Dignity and Respect: Why Therapeutic Assent Matters

Abstract

During therapeutic treatment and research in psychology and related fields, informed consent by the client or participant is required when they are over the age of 18; assent is required when a client or participant is under the age of 18 or a conserved adult. During both research and treatment, behavior analysts often work with neurodiverse individuals who have language deficits, and these clients may require unique assent procedures. This article will outline reasons behavior-analytic research and therapy require field-specific assent procedures. Furthermore, the goals of research and therapy are different and therefore assent may need to differ as well. This article will also argue that therapeutic assent during behavior-analytic treatment requires a unique set of guidelines and procedures that may differ from the behavior-analytic research.

Introduction

During therapeutic treatment in psychology and related fields (e.g., behavior analysis), informed consent is required from the client or participant, or their proxy, before beginning and at all subsequent steps of change in service provision (American Psychological Association [APA], 2016; Behavior Analyst Certification Board [BACB], 2021; National Association of School Psychologists [NASP], 2021). Consent is also necessary for research purposes, both for obtaining permission to implement procedures and to use a person’s information. Along with the requirements of the researcher’s research review board (BACB, 2021; National Commission for the Protection of Human Subjects of Biomedical & Behavioral Research [NCPHS], 1979), researchers should also provide information about the benefits, risks, and rights of the research participant. In the United States, participants, or clients over the age of 17 can give informed consent, whereas internationally the age of consent varies (Rivera et al., 2007). It is important to note that for those under the age of 17 and for adults under a conservatorship, assent should still be obtained even if formal consent was obtained via a parent or guardian.

Assent is an agreement to participate in service provision or research by a person who is not legally able to provide informed consent. Obtaining assent is an ethical duty of behavior analysts and is encouraged, “when applicable” (for service provision; Standard 2.11) and “when relevant” (for research; Standard 6.04) under the 20 Ethics Code for Behavior Analysts (ECBA; BACB, 2021). Like informed consent, assent requires participants/clients to be provided information about their participation (Lindeke et al., 2000).

Gaining informed consent during applied behavior analysis (ABA) research and service activities has long been an ethical mandate. This ensures behavior analysts provide services with dignity and respect to clients and participants while protecting their rights. However, assent requirements and guidelines are less clear. This article reviews the benefits of consent and assent, compares the ethical guidelines for gaining assent from three different, but related, fields; highlights the importance of assent during behavioral-analytic research and therapy; and, finally, discusses the need for separate field-specific assent protocols for both behavior-analytic research and therapy.

Informed Consent and Assent

Informed consent in research settings has multiple components and each needs to be articulated to the client: the treatment being proposed (including examples of activities), the risks and benefits of the treatment, the expected outcomes of the treatment, any alternative treatments, the limits of confidentiality, and a reminder that the treatment is voluntary and can be discontinued at any time without penalty (NCPHS, 1979). A child cannot give consent; this requires the child’s legal guardian. Though assent does not have the legal weight that consent does, most ethical guidelines recommend seeking assent (APA, 2016; BACB, 2021; NASP, 2021; NCPHS, 1979).

Informed consent during therapy is similar to informed consent during research (Poke, 1991). However, informed consent during therapy should include a stronger focus on the voluntary nature of the relationship, ensuring that the client fully understands what they are agreeing to, and assessing the competence of the client to consent to treatment (Poke, 1991). These items are possibly more important during the assent process because children and those under conservatorship may have limited language capacity and additional risk factors for exploitation.

Benefits of Informed Consent and Assent

Snyder and Barnett (2006) listed the potential benefits of gaining informed consent. Informed consent gives the client control over the therapeutic process and promotes independence. This often proves to be a rapport and trust building exercise for the therapist and client (Snyder & Barnett, 2006). Therapists reduce the risk of exploitation of clients and promote ethical treatment, thus ensuring therapists respect the client’s dignity and autonomy (Beahrs & Gutheil, 2001). It is recommended to obtain consent at the onset of the therapeutic relationship (Pomerantz, 2005). Pomerantz also suggested, due to the nature of some therapeutic relationships, both the therapist and the clients are served by continually checking and refining therapeutic goals, treatment modalities and activities.

Another consideration is the client's ability to comprehend the information involved in informed consent. This can be difficult when there is a language barrier or when the client has developmental delays but even adults without these barriers often have difficulty understanding if highly technical or advanced language and terminology are used in the consent information. One way to evaluate client comprehension is to use a checklist, where after each component of informed consent the therapist checks for understanding and offers space for the client to ask questions.

The primary purpose of informed consent is to protect the client’s rights by promoting client choice, client autonomy, and client dignity (Hall et al., 2012). When informed consent is gathered from those who are not the service recipient, informed consent may no longer serve that purpose, because the recipient may not be asked to provide input or agreement for the services their proxy has agreed to. Although ideally the custodian would keep the choice, autonomy, and dignity of the service recipient in mind, their perspectives may not represent that of the service recipient. In these cases, therapists are encouraged to gain assent from the service recipient. To gain assent, the therapist can provide an explanation of the services, the risks and benefits, and the rights of the person providing assent. This will provide similar therapeutic and ethical benefits, and meaningful client autonomy, choice, and dignity. Although the process of gaining assent looks similar to the informed consent process, finding researched guidelines here is difficult (Lambert & Glacken, 2011). Although the ECBA (BACB, 2021) explains that in research the researcher’s institutional review board (IRB) will generally provide guidelines for assent, therapeutic service providers are left without guidance. Even in the medical field and the human subjects research field, where assent is more commonly researched, it is difficult to find a common assent protocol. It is obviously difficult to create guidelines suitable for children of various ages and language comprehension levels (Lambert & Glacken, 2011). This is even more of an issue in behavior-analytic research and therapy because behavior analysts often research and service neurodiverse populations. Despite these difficulties, there are numerous benefits to inviting clients to assent.

Ethical Guidelines for Assent

Although guidelines for obtaining informed consent are similar across behavioral and psychological therapeutic services and research, guidelines for obtaining assent differ (APA, 2016; BACB, 2021; NASP, 2021). Behavior analysts sometimes have dual certifications and will often overlap in service provision with other professionals (Volkers, 2020; Yu, 2022). The following sections discuss the ethical guidelines and best practices for obtaining assent for behavior analysts, school psychologists, general psychology professionals, medical treatment providers, and research practices. Table 1 provides a comparison of assent guidelines in behavior analysis, school psychology, and general psychology.

Table 1.

Comparison of assent guidelines across ethics codes from the BACB, APA, and NASP

Assent Guidelines	BACB	APA	NASP
Considers assent independent from consent guidelines			X
Recommends vocal or nonvocal indication of agreement	X
Refers to other entities (i.e., IRB) for requirements	X
Requires practitioners to provide explanation of services		X	X
Requires practitioners to consider best interests of client		X	X
Requires practitioners to consider legal requirements			X
Requires practitioners to honor assent withdrawal when it is offered			X
Requires practitioners to avoid overwhelming client with options when choices are offered			X
Indicates client should participate in selecting and planning services			X
Requires assent for information disclosure			X
Requires documentation of assent		X
Requires practitioners to seek assent	X*	X	X*

“X” indicates this guideline/recommendation is present in the associated organization’s ethics code

BACB Behavior Analysts Certification Board, APA Association of Psychologist, NASP National Association of School Psychologist (NASP); * = “when applicable” or “when relevant” for BACB and “as much as feasible” for NASP

Assent in Applied Behavior Analysis

The BACB utilized the term “client” to include the individual receiving services, that individual’s parents/guardians, and/or other relevant stakeholders in the 2014 Professional and Ethical Compliance Code for Behavior Analysts (BACB, 2014). However, within that Code, all individuals involved in the behavior-analytic process should be informed of all aspects of services to be provided. Written consent to participate in that process needs to include information about the assessment process, any potentially effective services, the selection process of services being offered, and finally the environmental requirements for the services.

The ECBA (BACB, 2021) differentiates between clients (those receiving services) and stakeholders (those not receiving direct services but involved in the therapeutic process). In addition, the ECBA further emphasizes promoting choice, autonomy, and dignity for service recipients. The ECBA indicates behavior analysts should obtain assent from clients “when applicable” (BACB, 2021, Standard 2.11). Similar guidance is repeated in other relevant standards, including those that detail ethical responsibilities of behavior analysts when conducting research (Standard 6.04). However, there is no elaboration on when assent may be applicable or relevant, leaving behavior analysts to interpret these criteria individually.

Assent in School Psychology

The NASP Principles for Professional Ethics (NASP, 2021) outlines the roles of clients and stakeholders, including specific terminology for those who are minors. There are also definitions of both informed consent and assent. NASP’s ethics code outlines that school psychologists should attempt to gain assent from students/clients, but that assent is not necessary for services that are legally required or are deemed to be beneficial to the student by consenting guardians and stakeholders. Regardless of assent follow-through, school psychologists are obligated to inform students/clients of services to be provided. In addition, if a choice of treatment options or activities is offered, school psychologists are ethically required to make sure students/clients are well-informed and do not place undue pressure on the students/clients. Further, this ethics code suggests school psychologists obtain assent from students/clients prior to disclosing information to parents/guardians. In the end, school psychologists are ethically obligated to include students/clients in the recommendations and plans for student assistance “to the maximum extent appropriate” (NASP, 2021, Standard II.3.14).

Assent in Clinical and Counseling Psychology

The APA Ethical Principles of Psychologists and Code of Conduct (APA, 2016) also includes guidance for obtaining assent. When informed consent is not obtained from the person receiving services (e.g., when it is obtained from a stakeholder or guardian), psychologists are required to provide information to the service recipient, seek that person’s assent, and consider the person’s preference in service delivery as well as document the assent process. Given the breadth of service providers who fall under this ethics code (e.g., all psychologists and not just those who work with minors), there is limited additional guidance for assent. However, in general, the APA ethics code errs on the side of providing adequate information to clients and service recipients and to consider their best interests in all aspects of service delivery (see Principle E and Standard 9.03; APA, 2016).

Assent in Human Subjects Research

Although each of the codes discussed above have guidelines around informed consent and/or assent when conducting research, each research study is required to go through a process of approval to ensure the ethical conduct of research and to protect the rights of participants (NCPHS, 1978). This is typically done through an IRB or similar committee. According to the U.S. Department of Health and Human Services (n.d.), research involving children must include both parental permission and child assent when the child is capable of providing assent, based on age, maturity, and psychological state. Further, it is stated that the absence of objection does not constitute assent, and that children should actively state they agree to participate. However, no documentation of assent is required. Because those conducting research submit proposals to their local IRB, it is possible requirements for assent may vary but all IRBs will need to meet the minimum criteria for assent set by the federal government.

Guidance for Assent during Behavior-Analytic Research and Therapy

Behavior analysts commonly research and treat neurodiverse individuals who may have language deficits and may require unique assent procedures. Furthermore, behavior analysts commonly target behavior associated with dissent, such as escape- and avoidance-maintained behavior. This requires behavior analysts to consider assent carefully during both research and treatment.

Targeting Dissent

Dissent (e.g., noncompliance) and escape- and avoidance-maintained behaviors are often target behaviors in behavior-analytic therapy and research (Losinski et al., 2017). In other therapeutic relationships (e.g., counselor, therapist), these behaviors would be considered dissent, and an adjustment to the therapeutic techniques or dismissal from participation in the research would be considered if the client or participants engaged in these behaviors (Relvas & Sotero, 2018). Imagine a child in a clinical therapy setting stating “I don’t want to do this” and running out of the room during therapy. In this instance, the behavior may be interpreted as escape-maintained, and multiple methods may be used. Most important, the function of the client’s escape or avoidant behavior should be considered and assessed, in particular if the behavior represents that individual’s dissent.

As previously discussed, client dissent may take the form of escape-maintained behaviors, which as are often a target behavior in behavior-analytic therapy (Losinski et al., 2017). Because of this, assent should be prioritized during behavior-analytic activities. One method to prioritize and honor dissent is to establish an agreed upon dissent indication at the onset of therapy. An agreed-upon dissent word or gesture between the therapist and client could indicate the client needs a break. If a comprehensive assent procedure with dissent agreement is not being utilized during therapy, and dissent (e.g., escape-related behaviors) occurs during therapy, instead of immediately treating these behaviors behavior therapists should determine what was aversive and how to make therapy less aversive. Behavior therapists should consider all levels of social validity, especially the acceptability of the treatment, when assessing if treatment should continue. Although it is generally advised to delay use of aversive procedures, such as escape extinction, there may be situations in which dissent needs to be addressed differently (Matson & LoVullo, 2008). These situations occur when treating more severe behaviors, especially those that may result in harm and the safety of the client.

Dissent can also be a target behavior during research, and treated similarly as in therapy, but it can also be part of the assent process. Morris et al. (2021) identified 28 articles in behavior-analytic journals that offered detailed descriptions of assent procedures. Thirty-two percent of the 28 articles included using dissent (e.g., signs of distress) as part of the assent procedure. Brown et al. (2017) suggested the following guidelines be used when conducting research with children: accept reluctance as dissent, provide age-appropriate information, design studies to maximize engagement, monitor the child’s distress, and assess whether the parents are pressuring the child to participate. However, no similar guidelines or recommendation currently exist for behavior analysts providing therapeutic services.

Communication Skills

As previously discussed, the process of gaining consent in therapy is required in the ECBA (BACB, 2021). However, although gaining assent is recommended, the standard in question includes the qualifier, “when applicable,” (BACB, 2021, Standard 2.11). This is further recommended in ABA-based literature, where recommendations to include clients in treatment planning are made whenever the clients can be included, and to include stakeholders and guardians in their place when they are not able to contribute (Leaf et al., 2022). However, this statement does not address when it is applicable. Tait and Geisser (2017) recognize this limitation in assent guidance for research participation. To resolve this problem, they evaluated operational definitions of child assent. Although an operational definition for assent, including who can provide it and how it can be provided, is certainly helpful, even the final definition evaluated after rounds of expert reviewer feedback includes the qualifier “. . . unless . . . their clinical condition precludes their ability to communicate a choice. . .” (Tait & Geisser, 2017, p. 4). Further, Morris et al. (2021) outline a concurrent chains procedure for determining whether an individual understands what is being asked of them and provides assent.

Given this exclusionary factor for gaining assent from individuals receiving services, it is clear certain populations of clients, specifically individuals with communication limitations, may be differentially included/excluded from assent-based practices (Hamilton et al., 2017; Kliewer & Etscheidt, 2015). Special consideration should be made to improve inclusion of those with limited communication skills in therapeutic planning and assent. Kliewer and Etscheidt (2015) discussed this topic in a presentation, recommending that rather than maintain the “when applicable” status quo, clinicians presume competence, consistent with respecting the autonomy of persons. Some important considerations are presented, including the notion that verbal assent is not the lone means for gaining assent. Instead, clinicians should gain familiarity with the individual, so they can understand that child’s communication and can honor dissent when it is shown verbally, behaviorally, or emotionally (Dobson, 2008; Kliewer & Etscheidt, 2015). Using a psychomotor response for assent or dissent has been established as a useful technique when working with children in a research setting (Morris et al., 2021). This would provide differential reinforcement of an alternative behavior. It would likely decrease the probability of escape-related behaviors during therapy (Piazza et al., 1996).

Another problem noted in the literature is the exclusion of those who cannot consent or assent to research. This problem does not directly affect individuals to the extent their nonassenting inclusion does; however, there are significant implications for both implied effectiveness of evaluated treatments and the ethical standards of justice and equity. Hamilton et al. (2017) surveyed 21 clinical researchers and found that many reported loose guidelines surrounding the determination of individuals’ with disabilities capacity to consent. Many studies exclude those determined not to have the capacity to consent. McKinney et al. (2016) also noted the frequent exclusion of individuals with limited communication skills in research and provided some guidance for future work including these individuals. It should be noted that they suggest that it is important to include family members and stakeholders who are familiar with the individual’s verbal, emotional, and behavioral communication, “as a supplement to assent from patients themselves” (McKinney et al., 2016, p. 1635).

It is clear from the literature that there is a disconnect between ethical guidance (e.g., gaining assent when applicable), research, and clinical practice. The most pressing issue is the determination of what constitutes the ability to provide assent and how to alternatively gain assent/recognize dissent when working with individuals with limited communication skills. Although much of the literature focuses on these issues within a research setting, they also certainly apply in a therapeutic setting, perhaps even more so given the importance of the therapeutic relationship and previous work on choice and its effect on therapeutic outcomes (Bannerman et al., 1990; Totura et al., 2018). In the end, clinicians find themselves with a need to balance protecting individuals with limited communication skills while respecting the autonomy of those individuals and ensuring equitable practices.

Differences in Assent during Behavior-Analytic Research and Therapy

At first glance, gaining assent in a research or therapeutic setting may seem synonymous. There are similar language and overlaps in processes: both inform clients and participants of the voluntary nature of treatment, outline the expectations of the treatment, etc. Although a substantial amount of behavior-analytic research takes place in clinical settings using single-case design methodology, the differences between researchers with research participants and therapists with clients warrant differential treatment of assents. There are two primary reasons for these differences: the acceptability of null findings in research and social validity considerations.

Acceptability of Null Findings in Research

One important distinction to make between therapeutic versus research settings is the relative acceptability of null findings in a research context. In research, null findings may be considered acceptable in that those findings provide information about the parameters of effectiveness and contribute to the knowledge base whereas, in treatment, null findings mean the treatment was ineffective leading to a reconsideration of the problem and reattempt at successful treatment. As part of the informed consent and assent process in a research setting, no guarantees are made about participant outcomes—it is clear from the start that a null outcome is a possibility. Except for single-case design research, often research has the intent to contribute to our knowledge base, as opposed to benefitting the individual participants. Although most researchers hope for significant findings when testing hypotheses, null findings also provide important information about the relationship between variables. In fact, there are several arguments in support of the publication of null findings (Iwachiw et al., 2019; Kepes et al., 2014; McKinney et al., 2016; Tincani & Travers, 2019).

In particular, in the helping or therapeutic fields, null findings of experimental treatment research inform researchers and practitioners about the situations in which treatments may be more or less effective. This leads to improved practices and outcomes for consumers of services. For example, the file drawer problem (Iwachiw et al., 2019), or publication bias (Kepes et al., 2014), refers to researchers failing to publish research with null results, which skews efficacy estimates, limiting researchers’ and practitioners’ ability to make informed decisions about the likelihood of a given technique or intervention resulting in desired outcomes. Many advocate for the publication of null findings. This has been highlighted during the current replication crisis in psychology, where some researchers hypothesize the crisis may at least partially be a result of a lack of null or small effects being previously published (Kepes et al., 2014; McKinney et al., 2016; Tincani & Travers, 2019). In the end, null findings help develop the parameters of effectiveness, which leads to improved recommendations for services in practice.

In contrast, ineffective services in a therapeutic setting have little benefit. And although some level of hypothesis testing typically occurs during psychological treatment, in particular in behavior-analytic therapy, the purpose of therapeutic practices is not to test a hypothesis but to provide a means for socially valid behavior change. When an attempted treatment is ineffective with a client, the relationship does not end, unless requested by the client. Instead, attempts are made to revise the treatment to achieve the desired outcomes (Leaf et al., 2016; Slocum et al., 2014). In fact, this process exemplifies one of the seven dimensions of ABA, where effectiveness is considered a primary characteristic of the therapy—both because it is based on the science of behavior and because ineffective treatments are replaced by more effective treatments (Baer et al., 1968; Baer & Wolf, 1987). This ongoing analysis and modification of treatment highlights yet another way in which consent and assent should be considered differently in research and therapeutic settings.

In a research setting, consent and assent are gathered prior to the study. This consent/assent is typically collected for only one condition/treatment, as the study will end following data collection to test the hypothesis(es). In a therapeutic setting, consent/assent may involve several similar points, but the relationship may continue throughout several iterations of goals and treatments. Given the changing landscape of goals and treatment components in a therapeutic relationship, continuous consent and assent are recommended (APA, 2016; BACB, 2014; NASP, 2021). In the end, the differences in purpose and relevant outcomes between research and therapeutic settings may require differential considerations in the consent and assent process.

Social Validity Research in ABA

Wolf (1978) outlined three key levels of social validity: the social significance of goals, the social appropriateness of procedures, and the social importance of effect. The latter can only be assessed at the end of an intervention through social validity assessment. Research has identified a variety of methods for assessing social validity, such as questionnaires (Strohmeier et al., 2014) or caregivers blind to the purpose of the study rating video tapes of participants (Duda et al., 2008; McKeown et al., 2021). Information about the social significance of goals and social appropriateness of the procedures may influence whether the researchers publish the work. It also has implications for the limitations and discussion of the article. However, in a therapeutic setting, the social significance of goals and social appropriateness of the procedures are best assessed prior to therapy and throughout the therapy to ensure that stakeholders are involved in the planning process and deem the procedures acceptable both prior to and during implementation. In essence, social validity may be part of the assent process in a therapeutic setting, where it may be treated as an outcome in a research setting.

The lack of research examining social validity in behavior-analytic interventions is well- documented (Ferguson et al., 2019; Park & Blair, 2019; Snodgrass et al., 2022). Ferguson et al. (2019) found that social validity measures were reported in 12% of published articles in the Journal of Applied Behavior Analysis. Park and Blair (2019) found only 28 studies in single-case research between 2001 and 2018 addressing social validity. Snodgrass et al. (2022) found only 28 publications in special education journals between 2005 to 2016 addressing social validity. At the time of the present article, no articles were found exploring how often social validity is assessed during treatment. When using an intervention that has not been socially validated in the literature, comprehensive assent, consent, and social validation procedures become paramount to upholding the client’s dignity and ensuring ethical practice (Ferguson et al., 2019). Previous research has primarily sought to explore the amount of research including a social validity assessment from the perspective of the stakeholders. There was no mention of the clients’ perspectives in these literature reviews. Similar to how consent and assent are separate but similar concepts, social validity for stakeholders and clients should both be assessed.

To meet all levels of Wolf’s (1978) social validity, a behavior-analytic therapist needs to gain consent and assent and assess social validity. This is important in both research and treatment. Separate procedures for accomplishing consent, assent, and social validity in research and treatment would help ensure that all three levels of social validity are met across settings.

Discussion

Consent and assent are important elements of ethical and socially valid treatment. There are benefits to engaging in comprehensive consent and assent procedures. These include building rapport with clients and lowering the risk of exploitation (Snyder & Barnett, 2006). Assent is outlined in multiple ethical codes, including the ECBA (BACB, 2021), the NASP Principles for Professional Ethics (NASP, 2021), the APA Ethical Principles of Psychologists and Code of Conduct (APA, 2016), and U.S. Department of Health and Human Services (n.d.).

This article sought to provide a rationale for field-specific assent procedures during both behavior-analytic research and therapy. Due to the large number of neurodiverse clients and participants and well-documented social validity concerns in behavior-analytic research, behavior-analytic activities require special considerations during assent gaining procedures. Furthermore, considering the differences in overall goals between both research and therapy, assent likely requires a different set of procedures in each setting. Although null findings in research are both acceptable and beneficial to the field, null findings are unacceptable outcomes for treatment during therapy. Comprehensive assent procedures (paired with informed consent and social validity measures) increase treatment effectiveness by building rapport, creating buy-in, and involving clients in goal building. Each of these contributes to maintaining the rights and dignity of the individuals served.

Conclusion

It could be argued that ensuring dignity and autonomy to the client receiving services may be the most important ethical mandate for a behavior analyst, because this would ensure the client has a voice in the therapeutic relationship and is offered choice and involvement in the process. Comprehensive assent during treatment ensures that the client’s dignity is being upheld. The process to gain assent will look different than gaining assent during research. Research dedicated to the goal of creating a comprehensive assent practice for behavior-analytic therapy is needed, in particular research emphasizing the unique needs of learners who exhibit escape-maintained behaviors and have limited communication skills.

Data Availability

Data sharing not applicable to this article because no datasets were generated or analyzed during the current study

Declarations

Conflict of Interest

These authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human or animal participants performed by the authors.