Pushing past distractions to move toward assent-based practice and science: a response to Newcomb and Wine

We thank Newcomb and Wine for their thorough and thoughtful response to our recent publication, Assent in applied behaviour analysis and positive behaviour support: Ethical considerations and practical recommendations (Breaux and Smith 2023). The concept of assent-based intervention is relatively new within applied behaviour analysis (ABA) based interventions, including Positive Behavior Support (PBS). As the field moves in the direction of more wholistically incorporating learner choice and assent, nuanced discussions of practical implementation are both critical and necessary. Newcomb and Wine highlight many considerations for implementing assent-based ABA interventions with learners. Their examination of this topic further exemplifies the need for additional publication and practice guidelines.

We agree with Newcomb and Wine on the necessity of well-defined standards and further research, publication, and continuing education on assent-based intervention. To date, there are few publications on the concept of assent. Few, if any, peer-reviewed publications discuss the theoretical necessity of assent in clinical practice or the practical implementation of assent-based intervention across various contexts (e.g. school, community-based interventions), within family systems, or within cultures that are not aligned with and/or do not allow for an assent-based approach.

The need for assent in practice and true choice-making in ABA-based interventions

Newcomb and Wine bring up prudent future directions for research incorporating choice-making and its impact on self-determination. While we agree that ‘client choice, preferences, and a revision of approaches when outcomes are unrealized’ (Newcomb and Wine 2023, p. 3) should be incorporated in all ABA-based interventions, we strongly disagree with the delineation of learner assent only in research. We also disagree that self-determination and choice should be offered ‘commensurate to one’s age, and independence’ (Newcomb and Wine 2023, p. 5), because neurotypical ‘independence’ indicators should not gatekeep all learners from self-determination. Further, incorporating client choice alone does not ensure a fully realized human rights approach to disability services. Rajaraman et al. (2023) discuss the restrictiveness of choices often offered in clinical settings, stating that ‘Contemporary approaches to promoting choice must reckon with the notion that many evidence-based approaches to teaching choice-making involve ‘forced exposure’ to unknown stimuli or situations’ (p. 106) and that these approaches to choice-making teach the learner discriminations among making choices (i.e. if I select this, I get this), rather than addressing the ‘underlying spirit of promoting choice from a TIC [trauma-informed care] perspective’ (p. 106). We agree with this sentiment, and believe it also applies to assent-based intervention.

Medical necessity: suggestions for treatment comparisons

As clinicians continue to apply, research, and publish on assent and, more specifically, human rights in behavioral services, we encourage them to draw comparisons from fields and practices that share similar attributes to ABA-based interventions (e.g. psychological services). Although the quantitative nature of behavioral services may align with medical treatments, the longevity of services and the importance of relationships and trust more align behavioral services with psychological services. As Newcomb and Wine bring up, ABA-based interventions are often referred to as medically necessary. Treatments that are deemed medically necessary, as defined by the American Medical Association, differ in urgency from treatments that are lifesaving or life-sustaining, the primary goal of the latter is to prevent imminent death (AMA Council on Ethical and Judicial Affairs 2013, American Medical Association 2016).

Comparisons between medically necessary behavioral treatment (i.e. ABA) and emergency lifesaving treatment (e.g. emergency appendectomy) do not position our field to move forward in a productive discussion of learner assent. These are two very different types of intervention. Along the same vein, it is worth noting that the integration of patient assent in pediatric clinical practice is a growing body of literature, both in preventative/routine care (e.g. medically necessary) as well as lifesaving and life-sustaining treatment (De Lourdes Levy et al. 2003, Giesbertz et al. 2014, Self et al. 2017, Sen et al. 2021, Vaknin and Zisk‐Rony 2011). Certainly, obtaining patient/learner assent to medically necessary treatment leads to better outcomes and reduces the risk to patients/learners in both medical and ABA-based interventions (though this may require a topographical adjustment of procedures used to attain desired outcomes).

Acceptance of assent withdrawal from neurodivergent and neurotypical students in school settings

Newcomb and Wine make an important contribution, identifying that the incorporation of assent in clinical practice requires well-defined practice standards, evaluation of quality, and parameters to prevent harm. Additional research is needed in ABA-based interventions in various contexts (e.g. school and community-based interventions). However, we disagree with Newcomb and Wine’s suggestion that students with disabilities should not be afforded assent-based practices in school. In school settings, the restrictiveness of interventions used with neurodivergent learners are often significantly greater than that of their neurotypical peers. We rarely see a classroom of neurotypical children with desks positioned so they cannot easily get up and move around, teachers implementing escape extinction procedures that require physically holding students throughout the day, or classrooms in which teacher commonly use highly intrusive physical prompting even when students say ‘no’ to physical contact. When a neurotypical student in a general education classroom does withdraw assent, the classroom teacher responds by adjusting or restating contingencies. If that consistently does not work additional resources are provided in the form of counseling, IEP and 504 services, parent/teacher collaboration meetings, etc.

Future directions

We look forward to continued publication surrounding the reduction of restrictive procedures as assent-based practices become more fully realized in clinical practice. The clinical landscape is already shifting, with recently published literature on the implementation of assent-based practices in place of historically used restrictive procedures (e.g. escape extinction) in feeding (Gover et al. 2023), and the use of Universal Protocols and an enhanced-choice model to increase learner participation in therapeutic sessions and reduce extreme challenging behavior (Hanley et al. 2014, Rajaraman et al. 2022).

As the field continues to apply assent-based practices across various forms of interventions, we are optimistic that the quality indicators of ABA-based intervention put forth by Newcomb and Wine will be fully and systemically realized in clinical practice. We thank Newcomb and Wine for their acknowledgement of our publication and look forward to future publication in these areas.

Biographies

Cassi (Cas) Breaux, M.A., M.S., BCBA, LBA (pronouns they/them) is a content creator and the manager of educational content development for CRInstitute at CentralReach. They have been in the field of behaviour for more than 15 years, most notably as a special education teacher and behaviour specialist for NYC public schools, a tech and BCBA in private clinics, and a private practice owner. They have been adjunct faculty for Association for Behavior Analysis International approved Verified Course Sequence courses for more than 9 years. They have created more than six hours of assent and dignity continuing education courses for CRInstitute, as well as over 100 hours of content on the BCBA Task List (5th ed.). Their goal is to help the field of applied behaviour analysis become assent-based and person-centered, through a lens of anti-ableism.

Kristin Smith, M.Ed., BCBA, LBA is a behaviour analyst who specializes in instructional design and measurement. She began her career in the field of behaviour analysis in 2002. She has experience implementing and designing intervention programs across a variety of contexts, with learners ranging in age from 18 months to 40 years. She’s provided behaviour analytic services to learners including, but not limited to those with autism, chromosomal deletions, cognitive impairments, learning disabilities, social-emotional and/or behavioural problems, significant challenging behaviour, blindness, and children with multiple disabilities. Kristin is passionate about disseminating the practice of behaviour analysis that is rooted in learner autonomy and dignity, maximizes efficiency, and incorporates a constructional approach to intervention. Kristin brings her areas of expertise including measurement, instructional design, assessment, and data analysis to her role as a Sr. Instructional Designer at CentralReach.

Disclosure statement

No potential conflict of interest was reported by the authors.