Applied Behavior Analysis has many powerful tools to help children with behavior problems and children with autism spectrum disorder to modify their behavior toward ever-more positive milestones. One of the more interesting concepts within the realm of ABA therapy is “Assent and Assent-Based Treatment.” This model aims to eliminate instruction via coercion.
Rather they focus on developing a repertoire with patients in a way that encourages autonomous positive behavior. It has proven to be effective for children with ASD and behavioral issues as well as adults who were diagnosed later in life with autism spectrum disorder.
Within these approaches, several key concepts are important to understand. Both for clinicians and patients of any age.
Informed consent is a critical concept throughout the healthcare and mental health industries. It has several key components and reasons why it is important. Not the least of which is that informed consent is required from a legal standpoint. It ensures that the clinician has informed the patient fully while minimizing the risk of a patient being confused or feeling exploited.
In ABA therapy, informed consent also includes informing the patients about all aspects of the therapeutic process. This further builds a patient-clinician relationship founded on mutual respect and reciprocity.
Assent is a term that’s akin to consent. However, it expands even more in terms of providing a client with a sense of agency, and autonomy, with an active agreement to participate in the therapeutic process.
It allows clinicians to deftly shift the balance of the power structure in the therapeutic relationship they build with their patients. It brings with it an added effort for clinicians to self-reflect in situations where the patient might feel that the power dynamic has given too much sway to the clinician. Left unaddressed it could hinder a reciprocal therapeutic relationship.
Assent might also be defined as the expression of approval or agreement from the patient without coercion. This encourages trust in the patient, making them a more willing participant in the process without feeling forced or persuaded.
How to Tell If a Patient Is Withdrawing Assent?
There are many ways that a patient might subtly withdraw their assent. Sometimes these are clearly communicated statements, though many times they are not. Not all patients feel comfortable verbally requesting cessation of activity. Many times, withdrawal of assent manifests as redirection to another topic, or the patient only making a half-hearted effort in the current therapeutic exercise. For a clinician, it’s important to recognize these subtle signs for each patient and honor when patients withdraw assent. Even if they aren’t directly stating it.
Assent-Based Learning Models
Assent-based learning models involve actively looking at your organization’s policies and practices to ensure that assent is being offered freely at every level. This starts with assessment through treatment planning and analysis of intervention effects.
Creating Appetitive Contingencies for Learning
Successful ABA clinicians typically start instilling assent-based programs from their first interactions with a patient. This immediately starts building a repertoire with a patient from the very first second they start interacting with you.
It also helps teach patients how to advocate for themselves and withdraw assent as they go through the process together. It’s important to build interventions based on what motivates the child, versus designing programs based on a template.
Self-advocacy is an important aspect of skill building in general. It can also be used to develop a strong repertoire between a patient and a clinician during assent-based learning.
The overarching goal of this type 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.
It’s also worth noting that there are several ways to communicate assent withdrawal, even in patients who might have communication skill deficiencies. This includes the use of functional communication training to provide a patient with non-verbal ways to say “No” with a sense of agency.
Of course, one possible concern with this model is that a patient might continually withdraw assent as soon as a certain task takes them outside of their established comfort zone. In a scenario like this, the clinician should seek to determine why the patient has an aversion to the therapy. Then determine 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.
Using Reinforcement With Assent & Assent Withdrawal
Reinforcing assent takes on a different form with cooperative participation therapy models like assent training. One pillar of effective assent-based programming includes honoring requests for cessation. An ABA clinician needs to consider any precursor behaviors before deciding what should signal immediate reinforcement or activity termination.
Analysis & Environmental Contingency Manipulation
Many clinicians wonder if assent-based methods impair or slow down the learning of technical skills that take a patient out of their established comfort zone. Though a growing body of research has found that continual analysis of data and changes based on the patient’s tracked motivations actually support effective and efficient skill acquisition.
Training the Patient’s Support Team
Of course, all ASD patients reach milestones faster when they experience consistency throughout their support team. This includes other clinicians, caregivers, teachers, and family members.
When engaging in a treatment plan with an assent core principle, you need to make sure that all other members of the patient’s support team are well-trained in how to recognize assent withdrawal. This often includes parent and caregiver training.
Then you further assert this assent in policy and how will support these efforts. These strategies should also be reflected in session documentation.
The Importance of Measurement & Tracking
Measurement and tracking are of critical importance in any ABA treatment strategy. This includes tracking assent withdrawal along with other associated behaviors. This gives clinicians and caregivers a clear picture of what training and treatment methods are working and what aren’t.
Developing a data-driven understanding like this can factor heavily into the various therapeutic programs the child engages in as they progress through ABA therapy over the years.