Assent in applied behaviour analysis

and positive behaviour support: ethical

considerations and practical
recommendations
Cassi A. Breaux1,2 and Kristin Smith1
1
CentralReach, Fort Lauderdale, FL, USA; 2Center for Behavior Analysis, University of West Florida, Pensacola,
FL, USA

The term positive behaviour support (PBS) is used to describe the integration of the contemporary ideology
of disability service provision with the clinical framework of applied behaviour analysis (ABA). Assent, the par-
ticipation consent of those not legally able to consent, has gained recent popularity in the fields of ABA and
PBS. The goal of assent-based ABA and PBS is a person-centered approach to assessment, intervention,
and all other decision-making. In this model, the learner’s assent withdrawal for participation is honored,
whether it be a vocal ‘no’ or a non-vocal expression of verbal behaviour. There is currently a limited subset
of studies that mention or utilize assent with learners in ABA or PBS. The lack of published research can
make assent-based practices seem to be a choice of the practitioner. The authors of this manuscript seek to
further define assent, illuminate the necessity of assent-based practices, and offer assent-based procedures
in ABA- and PBS-based intervention.
Keywords: assent; assent withdrawal; disability; choice; dignity; supported decision-making

The purpose of this article is to discuss the role and ABA brings improvements and change in socially relevant
behaviours within the context of the individual’s social
value of person-centered values, supported decision- environment; is conducted within the scientific framework;
making, ethics, and human rights within the profes- focuses on functional relationships and replicable procedures;
sional disciplines of applied behaviour analysis (ABA) is conceptually systematic and reflective; achieves measurable
changes in relevant target behaviours that last across time
and positive behaviour support (PBS). Specifically, we
and environments; is accountable, public, doable,
seek to define assent and give practical recommenda- empowering, optimistic; and is more effective than eclectic
tions for utilizing assent in ABA- and PBS-based treatments. Aversive methods are avoided in favour of
intervention. interventions based on functional assessment and functional
analysis and positive reinforcement. (p. 194)

Defining applied behaviour analysis Similarly, Keenan and Dillenburger (2018) offered a
A simple definition of ABA is the applied use of the definition more targeted to a clinical approach that cov-
principles of operant psychology to solve problems of ers the seven dimensions of ABA as described by Baer
social significance (Baer et al. 1968). In the five deca- et al. (1968):
des that have passed since this definition was articu- It is applied to problems of demonstrated social importance;
lated, ABA has made considerable contributions to a it has measurable behavioural outcomes; it uses systematic
variety of areas including comprehensive attention to analysis to demonstrate that specific procedures produce
specific effects; procedures are technologically described well
disability services, organizational and systems change, enough to be replicated; it is conceptually compatible with
behavioural medicine, and support for concerns experi- behaviourism; it uses effective procedures with strong,
enced by so many (i.e. feeding, weight management, socially important effects; and it achieves generality from the
outset to ensure longevity of effects. When working with
sleeping) (Hayes et al. 1980). Dillenburger and Keenan individuals, no single intervention is used in a one-size-fits-all
(2009) expanded on the definition offered by Baer approach. Instead, the scientific method is used. Central to
et al. (1968): the scientific method is the notion that decisions about
procedures are guided by, and evolve with, the progress of
Correspondence to: Cassi Breaux, Center for Behavior Analysis, the learner. There is no ‘normalising agenda’, but instead the
University of West Florida, 11000 University Parkway, Pensacola, FL, goal is to work in partnership to arrange educational
32514, USA. Email: [email protected]

# The British Society of Developmental Disabilities 2022

DOI 10.1080/20473869.2022.2144969 International Journal of Developmental Disabilities 2023 VOL. 69 NO. 1 111
Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

experiences that maximise the individual’s skills levels. Doing Assent: An emerging but important concept in
so increases behavioural repertoires and choices and
ABA and PBS
alleviates obstacles to independent living. (p. 33)
Consent is a noun used to describe the agreement to
In both definitions, the breadth in application of the participate. It is most often legally and ethically
strategies within ABA is highlighted as well as the required for all ABA-based intervention services, as
dimensions required for use of the label applied behav- well as many other medical, educational, and psycho-
iour analysis. Categories of central themes include gen- logical services. Typically, practitioners of ABA or
eral principles, assessment, intervention, and outcomes/ PBS obtain informed consent from a learner or their
measurement. General principles of contemporary legal guardian at the start of services, for any new serv-
applications of ABA include the selection and analysis ices, and for any forms of research (Behavior Analyst
of target behaviours and behaviour change procedures Certification Board 2020). Informed consent involves
that are: of social importance, conceptually systematic, making the learner or the learner’s guardian aware of
empower clients, individualized, minimize aversive pro- what will happen during the provision of services, the
cedures, and maximize choices and behavioural reper- potential benefits and risks of proposed interventions,
toires. Central themes related to assessment and how data will be used, and the right to remove consent
intervention in ABA include data analysis, the use of to participate at any time without penalty (United States
functional behaviour assessment and functional behav- Department of Health and Human Services 2021,
iour analysis to guide interventions, and the demonstra- Dockett et al. 2012, Fabrizio 2005, Smith and
tion of functional relations. Themes related to outcomes Breaux 2020).
include significant and generalizable behavioural The concept of assent is a legal extension of consent.
change. These convergent themes define ABA, making While informed consent is codified within law and a
ABA application of an expansive science that is easily common component of ethical and professional codes
used with a wide variety of situations, settings, behav- of conduct in most helping professions, assent is a
iours, and populations. recently emerging legal and ethical concept. Assent is
generally described as the legal agreement of someone
who is not able to provide informed consent to partici-
pate, such as children or people with intellectual and
Defining positive behavior support and its
developmental disabilities who participate in research.
relation to applied behaviour analysis
Although assent is an important and emerging topic
Positive behaviour support (PBS) is an applied science
in ABA and PBS, a comprehensive definition of the
that encompasses a variety of evidence-based practices
term has not been put forth. To address this gap, we
and educational methods to improve an individual’s
identified multiple definitions of assent across disci-
quality of life and minimize problem behaviours (Carr
plines and analyzed the definitions to identify common
et al. 1999, 2002, Singer and Wang 2009). In PBS, the
themes. Table 1 displays definitions of assent in
positive behaviours targeted for increase are those
research (Code of Federal Regulation 2021, Dockett
behaviours considered to be adaptive and likely to
et al. 2012, 2013, Huser et al. 2022, Vitiello 2003),
increase personal satisfaction and access to desired
medicine (Ford et al. 2007), and behaviour services
activities (Carr et al. 2002). Tincani (2007) describes (Behavior Analyst Certification Board 2020, Breaux
PBS as a unique application of ABA, which focuses on 2020a, Fabrizio 2005).
the following core components: All reviewed definitions stated that assent was in
(a) achievement of comprehensive lifestyle change and addition to guardian consent and/or in lieu of legal con-
improvement of quality of life across the lifespan; (b) sent. The strongest theme across all types of assent def-
incorporation of person-centered values and stakeholder
input; (c) ecological and social validity of interventions; (d) a
initions was agreement to participate. Multiple
focus on prevention; (e) systems change; (f) functional definitions mentioned ‘voluntarily’ or ‘without coer-
assessment of problem behavior; (e) multi-component cion’, suggesting that assent cannot be provided via
intervention; and (f) empirical validation of behavior change coercion (Fabrizio 2005, Huser et al. 2022) and that the
procedures. (p. 493)
‘absence of objection’ or ‘failure to object’ was not suf-
These components align well within the dimensions ficient to infer the presence of assent (Code of Federal
of ABA, validating the notion that PBS is not a separate Regulation 2021, Vitiello 2003). Similar to consent,
science from ABA but rather a specific application of assent was also described as able to be revoked or
ABA. Though PBS fits within the dimensions of ABA, withdrawn at any time, a concept termed ‘dissent’
PBS does not encompass the breadth of ABA research (Dockett et al. 2012, 2013) or ‘assent withdrawal’
and application. Instead, PBS is a specialized approach (Breaux 2020a, Fabrizio 2005). All but one definitions
of ABA, not unlike precision teaching or organizational referencing clinical or medical practice (Breaux 2020a,
behaviour management (Tincani 2007). Fabrizio 2005, Ford et al. 2007) mentioned directly or

112 International Journal of Developmental Disabilities 2023 VOL. 69 NO. 1

 Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

Table 1. Definitions of Assent.

Definition Citation
Assent is meant to be an explicit, affirmative agreement to Vitiello 2003
participate, not merely absence of objection.
To agree to something freely and with understanding. Giving Fabrizio 2005
assent is coming to a task willingly, participating in learning
interactions without coercion.
Assent is the term used to convey a sense of agreement obtained Ford et al. 2007 (p. 21)
from those who are not able to enter into a legal contract.
Where children are considered unable—either legally or by virtue Dockett et al. 2012 (p. 245)
of their developmental status—the concept of assent is often
invoked. When children are invited to either consent or assent
to participation, they retain the right to dissent.
Assent acts as a supplement to the legal requirement of consent Dockett et al. 2013 (p. 804)
provided by a parent or guardian … agreement for
participation.
Vocal or nonvocal verbal behavior that can be taken to indicate Behavior Analyst Certification Board 2020 (p. 7)
willingness to participate in research or behavioral services by
individuals who cannot provide informed consent (e.g. because
of age or intellectual impairments).
The expression of approval or agreement by someone not legally Breaux 2020a
able to give consent. Assent can be given vocally/verbally, can
be given in contract form, can be given using behaviours, can
be revoked at any time.
Assent means a child’s affirmative agreement to participate in United States Department of Health and Human Services 2021
research. Mere failure to object should not, absent affirmative
agreement, be construed as assent.
Children’s ‘active agreement’ to participate voluntarily. Huser et al. 2022 (p. 49)

in adjacent sentences that the provision of assent is a fundamental rights and freedoms as everyone else,
dynamic and ongoing process, not a singular event. including the right to choose, and disability should not
Based on these definitions, assent is the agreement to be used as an excuse to deny a person access to their
participate by an individual who is unable to legally rights and freedoms. The human rights model of dis-
consent that can be revoked or withdrawn at any time ability centers the voices and choices of the person with
(i.e. assent withdrawal or dissent), and assent with- disabilities in all aspects of decision making about their
drawal is the nonagreement to participate by an individ- own life, regardless of diagnostic characteristics, per-
ual who is unable to revoke or withdraw legal consent. ceived competence, or the culture or society they
Assent-based intervention is a phrase used to inhabit (Lawson and Beckett 2021). Respect of assent
describe a way of delivering services that emphasizes and assent withdrawal is paramount to dignity, equality,
and actively seeks to obtain learner assent. In assent- and decision making (Breaux 2020a). The fundamental
based intervention, both assent and assent withdrawal principles of the human rights model are encapsulated
are individually defined for the learner, continuously in the United Nations Convention on the Rights of
evaluated, and responded to during interactions between Persons with Disabilities (CRPD; United Nations
the interventionist (e.g. BCBA, therapist, teacher or par- 2006), which gives clear directives on the rights of per-
ent). As part of the delivery of intervention, the learner sons with disabilities regardless of their age, gender,
is provided with opportunities to provide and withdraw ethnicity, or socioeconomic status. Of relevance are
their assent, and the teaching of related choice-making Articles 7, 8, 14, and 21, which state:
behaviour is prioritized. Data on the provision of assent,
the withdrawal of assent, and the related skills of choice (a) States Parties shall ensure that children with disabil-
making and functional communication are collected, ities have the right to express their views freely on
analyzed, and used as decision-making tools within and all matters affecting them, their views being given
across intervention sessions. due weight in accordance with their age and matur-
ity, on an equal basis with other children, and to be
provided with disability and age-appropriate assist-
The relation between assent and ance to realize that right (Article 7)
human rights (b) States Parties undertake to adopt immediate, effect-
Assent is a human right that is inequitably afforded to ive and appropriate measures: (a) To raise aware-
those deemed ‘competent’ by the culture and society ness throughout society, including at the family
they inhabit. In other words, individuals with intellec- level, regarding persons with disabilities, and to
foster respect for the rights and dignity of persons
tual and developmental disabilities may be assumed to
with disabilities; (b) To combat stereotypes, preju-
be incapable of providing and withdrawing assent. dices and harmful practices relating to persons with
However, the human rights model of disability asserts disabilities, including those based on sex and age,
that individuals with disabilities have the same in all areas of life; and (c) To promote awareness

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Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

of the capabilities and contributions of persons with allows for practitioners to decide when assent and
disabilities (Article 8) assent protocols are utilized. Cultural and societal
(c) States Parties shall ensure that persons with disabil- norms of communication and autonomy have been
ities, on an equal basis with others, enjoy the right
found to influence attitudes toward assent (Onoh et al.
to liberty and security of person (Article 14)
(d) States Parties shall take all appropriate measures to 2014) that may limit the opportunities assent is
ensure that persons with disabilities can exercise recruited. The rights and assent withdrawal behaviours
the right to freedom of expression and opinion, of learners with perceived ability and competence are
including the freedom to seek, receive and impart often more respected by professionals (French et al.
information and ideas on an equal basis with others 2010); but we argue that learner’s rights and respecting
and through all forms of communication of their
the assent of learners can be more broadly applied
choice (Article 21)
within the field of ABA, regardless of the perceived
In addition, the general principles of the CRPD ability of the learner.
(United Nations 2006) include respect for inherent dig-
nity; individual autonomy including the freedom to The relation between assent and ableism
make one’s own choices, and independence of persons; Assent, the free and voluntary agreement to participate,
is not afforded equitably across all ages and perceived
full and effective participation and inclusion in society;
abilities (Dockett et al. 2012). In research, judgment
respect for difference and acceptance of persons with
about the capacity to assent is often related to age or
disabilities as part of human diversity and humanity;
perceived competence to understanding the research
and equality of opportunity. Incorporating strategies for
and potential outcomes (Heath et al. 2007). In ABA-
obtaining assent and responding to assent withdrawal
based practice, where a significant proportion of recipi-
during ABA and PBS-based services is one way to pro-
ents may not be perceived by others as competent to
tect and uphold the dignity, autonomy, and independ-
assent, it is important to reflect on ableism when con-
ence of the learner during intervention. Respecting the
sidering the concepts of assent and assent withdrawal.
assent, or assent withdrawal, of another person is a cru-
Ableism was first used in disability advocacy to
cial part of acceptance of persons with disabilities as
describe discrimination in favor of able-bodied people,
part of human diversity (Breaux 2020a). Teaching an
but in addition is now used to describe discrimination
assent repertoire allows for more choice, voluntary par-
in favor of nondisabled individuals (Kapp et al. 2013).
ticipation and inclusion, and equality of opportunity for
Ableism can affect how a practitioner balances duty of
persons with disabilities (Smith and Breaux 2020). It is
care with dignity of risk (Friedman 2021). In ABA-
the position of these authors that assent and assent pro- interventions, ableism may support a practitioner choos-
cedures allow practitioners of ABA and PBS to apply ing an effective yet aversive intervention, to meet their
these values more broadly and more consistently, thus duty of care or service provision, over an intervention
upholding the rights afforded by the CRPD with a history of learner assent, which affords more
more equitably. dignity of risk. In ABA-intervention, any form of the
learner’s assent withdrawal behaviour should be hon-
The relation between assent and ored, even if that learner would prefer to engage in a
professional ethics behaviour not prioritized by the practitioner instead of
The Behavior Analyst Certification Board (BACB) engaging in the planned activities (Fabrizio 2005,
recently updated The Ethical Compliance Code for Breaux 2020b). Practitioners should use this informa-
Behavior Analysts with The Ethics Code for Behavior tion to modify future activities to support voluntary
Analysts (Behavior Analyst Certification Board 2014, participation, which is discussed later in this paper. For
Behavior Analyst Certification Board 2020). The Ethics example, if the learner leaves the workspace to stack
Code for Behavior Analysts offers more specific prac- rocks instead of completing a puzzle, the practitioner
tice outlines for assent and dignity than The Ethical can honor that assent withdrawal and consider incorpo-
Compliance Code for Behavior Analysts (Behavior rating rocks, stacking, or some combination into a
Analyst Certification Board 2014, 2020). To summarize future activity. The next section gives suggestions and
ethical requirements connected to person-centered val- guidelines for respecting assent withdrawal and incor-
ues, practitioners of ABA are required to: (a) ‘involve porating assent procedures for all learners.
clients and relevant stakeholders throughout the service
relationship’ (p. 11); (b) obtain informed consent, and Practical recommendations for developing and
assent when applicable; and (c) ‘act in the best interest delivering assent-based intervention
of learners, taking appropriate steps to support learners’ It is the position of the authors that for practitioner to
rights, maximize benefits, and do no harm … ’ (p. 13) fully adhere to the BACB’s Ethics Code for Behavior
(Behavior Analyst Certification Board 2020). The lan- Analysts, the United Nations Convention on the Rights
guage of ‘when applicable’ when referencing assent of Persons with Disabilities, and the current (though

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 Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

limited) body of research on assent, practitioners imple- to a strong functional definition, establishing a detailed
menting behaviour analytic interventions, including list of the common topographical forms of assent and
PBS, should implement assent-based intervention as a assent withdrawal for a specific learner ensures the reli-
service delivery model. Assent-based intervention goes able communication of information across the treatment
beyond simply obtaining the learner’s assent and/or team. Establishing these definitions and examples may
honoring their assent withdrawal during an intervention include both direct and indirect methods: interviewing
session. Assent-based intervention is a model of inter- the learner themselves, interviewing stakeholders (e.g.
vention in which a learner’s uncoerced assent to partici- teachers, practitioners, parents), observing the learner in
pation is critical to all treatment-based decisions, their therapeutic context, and/or observing the learner in
whether these decisions occur within a single treatment other contexts (e.g. school, work; Hanley 2012).
session or across multiple treatment sessions. The crit- A learner will likely use a myriad of topographies to
ical features of assent-based intervention include: give or withdraw assent, depending on the environment,
relationship with instructors, the aversiveness of the
(1) learner assent and assent withdrawal behaviours are stimuli, and the exact treatment features from which
informed, individually defined for the learner, con- they withdraw assent. When creating the list of assent
tinually evaluated, and characteristically reinforced and assent withdrawal behaviours specific to the
throughout the session
learner, practitioner should list all possible topogra-
(2) instruction on assent, self-advocacy, and related
repertoires is carefully designed, delivered, phies, even those that are considered ‘socially unaccept-
and evaluated able’. Table 2 includes an example list of topographies
(3) data on assent, the withdrawal of assent, and related of assent and assent withdrawal. These are categorized
skill repertoires are collected, analyzed, and used in into ‘vocal’ and ‘non-vocal’ sub-groups to reiterate that
decision-making within and across interven- learners can demonstrate a variety of different forms of
tion sessions
behaviour to withdraw assent and that a learner’s verbal
skills (or lack thereof) should not determine whether
We suggest that assent-based intervention is not yet
they can assent (Morris et al. 2021).
widely practiced in ABA and PBS. Few peer-reviewed
publications outline the critical features of an assent-
Assent to treatment conditions
based approach to intervention or how to apply this
A learner’s assent extends to all features of treatment.
approach within everyday clinical practice. Assent is
Assenting to treatment does not simply refer to the
rarely evaluated or obtained as part of the research pro-
learner’s agreement to participate in a traditional
cess (Morris et al. 2021), and, historically, behaviour
‘tablework’ task. Instead, assenting to treatment more
analysts have received certification without any globally refers to a learner’s assent to participate with
required training on assent (Behavior Analyst environmental stimuli and contingencies (treatment
Certification Board 2017). Further, behaviour analysts conditions). These stimuli may be in the learner’s cur-
rarely involve the direct recipients of behaviour analytic rent environment or may exist or be perceived in other
interventions in the social validation process (Hanley environments. Contingencies may be stated or implied
2010). A lack of published guidelines on how to incorp- by the practitioner or perceived by the learner.
orate and evaluate assent and assent withdrawal as part Treatment conditions (or, more globally, ‘treatment’)
of ABA- and PBS-based interventions may result in includes every interaction between the learner and their
practitioners adopting and applying assent-based proce- environment during the therapeutic session. The follow-
dures haphazardly (or not at all) as part of the provision ing demonstrate the range of treatment conditions a
of services. learner experiences: a perceived or actual demand (e.g.
social question, request to transition), the presence of
Defining assent for a learner and relationship between environmental stimuli (e.g.
Developing functional and topographical bright light, table positioned to block the learner from
definitions freely leaving the workspace), or the absence of stimuli
It is critical to conceptualize an individual learner’s (e.g. limited preferred activities, minimally delivered
assent and assent withdrawal both in terms of what it reinforcers). Redefining treatment in this way promotes
looks like (topography) and why it is happening (func- the practice of analyzing all factors to which a learner
tionally). Practitioners cannot broadly define assent and assents, which requires practitioners to engage in a
assent withdrawal topographically across all learners— much more refined analysis of the variables that may
each learner presents with their own function (or why) influence learner assent.
and topography (or how). As with other behaviour To ensure the consideration of all treatment condi-
change procedures implemented by practitioners, the tions and their impact on a learner’s assent, it may
first step to reinforcing a learner’s assent withdrawal is benefit treatment teams to categorize assent more spe-
to develop a detailed functional definition. In addition cifically, based on treatment features—(e.g. assent to

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Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

Table 2. Example Topographies of Assent and Withdrawal.

Possible Topographies of Assent

Vocal Non-vocal
Answers ‘yes’ or a functionally equivalent phrase Nods
Signals ‘start’ by touching ‘start’ picture icon
Touches a ‘yes’ icon
Leans in toward practitioner or materials and smiles
Reaches for materials
Takes materials and arranges materials for instruction
Enters the treatment area
Approaches and sits with the practitioner
Possible Topographies of Assent Withdrawal
Vocal Non-vocal
Answers or says ‘no’ Touches ‘stop’ or ‘all done’ icon
Says ‘stop’ or any functionally equivalent phrase, word, or sound Shakes head no
Negative statements about task, practitioner, session Ignores or does not respond to the practitioner (non-response)
Repeated attempts to talk about a different topic Leans away
Turns body away from the practitioner or workspace
Swipes or throws materials
Runs from treatment environment
Looks in opposite direction from work
Refuses to transition (to/from environment, activity, people)
Aggression
Self-injury
Elopement

interaction, assent to skill building instruction, assent to builds the learner’s confidence in choice-making, and
physical prompting, assent to enter a treatment space, increases the individualization of the treatment design
etc). Doing so minimizes the possibility of over- (Morris et al. 2021, Rajaraman et al. 2021, Shogren
assuming assent. For example, a practitioner may et al. 2017).
assume a learner assents to a physical prompting pro- The following proposed framework provides practi-
cedure because the learner approached and sat down tioners with a methodical procedure for responding to a
next to the practitioner at the start of skill instruction, learner’s assent withdrawal. When a learner withdraws
however, the learner did not actually assent to the assent, the practitioner’s first step is to reinforce that
prompting procedure, but instead assented to sitting in withdrawal of assent by terminating the treatment con-
proximity and/or engaging in the skill instruction with ditions to which the learner does not assent. As outlined
the practitioner; the practitioner needs to also obtain in the previous section, treatment conditions refer to
assent to physically prompt the learner. Additionally, stimuli and contingencies experienced by the learner.
continuously updating assent and assent withdrawal top- This may include work/reinforcement conditions, a
ographies and reviewing changes with the treatment social interaction with the practitioner, a transition into
team promotes fidelity in responding to the learner’s a new location, etc. The second step is to decide if the
varied forms of assent withdrawal. practitioner should (a) not re-introduce treatment condi-
tions for the duration of the treatment session, (b) re-
Assent withdrawal: What next? present treatment conditions later during the treatment
Often, practitioners hesitate to offer assent withdrawal session, (c) re-present treatment conditions with fea-
as an option. They say or think, ‘Am I just giving them tures of the conditions modified, added, omitted, or
an option to get out of work?’ The short answer is, yes. with accommodations. Figure 1 illustrates this
Learners must know that they always have the option to choice model.
revoke their assent. Telling the learner that they can
withdraw their assent reinforces that assent to treatment Option 1: Do not re-present the
is the learner’s choice, not an expectation that will be treatment conditions
enforced by any means necessary. Forcing an unwilling If the learner’s assent withdrawal is a function of fea-
learner into a situation through coercion, physical inter- tures of treatment that cannot be adjusted within the
vention, or other strategies degrades trust and can com- session, the practitioner cannot manage the intensity of
plicate the therapeutic relationship. In addition, the use the learner’s assent withdrawal, or the learner makes it
of physical strategies to force participation may lead to clear that they will not engage in these conditions for
further challenging behaviour that poses a safety risk to the remainder of the treatment session, then the practi-
the person or others, which can lead to the use of tioner does not re-present treatment conditions (Figure
restrictive practices, such as restraint and seclusion 1, Option 1). After the practitioner decides to not re-
(Trader et al. 2017). Conversely, offering the choice to present the treatment conditions in the present session,
participate strengthens the therapeutic relationship, they have two options moving forward: (1) re-present

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 Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

Figure 1. Choice Model: Responding to Assent Withdrawal.

during the next treatment session to determine if the would like to change. Table 3 offers treatment features
learner’s assent withdrawal is related to the specific that may impact a learner’s willingness to assent, and
conditions or feature of treatment or if it was evoked by possible solutions.
other unidentified features of the environment, or (2)
analyze the treatment conditions outside of the treat- Building repertoires: Skill building and
ment session to determine which specific features evoke skill refinement
the learner’s assent withdrawal, and then adjust those Assent, self-advocacy, and choice-making are not sim-
features for future implementation. ply things to include or measure as part of an interven-
tion package; instead, these are also important
Option 2: Re-present the treatment outcomes of intervention. Behaviour within these reper-
conditions later toires, including assent to treatment, the withdrawal of
If the function of the learner’s assent withdrawal is assent, choice-making, manding to change work contin-
unknown or is based on other uncontrolled environmen- gencies, tolerating a delay to reinforcement, etc., are
tal stimuli, the practitioner re-presents the treatment operant behaviour (Skinner 1963). As such, these
conditions later in the treatment session (Figure 1, behaviours must be established, shaped, and refined
Option 2). This evaluates whether the learner’s assent through well-designed and sequenced behaviour ana-
withdrawal is related to specific features presented by lytic intervention (Tiemann and Markle 1990).
the practitioner, unrelated environmental stimuli present Treatment goals focused on building skill repertoires
in the treatment setting, or private events experienced should be included in the learner’s behaviour analytic
by the learner (e.g. fatigue, discomfort). treatment plans as active treatment goals, regardless of
the learner’s age or skill level (Behavior Analyst
Option 3: Re-present the treatment conditions Certification Board 2020, Rajaraman et al. 2021).
with modifications When selecting assent withdrawal behaviours and
If the cause of the learner’s assent withdrawal is known repertoires to establish or refine for a learner, practi-
and/or if the learner engages in mild (or precursor) tioners must first identify the learner’s current perform-
assent withdrawal behaviours, the practitioner re- ance, define an acceptable ‘short term’ alternative, and
presents a modified version of the treatment conditions. identify a desired replacement behaviour. An acceptable
Within this option, the practitioner has a hypothesis as short-term alternative behaviour serves the same func-
to the features of instruction that evoked the assent tion as the learner’s initial response (e.g. terminates
withdrawal and how to modify these features to make a aversive or non-preferred stimuli), but requires minimal
more acceptable treatment experience for the learner. effort on the part of the learner and meets the expecta-
This may include presenting the adjusted task to the tions/rules that exist in the learner’s context. Table 4
learner and evaluating their assent to participate or illustrates examples of this analysis.
engaging in this problem-solving practice with the In addition to refining the learner’s form of assent
learner to determine which features of the task they withdrawal, it is essential to focus on building

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Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

Table 3. Treatment Feature Evoking Assent Withdrawal and Possible Variations and Accommodations.

Treatment Conditions Accommodations and Variations

If the learner does not assent to entering or remaining in the Increase reinforcing features of the clinical environment
treatment environment Identify and remove aversive features/stimuli within the treatment
environment
Provide ample opportunities for non-contingent access to highly
preferred items or activities
Establish a positive therapeutic rapport between the practitioner
and learner
Significantly decrease task demands
Select instructional arrangements that prove most beneficial for
the learner based on their presenting skills and their
engagement with the treatment environment (e.g. naturalistic
learner-led instruction vs. discrete trial instruction)
If task demands are too difficult Offer help
Offer break
Deliver error correction procedures
Utilize different teaching arrangement
Reduce performance criteria
Reduce number of teaching trials
Increase reinforcement for task completion
If the learner does not understand a task Utilize teaching procedures to ensure understanding of the task
(e.g. model, lead, test)
Offer break(s)
Show the learner the task using audio-visual supports (e.g. video
on YouTubeTM)
Give the learner an opportunity to ‘be the teacher’ and present
the stimuli to the practitioner, then the practitioner
demonstrates the expected response
Increase reinforcement for persistence in engaging with the task
If the learner does not assent to some features of a Do not physically touch the learner
teaching procedure Provide opportunities for the learner to receive teaching,
prompting, and error correction procedures in a less intrusive
way (e.g. offer to guide the learner rather than physically
prompt the learner)
Modify the environment so the learner has a comfortable amount
of personal space
Speed up or slow down instruction to meet the learner’s
preferred instructional pace
Increase opportunities for choice in instruction (e.g. where
instruction occurs, at what pace, the number of teaching
opportunities, etc.)
If the learner does not assent to an interaction with the Significantly reduce practitioner demands
practitioner Increase non-contingent access to reinforcing items in the
environment
Parallel play with the learner
Focus primarily on improving therapeutic rapport between the
learner and practitioner
Increase opportunities for learner choice in interactions between
the practitioner and learner (e.g. allow the learner to control
interactions)
Solicit and implement feedback from the learner on ways to
improve the therapeutic relationship

Table 4. Examples of Refining Assent Topography.

Current Performance Acceptable (Short-Term) Alternative Desired Replacement Behaviour

Learner throws materials off table Learner looks at or touches ‘stop’ symbol Learner uses AAC device or sign to
affixed to worktable say ‘stop’
Learner runs from treatment room Learner says ‘no’ Learner mands for alternative (e.g.
more time)

behavioural repertoires related to functional communi- complete difficult tasks, tolerate longer delays to
cation, making choice, and participation in treatment reinforcement, and advocate for conditions that allow
(Hanley et al. 2014, Rajaraman et al. 2021). These them to continue working comfortably (Smith and
include, but are not limited to, functional communica- Breaux 2020).
tion training, resilience/tolerance, self-advocacy, self-
management, and problem-solving. Building these
replacement repertoires gives the learner skills neces- Measurement and analysis
sary not only to manage their own experience and advo- This model provides a basic framework through which
cate for accommodations, but also to use strategies to practitioners promote and respond to assent and assent

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 Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

Table 5. Measurement for Assent and Assent Withdrawal.

Assent Measures Assent Withdrawal Measures

Frequency of the learner approaching and engaging with the Frequency of assent withdrawal per session
practitioner outside of a perceived ‘work’ task Frequency of acceptable alternative (topographical) assent
Frequency of happiness indicators (individually defined for the withdrawal per session
learner—for example, smiling, laughing) Frequency of desired (topographical) assent withdrawal per
Frequency of learner initiating engagement in treatment activities session
or with treatment materials Notation on each skill/program when a learner withdraws assent
Frequency of staff offering opportunities for the learner to initiate Frequency of assent withdrawal per staff member
assent Frequency of staff offering opportunities for assent withdrawal
Latency to initiate a practitioner-directed task (i.e. work task) Intensity rating of assent withdrawal behaviours
Latency to follow instruction from a practitioner
Latency to withdrawal assent from treatment features that
previously evoked assent withdrawal

withdrawal during treatment sessions. A critical aspect universally define an individual’s capability to make
of this model is continual evaluation and procedure decisions and choices about their life, including their
change, as needed. Through data collection and ana- participation in treatment. As previously suggested in
lysis, practitioners should adapt this model and indi- this paper, often capability is assigned based on per-
vidualize it for each learner, just as they do with ceived competence. We argue that capacity to make
behaviour support plans and skill-building one’s own decisions, including assenting to all or some
aspects of ABA- and PBS-based interventions should
interventions.
be based on a human rights model and not be based on
As a part of treatment evaluation, practitioners
should collect and analyze data for both practitioner traditional legal and medical models, whereby an indi-
and learners, specific the instruction, opportunity, and vidual is capable to make decisions for themselves if,
demonstration of assent, choice, and related repertoires. and only if, they can do so ‘competently’ without
Measuring practitioner behaviour related to on-going assistance from others. Limiting decision-making cap-
assent practices not only ensures the inclusion of these acity based on this definition furthers the narrative that
elements in therapeutic sessions, but it also allows persons with disabilities are incapable to make deci-
supervisors to identify trends in the learner’s data that sions and not full members of society simply because
occur because of practitioner performance. For of their disability and unique skill profile (Arstein-
example, if practitioners do not offer the opportunity to Kerslake et al. 2017). Instead, if we look to the current
withdraw assent, learners may engage in higher inten- research on supported decision making, we can redefine
sities of assent withdrawal behaviour. To build skills capacity as the ability to make decisions for oneself
and repertoires related to assent, as well as to refine with the appropriate supports in place (Arstein-Kerslake
existing topographies of behaviour, practitioners need et al. 2017). With this refined definition of decision
to diligently implement assent-based procedures, capability, all humans, with the correct supports, can
including incorporating opportunities to initiate assent, choose whether to assent to treatment and/or treat-
withdraw assent, and demonstrate acceptable alternative ment conditions.
or desired topographies of assent withdrawal. Universally accepting that participation in treatment
Practitioners also must respond to data collected (assent) is an informed choice that can and must be
both within and across intervention sessions, simply made by anyone participating in ABA- and PBS-based
collecting the data is insufficient. For example, a learn- intervention and can be withdrawn at any time (assent
er’s assent withdrawal may occur during instruction on withdrawal) is the first step in moving service delivery
one specific skill or skill type, with one practitioner, at to an assent-based model. Further publication on how
certain times during the session, or may indicate a to obtain informed assent, operationally define assent
physiological need not being addressed. Conversely, a withdrawal, and identify and teach assent and choice-
learner’s assent or self-advocacy guides practitioners in making repertoires is necessary to support the expan-
selecting future skills and repertoires to address as part sion of assent-based intervention across all ABA- and
of intervention. Table 5 offers possible options for PBS-based interventions.
data collection. Though the literature on supported decision making
is a growing rapidly, further research is also necessary
Conclusion and future directions to determine what constitutes ‘informed assent’.
Practitioners of ABA- and PBS-based interventions Specifically focusing on the types of accommodations
must continue to evolve their practices to incorporate that are effective within supported decision making,
assent and prioritize learner dignity and choice (Breaux how to evaluate the effectiveness of these accommoda-
2020a, Rajaraman et al. 2021). As part of this evolu- tions, and how ensure they are free of influence and/or
tion, ABA- and PBS-based interventions need to coercion (Bigby et al. 2015). Studies in this area may

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Cassi A. Breaux and Kristin Smith Assent in applied behaviour analysis and positive behaviour support

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