat, leaving the area, or known precursor behaviors (small signs before bigger behavior). Two topographies point to two problems. Name the condition and you know what to change.

So treat each refusal as a question. What exactly is the learner turning down? The task, the prompt, the reward rule, or the room? Your answer sets your next move.

The Choice Model: Three Ways to Respond to a Refusal

The group hit the hard objection head on. Does letting a learner refuse just teach escape from work? The answer in the talk was yes, in part, and do it anyway. Forcing work through pressure or physical help costs you the relationship. It also tends to grow challenging behavior. Goals do not get dropped. The conditions get examined.

The article gives three options after a refusal. Option one is simple: do not present that condition again this session. Use it when you cannot change the setup right now. Use it when the refusal is strong, or too intense for the setting. One clinician uses option one while building functional communication (asking instead of acting out). If the learner says all done, the song or activity stops at once. That rewards the request.

Option two is to bring the condition back later in the session. This fits when you do not yet know what drove the refusal. Change the setting, build a few easy wins, wait for calm, then try again.

Option three is to bring it back with changes. This fits when you have a hunch about the cause. If the task is too hard, offer help, cut the number of trials, or reword the instruction. If pushing materials away tracks with table work, run a program with no table materials and watch what happens. One presenter asked for that table as a flow chart, so staff can pick a change in the moment. That is a good project for your clinic.

So, that doesn't necessarily mean that we have to stop working towards our goals, but we do need to evaluate the conditions that might be contributing to assent withdrawal.

From the talk — Pauli Catanese & Sam Mueller

Three Messy Scenarios the Group Worked Through

The second half ran three scenarios, each built to be messy. In the first, a learner in a school removes their clothing in class. The tech brings the clothes and prompts getting dressed. The learner says no and turns away. A choice between doing it alone or with help also gets a no. The group's first move was to ask what the setting allows. Dignity sits in the ethics code too, for the learner and for everyone nearby. One option is a private space with the door closed, plus rewards for getting dressed. A temporary cover can protect dignity while you work. Clear boundaries help: clothes on near friends, clothes off only in a private spot. Look at what happens right before, since the behavior may start a chain. And this one does not stay in school. In the community it can break the law. So teaching the skill, and helping it hold up in new places, both matter.

In the second, a learner is in DTT (short, repeated teaching trials) on receptive identification (pointing to a named item). They walk to the table and work on their own. After several wrong answers, they swipe materials and turn away. Mastered targets bring responding right back. The original program gets an instant push away. The data show little progress after weeks of teaching. The group read that as a curriculum problem, not a motivation problem. Shrink the array, use errorless teaching (prompting so mistakes rarely happen), or shape the skill in small steps.

In the third, a learner is doing well, then the team thins the reward schedule and gives rewards less often. Now they push materials, ask for breaks, and try to leave. A break is offered and taken. Other work goes fine. Only the thinned program draws refusal. Two fixes came up. The jump may be too big, so thin more slowly. Or the reward may be only mildly liked, so it cannot carry a leaner schedule.

That last sentence really pointed to the curricular modification and that aversive pairing with a difficult task.

From the talk — Pauli Catanese & Sam Mueller

Teaching Self-Advocacy Without Ignoring the Learner's Current No

Honoring refusal is only half the work. The article's second feature is teaching self-advocacy (speaking up for yourself) and choice making. Start with what the learner can already do. Teach and reward an easier way to say stop. Then shape it toward the long-term goal.

Table four lays the path out in three steps. Current behavior: the learner throws materials off the table. Short-term option: the learner looks at and touches a stop symbol. Desired replacement: the learner signs stop or says it on a speech device.

Here is the part teams skip. While you teach the new form, keep honoring the old one. If leaving the area is the current refusal, respect it. At the same time, set up practice. One learner takes breaks on a mat nearby. So the team builds in chances to ask for that break at the desk. Teach the related skills too: making choices, asking to change the setup, and waiting out a short delay.

Some learners also fall back on an older signal, like a flat no that was never offered as a choice. Treat that as your first flag and adjust what you are doing.

Measuring Assent, Including Your Own Staff's Behavior

The last critical feature is measurement and analysis. We already take piles of data on learner skills. The article asks us to take data on assent too. Count how often the learner starts contact with you or with the materials. Track latency (time before the learner begins) after an instruction.

For refusal, look at more than rate. Which programs draw it? Which staff member is in the room when it spikes? Code 2.17 covers collecting and using data, so this is not extra credit.

That last question points the data at us. If one staff member sees more intense refusals, ask why. Maybe they offer fewer chances to say stop. Maybe they honor fewer of them. Maybe breaks and help requests never get taught in their sessions. One team already has skill checks for techs, and they often sit unused.

The group left with a short list. Put assent and refusal definitions in session notes, not just the behavior plan. Add them to single programs, starting with communication goals. Build a cheat sheet or flow chart for techs. Track prompted versus independent self-advocacy, then graph it next to challenging behavior.

It's important to also take data on practitioner behaviors instead of just the behaviors of our learners.

From the talk — Pauli Catanese & Sam Mueller