BHCOE recently hosted a webinar on Integrating Assent-Based Thinking in Policies, Practices, and Goals.
An Assent-Based Treatment model aims to end instruction through coercion. Instead, the focus is on building repertoires necessary to produce autonomous individuals who have agency in their lives as adults. This presentation provides a concept analysis of assent and assent withdrawal, the values from which an assent-based program thrives, and suggest practices and measurement pinpoints to enhance your current clinical practices.
Below are some of the top takeaways from the webinar.
The difference between consent and assent
Informed Consent:
There are several key components of informed consent and reasons why it is important. Informed consent is a legal requirement and minimizes risk of patient exploitation and confusion. Including and informing the patients about all aspects of the therapeutic process also builds a patient-clinician relationship founded on mutual respect and reciprocity.
Assent:
Assent is related to consent, but expands even more into client agency, autonomy, and agreement to participate.
Mari Cerda noted that as a clinician working with a patient, we inherently can shift the balance of the power structure in the therapeutic relationship. It is important to self-reflect in situations where we feel that the power dynamics have shifted too heavily in our favor of the clinician and when we may not be engaging in a balanced, reciprocal therapeutic relationship.
Assent can be defined as the expression of approval or agreement (without coercion) and Liz Lefebre pointed to out several requirements for assent giving behavior.
- It must be overt
- There has to be a motivating operation
- The behavior must occur within a contingency arranged by someone other than the patient
- The behavior must be emitted by the patient
- The behavior must be reinforced by another person
Assent Withdrawal can be defined as the expression or demonstration of disapproval or unwillingness to participate.
Liz Lefebre stated that assent withdrawal behaviors must:
- Be an overt and observable change in behavior
- Be emitted by the patient
- Occur within a social context and under contingencies arranged by someone other than the patient
- Be maintained by aversive control
How to know when someone withdrawing assent?
There are many ways that someone may communicate they are withdrawing assent for participation in an activity. Some ways of withdrawing assent may be clear such as a vocal request for cessation of an activity, but some may be more subtle. For example, needing to consistently redirect a patient during an activity. Therefore, it is important for clinicians to learn to recognize signs for each patient and honor when patients withdraw assent.
Assent Based Learning Models
Incorporating assent-based learning models into your organization starts from the beginning. This involves actively looking at your organizations policies and practices to ensure that assent is being considered from assessment through treatment planning and analysis of intervention effects.
Creating appetitive contingencies for learning
Clinicians should begin thinking about building assent-based programs from their first interactions with a patient. Liz Lefebre suggests asking oneself if the assessments being used assess repertoires that will teach patients how to advocate for themselves and withdraw assent? From there, it is important to build interventions based around what motivates the child, versus designing programs based on a template.
Skill building
Decision making skills and self-advocacy are important aspects in any repertoire but are especially salient for assent-based learning. One goal of assent-based skill building is that the patient will learn how to make decisions for themselves about their willingness to participate and then communicate that decision effectively. Liz Lefebre points out that since, as mentioned above, there are many ways one may try to communicate assent withdrawal, functional communication training should include different ways to say no and withdrawal and should incorporate new advocacy statements based on the variables present.
It is possible that a patient may continually withdraw assent as soon as a certain task is presented. In these situations, the clinician should seek to determine why it is aversive and if there is anything that could be incorporated or changed to make the patient more likely to assent versus following a strictly compliance-based model.
Reinforcement of assent and assent withdrawal
The idea of reinforcing assent and cooperative participation in activities is well rooted. However, a cornerstone of effective assent-based programing is also honoring requests for cessation. Clinicians should consider any precursor behaviors and decide with the team what should signal immediate reinforcement in the form of activity termination.
Analysis and environmental contingency manipulation
One commonly asked question is if assent-based methods impair or slow down learning. The research presented shows that continual analysis of data and changes based on patients’ motivations support effective and efficient skill acquisition and all while the patient is happy.
Training the team
Clinicians should make sure that staff and other relevant stakeholders (e.g., parents/guardians, teachers) are well trained in how to recognize assent withdrawal. Emphasis on assent in policy will support these efforts. According to Kelly Ferris this involves emphasizing the importance of assent in sessions versus a heavy focus on measures such as number of trials or programs implemented. The importance of assent strategies should also be reflected in session documentation.
Measurement
Kelly Ferris has several suggestions for how clinicians can effectively measure assent practices. She first suggests that one should measure a wide array of things to see what ideas work best and increase joy and participation with new patients. Post this initial measurement phase, it is important to evaluate and reflect on the data collected to see which measures may be valuable to future programming. As Kelly Ferris said, it is important to measure for inductive discovery, not just confirmation.
For more information on measurement techniques and what to measure, please listen to the full webinar.
Importance of the Investment in ‘No’
Many of our patients’ neurotypical peers are taught about consent and are encouraged to withdraw consent and say no when they are in a situation that makes them feel uncomfortable. We should be teaching and encouraging these same skills in our patients. Leaning too heavily on a compliance driven model can cause patients to learn that someone else always knows better and will make decisions for them. This is problematic because they are denied learning of decision-making skills and because blindly following the requests of other individuals poses serious safety concerns.
Clinicians in the field of applied behavior analysis work with patients across developmental levels and ages, and all patients should have access to care that is assent based.
Kelly Ferris posited a visual scenario explaining why these types of assent programs are essential, regardless of the patient’s age.
Many clients receiving applied behavior analysis services are young children, and clinicians and other stakeholders may find it hard to understand why centering programs around assent is so crucial at this stage of development. It can be challenging to develop programing around assent when children are young as, in most communities, people do not allow leeway for young children to make their own decisions. However, Kelly Ferris asserts that the ability to clearly and forcefully withdrawal assent, and the expectation that assent withdrawal will be respected is crucial to teach so that patients may appropriately understand and expand upon this concept as they grow older. During one’s adolescent years, clinicians and parents/guardians may not have complete control over who patients interact with. For some patients, being explicitly taught that it is not only acceptable, but expected that they withdraw their assent from activities that may be uncomfortable is important especially for safety reasons. Furthermore, in late adolescent and adult years it becomes equally important to recognize, interpret, and respect someone else’s consent and assent withdrawal, which requires previous understanding of what it means to procure and honor consent and assent.
Watch the entire webinar to understand the concept analysis of assent and assent withdrawal in ABA.
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