As Ethics Code abiding behavior analysts, we promise to first do no harm, to obtain informed consent prior to intervening, and to only target socially significant goals. As board certified and licensed professionals in this field, we share this common objective of improving the quality of lives of our clients and their families, but are we actually following our code of ethics by solely obtaining informed consent from the client’s legal parent or guardian?
When is there consent?
Consent occurs when an individual, typically a parent or guardian, legally permits another individual’s participation. Consent is typically obtained through spoken and written authorization. Assent, on the other hand, is a non-legally binding agreement to participate in an intervention, provided by the client themself. Assent is obtained usually by a child or a dependent adult who cannot make legal decisions for themselves. Acquiring assent from a client may occur in spoken or written communication, but can also differ based on the language and cognitive abilities of that individual.
Why is assent important, if we already are obtaining legal authorization, or consent, from a legal guardian? Behavior Analysts have an ethical duty to acknowledge “…personal choice in service delivery…by providing clients and stakeholders with needed information to make informed choices about services” (BACB, 2020, p.4). Making an effort to obtain assent is how we keep client dignity and provide trauma-assumed care. According to the Federal Policy for the Protection of Human Subjects (FPPHS), it is not legally required to obtain assent from children prior to proceeding with interventions (2008). However, according to the Behavior Analyst Certification Board Code of Ethics (BACB), it is our responsibility to treat all individuals equally regardless of disability and age and to “acknowledge that personal choice in service delivery is important” (2020, p. 4). There are a lot of choices that professionals make when designing a behavioral plan. Prioritizing social validity in our practice includes seeking assent when choosing goals, procedures, and the results of the intervention (Wolf, 1978). There are many evidence based approaches for obtaining assent with young children and those with developmental disabilities.
What does assent look like?
Acquiring assent can look differently, depending on the individual one works with. With older children or children with advanced language abilities, one might simply ask the child if they would like to participate. One might also put an agreement in writing for the child, however there are several strategies that can be used with young children or language impaired individuals to acquire assent (Morris, Detrick & Peterson, 2021). Rapport building and instructional fading is one evidence based approach to increase a client’s voluntary participation (Shillingsburg, Hansen, & Wright, 2019). The implementer systematically fades from child-led play to an intensive teaching model across various phases. Instructional fading has shown to decrease problem avoidance maintained behavior, and increase longer durations of time of the child in close proximity to the therapist and in one’s seat without needing many additional resources (2019). In addition, BCBAs may find it simpler to train novice therapists and parents to utilize an instructional fading approach.
Morris et al. (2021) suggests the presentation of choices as another strategy to increase client voluntary participation and thereby accounting for assent. We should “respect and actively promote our client’s self-determination” and acknowledge the importance of our client’s choice during service delivery (BACB, 2020, p. 4). Instead of incorporating aversive interventions such as punishment and extinction to decrease problem behavior, try accounting for the child’s preference by offering choices. McComas (1996) allowed children to choose between emitting a maladaptive response versus utilizing functional communication in order to get access to a reinforcer, such as attention from an adult. By manipulating the duration of time allowed with the reinforcer and the quality of the reinforcer, one can teach children to prefer to use a more adaptive form of communication and to choose against emitting the maladaptive behavioral response. The children were provided access to a preferred stimulus for longer durations when emitting a functional communication response, and less time when emitting maladaptive behavior.
Utilizing concurrent chain procedures is one more way to account for the child’s preference of intervention procedures. By allowing the child to choose the treatment procedures, we are likely to see positive results, lower rates of problem behavior, and our practice remains socially valid. Torellii et al. (2016) conducted preference assessments to assess which topography children preferred when manding. Based on the child’s increased mand responses with the iPad®, it was decided that the child would utilize the iPad® for communication instead of the GoTalk® device. Other studies present how to utilize a concurrent chain procedure to examine client preference to using a microswitch, PECs, sign language, vocal speech and assistive technology device for manding (Winborn, Wacker, Richman, Asmus, & Geier, 2002; Winborn-Kemmerer, Ringdahl, Wacker, & Kitsukawa, 2009). For example, the instructor teaches the child two different mand topographies and then provides simultaneous access to both types of responses. The choice that the child makes when both options are available teaches the instructor which response type is preferred, thereby accounting for assent in procedures and results of the intervention.
How to approach assent and assent withdrawal
How often should we give choices to our clients and how can we account for assent withdrawal? There isn’t a one size fits all response, but it’s better to follow the rule of “the learner is always right” (Keller, 1968). Hanley (2021) encourages choice making and encourages professionals to listen to the child and attend to behaviors, even when we feel like it would be best to ignore those attention seeking behaviors. He also encourages all professionals to keep an open door because “leaving means something is missing or something aversive is present” (2021). By reducing physical behavioral management, and allowing freedom to move and choose where one prefers to be, we are allowing children to consent to the intervention. Rajamaran et al. (2020) gave the ongoing choice for children to either go to the instructional room, a “hangout room” with free access to preferred items and adult attention, or to go home. These children were selected because they exhibited dangerous problem behavior in order to escape or avoid demands and to get access to what they wanted. The results from this study showed that all three children chose to stay and learn important life skills such as functional communication, toleration responses, and contextually appropriate behavior (CAB) (2020) over 90% of the time and did not choose to go home (Rajamaran et al., 2021).
When given a choice between taking a break, or completing work, research has shown that children will choose to work in order to receive a longer or better break than receiving shorter breaks for “free” (Peterson et al., 2005). Children are more likely to stay engaged with a work task without problem behavior when the choice to not work is just as accessible. According to the matching law, individuals will choose to engage in more than one response type, based on the proportion of the reinforcement delivered for each response. Replacing problem behavior that includes partial extinction procedures encourages adaptive behavior through the delivery of higher levels of reinforcement for such positive behavior and lower levels of reinforcement for negative behavior. Many researchers such as Peterson et al. (2005) and Rajamaran et al. (2021) have shown how considering the child’s preference in participation has resulted in a decrease in problem behavior and an increase in children choosing to engage in learning tasks.
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Written by Kristin Fayad, MA, MEd, BCBA, LBA