The Shift That’s Already Happened

LITTLETON, COLORADO – When the Behavior Analyst Certification Board updated its ethics code in January 2022, most attention focused on the expanded sections on cultural responsiveness, social media, and multiple relationships. Less discussed but equally significant was the formalization of a term that had previously lived only in academic literature and reform-minded practice circles: assent. For the first time, the BACB’s Ethics Code for Behavior Analysts — the governing document for all BCBA and BCaBA certificants — defined assent as a required ethical consideration and gave it its own standard: Code Section 2.11, Obtaining Informed Consent, which states that behavior analysts are responsible for obtaining assent from clients “when applicable.”

That phrase — “when applicable” — is deliberately broad. It applies to any client who cannot provide legal informed consent due to age or intellectual disability but who nonetheless has the right and the communicative ability to indicate agreement or disagreement with services. In ABA, that describes the majority of the client population. And the BACB’s 2022 definition of assent is unambiguous: it is “vocal or nonvocal verbal behavior that can be taken to indicate willingness to participate in research or behavioral services by individuals who cannot provide informed consent.”

The ethics code change did not create assent-based practice — academic behavior analysts had been writing about it since at least the early 2000s, and advocates within the neurodiversity movement had been demanding something like it for longer. But it transformed it from a practice philosophy into a compliance requirement. A BCBA who ignores a client’s clear signals of unwillingness and continues intervention is now operating in potential ethics violation territory, not just ethical gray area. That distinction matters for every supervisor, program manager, and clinical director in the industry.

What Assent Actually Is — and What It Is Not

Assent is frequently misunderstood as a one-time event at the start of a session — a thumbs-up before starting work, equivalent to parental consent but for the child. That framing misses the operational reality. Assent, as defined in the current behavioral literature, is continuous, dynamic, and individualized. It is not a form. It is not a verbal yes at session start. It is an ongoing behavioral reading of a client’s willingness to participate that must be operationally defined for each individual learner and monitored throughout every interaction.

Assent behaviors include: active engagement with materials, approach behaviors toward the therapist, calm body language, smiling, nodding, and spontaneous participation. Assent withdrawal behaviors — the signal that a child is no longer willing to continue — include turning away, pushing materials off the table, vocalizing “no” or “stop,” walking away from the work area, crying, physical resistance, dropping to the floor, or making a half-hearted effort that represents disengagement rather than skill deficit.

The critical clinical distinction is between assent withdrawal and task avoidance. A child who does not want to do a hard thing because it is hard is not the same as a child who does not want to do it because they are unsafe, overwhelmed, or telling you something important about the environment, the relationship, or the program. The 2024 paper by Morris and colleagues in the Journal of Applied Behavior Analysis, “Toward a Further Understanding of Assent,” addresses this directly: assent withdrawal must be individually operationalized per client so that the team can distinguish between the two with data, not intuition.

“Partnering with learners by honoring their assent and assent withdrawal moment by moment during intervention is a critical form of autonomy for the learner. The ability to make one’s own decisions, without being controlled by anyone else, is a fundamental human right.” — Alison Moors Lipshin, BCBA, Science in Autism Treatment (2025)

This is where assent-based practice becomes operationally demanding in a way that the ethics code language obscures. To implement it correctly, a BCBA must: operationally define what assent and assent withdrawal look like for each specific client before treatment begins; train every RBT on that client’s individualized assent/withdrawal indicators; document assent-related data in session notes; and have a clinical decision tree for what happens when a client withdraws assent — which activities pause, which alternatives are offered, and when withdrawal signals something requiring program revision rather than simple redirection.

The Operational Requirements

Translating assent principles into clinic operations requires changes at four levels: assessment, treatment planning, session delivery, and documentation.

At assessment: The BCBA should conduct preference assessments and observe the client’s behavioral repertoire for communication of agreement and disagreement. For nonverbal clients, this means identifying idiosyncratic signals — a specific body posture, a particular vocalization, a reaching behavior — that the entire treatment team learns to recognize. For verbal clients, it means establishing that “no” and similar refusals are functionally meaningful and will be honored. The assessment process itself should avoid coercive elements: pushing through repeated refusals during initial pairing to collect assessment data sets a tone that works against the trust required for genuine assent.

At treatment planning: Goals should be developed around what motivates the client, not around templates. Choice should be embedded structurally into the treatment plan — choice of activities, reinforcers, work-to-break ratios, and session pacing — rather than added as a procedural afterthought. If a client withdraws assent from a specific activity repeatedly across sessions, that pattern is data. It should trigger a program review, not a more robust extinction procedure. The Behavior Health Center of Excellence and others in the field have recommended that assent considerations be embedded in functional behavior assessments from the outset, so that the function of refusal behaviors is analyzed rather than simply suppressed.

At session delivery: RBTs are the front line of assent implementation, and this creates a training challenge. The skills required — reading nonverbal communication, distinguishing assent withdrawal from escape behavior, responding to withdrawal without reinforcing avoidance, and maintaining a collaborative rather than compliance-based therapeutic stance — are not automatic. They require explicit training, modeling, and ongoing supervision. When a client withdraws assent mid-session, the recommended protocol is to pause immediately, validate the signal, offer alternatives, and document the incident and response. Reauthorization proceeds when the client indicates renewed willingness. Extinction during active assent withdrawal — continuing to run a program while a child is clearly signaling they do not want to participate — is the practice that assent-based approaches are specifically designed to replace.

At documentation: Session notes must reflect assent patterns. This includes documenting indicators observed, how the team responded to withdrawal, and what alternatives were offered. Over time, this data should be aggregated and reviewed during supervision to identify whether specific programs, settings, therapists, or time-of-day patterns are consistently associated with withdrawal. That analysis is the input for treatment modifications that actually address the cause rather than the symptom.

The Tension With Payer Requirements

Assent-based practice exists in structural tension with one of the most persistent pressures in the ABA industry: authorized hours. Insurers authorize a specific number of hours per week based on a clinical determination of medical necessity. When a client withdraws assent repeatedly during a session and the session ends early, or when significant portions of a session are spent in rapport-building and preference-based activities rather than running discrete trial programs, the question of billable unit integrity arises.

This tension is real and is discussed openly in clinical circles. A child who withdraws assent from a two-hour session after 45 minutes has not received less of a good thing — they have communicated something clinically important. But from a payer’s perspective, a pattern of sessions that consistently run significantly short of authorized hours may generate utilization review. The answer the field has arrived at, broadly, is better documentation: session notes that explain what assent withdrawal patterns are communicating clinically, what program modifications were made in response, and how the treatment plan is evolving to better match the client’s actual engagement profile. Assent data, in this framing, is not evidence that therapy is failing. It is evidence that the provider is paying attention.

The longer-term compatibility of assent-based practice with the ABA reimbursement model may depend on the industry’s movement toward value-based care. As payers increasingly focus on functional outcomes rather than hours-delivered, a treatment approach that optimizes for genuine engagement and self-advocacy may be more defensible than one that maximizes seat time. That transition is still in its early stages in most markets. In the meantime, providers implementing assent-based practices need robust documentation systems and clinical supervisors who can articulate the clinical rationale for assent-informed session modifications clearly and specifically.

Where the Research Stands — and Where It Doesn’t

The research base for assent-based practice is growing but uneven. The 2023 paper by Breaux and Smith in the International Journal of Developmental Disabilities, “Assent in Applied Behaviour Analysis and Positive Behaviour Support: Ethical Considerations and Practical Recommendations,” remains one of the most comprehensive frameworks in the literature. The 2024 Morris et al. paper in JABA advanced the field’s operational definitions. The 2023 paper by Flowers and Dawes in Behavior Analysis Practice, “Dignity and Respect: Why Therapeutic Assent Matters,” connected assent to autonomy development and long-term outcomes. The 2021 Rajaraman and colleagues trauma-informed ABA paper in JABA, which directly links compliance-based approaches to potential harm, provides the strongest evidence base for why the reform is necessary.

What the research has not yet produced at scale is controlled outcome data comparing assent-based protocols against standard protocols on treatment goals. The clinical logic is strong — a child who is genuinely engaged learns more effectively than one who is not — and anecdotal clinical experience among practitioners who have made the shift is generally positive. But the field does not yet have the randomized trials it would need to make authoritative claims about outcomes differences. A 2025 review of ABA reform efforts in PMC, “Applied Behavior Analysis at a Crossroads: Reform, Branding, and the Future of Behavior Analysis,” noted directly that the proliferation of reform-branded approaches — assent-based ABA, trauma-informed ABA, compassion-focused ABA, neurodiversity-affirming ABA — creates a differentiation problem: practitioners, families, and regulators struggle to evaluate what any of these labels actually mean in practice without standardized definitions and outcome data.

That gap matters for the industry because payers are increasingly asking for exactly that kind of evidence. Providers who have built assent-based practices and want to defend them in utilization review — or eventually in value-based contracting negotiations — will need more than clinical philosophy. They will need data.

What Implementation Actually Looks Like

Practices that have moved toward genuine assent-based implementation describe a process that typically takes 12 to 18 months to fully embed, and that requires leadership commitment rather than clinical add-on. The changes tend to cluster in three areas.

Culture shift: The foundational change is moving from a compliance-centered to a collaboration-centered clinical culture. This means training supervisors and RBTs to view refusal as communication rather than behavior to be extinguished, and to understand that a child who says no and is heard is being taught self-advocacy. That cultural shift is harder to train than any procedural protocol, and it does not happen through a one-time CEU. It happens through supervision practices, case review norms, and leadership modeling.

Individual assent protocols: Each client’s treatment plan should include an operationally defined assent-withdrawal protocol that is as specific as any skill acquisition program. What does this client’s assent look like? What does withdrawal look like? What is the immediate response protocol when withdrawal is observed? What data is collected, and by whom? These questions have different answers for a nonverbal three-year-old and a verbal twelve-year-old, and the protocol must reflect that.

Documentation architecture: Session notes, progress reports, and treatment plans need to be structured to capture assent data. Most EHR platforms used in ABA do not have assent-specific fields built in by default. Practices implementing this model often add structured fields or note templates that prompt RBTs to document assent observations during and after sessions. Supervisors reviewing session notes for assent patterns need that data to be findable.

The question the industry is still working out is whether assent-based practice is a reform of ABA — a better way to implement the same science — or something more fundamental. The research and ethics literature suggest the former. The practice change it requires suggests that whatever it is called, it is substantial enough to be treated as an organizational transformation, not a clinical update.

AT A GLANCE

BACB Code Section: 2.11 (Obtaining Informed Consent) — requires assent from clients “when applicable”; effective January 1, 2022
BACB Definition: Assent = “vocal or nonvocal verbal behavior indicating willingness to participate” by those who cannot legally consent
Key Distinction: Assent ≠ one-time session start check. It is continuous, dynamic, individually defined, and can be withdrawn at any moment
Assent Withdrawal: Any behavior indicating unwillingness: turning away, pushing materials, vocalizing no/stop, eloping, crying, physical resistance
Clinical Distinction: Assent withdrawal vs. task avoidance — must be operationally defined per client; requires data, not intuition
Operational Steps: (1) Operationally define assent/withdrawal per client. (2) Train full team. (3) Document in session notes. (4) Embed choice in treatment plans. (5) Review patterns in supervision.
Payer Tension: Sessions ending early due to withdrawal may trigger utilization review; robust clinical documentation of rationale is the current solution
Reform Literature: Breaux & Smith 2023 (Int’l J Dev Disab); Morris et al. 2024 (JABA); Flowers & Dawes 2023 (BAP); Rajaraman et al. 2021 (JABA)
Evidence Gap: No large-scale RCTs yet comparing assent-based vs. standard protocols on treatment outcomes; anecdotal clinical experience is positive
Implementation Timeline: 12–18 months typical for full organizational embed; requires culture shift, individual protocols, and documentation architecture
Key Risk: “Assent-washing” — using the label without the substance; distinction between genuine practice change and marketing requires stakeholder scrutiny

SOURCES & REFERENCES

1. – Behavior Analyst Certification Board. Ethics Code for Behavior Analysts. Effective January 1, 2022. Updated August 2024. bacb.com

2. – Breaux CA, Smith K. Assent in applied behaviour analysis and positive behaviour support: ethical considerations and practical recommendations. Int J Dev Disabil. 2023;69(2):111–121. doi:10.1080/20473869.2021.1937647. PMC9897747

3. – Morris C, Oliveira JP, Perrin J, Federico CA, Martasian PJ. Toward a further understanding of assent. J Appl Behav Anal. 2024;57(2):304–318. doi:10.1002/jaba.1063

4. – Flowers J, Dawes J. Dignity and respect: Why therapeutic assent matters. Behav Anal Pract. 2023;16(6):913–920. doi:10.1007/s40617-023-00980-4

5. – Rajaraman A, Austin JL, Gover HC, Cammilleri AP, Donnelly DR, Hanley GP. Toward trauma-informed applications of behavior analysis. J Appl Behav Anal. 2022;55(1):40–61. doi:10.1002/jaba.881

6. – Lipshin AM. Clinical Corner: What is “assent” in ABA intervention? Science in Autism Treatment. 2025;22(5). asatonline.org

7. – Schuck RK, Lambert JM, Pompa JL. Assent-Based Practice in Applied Behavior Analysis: Rethinking Compliance-Driven Approaches. J Appl Behav Anal. 2022;55(2):542–558

8. – Linnehan AM, Abdel-Jalil A, Klick S, et al. Foundations of preemptive compassion: A behavioral concept analysis of compulsion, consent, and assent. Behav Anal Pract. 2023;1–8

9. – Applied Behavior Analysis at a Crossroads: Reform, Branding, and the Future of Behavior Analysis. PMC. 2025. PMC12411353

10. – Marshall S. Autistic Experiences of Applied Behavior Analysis (ABA): Toward Improved Autistic-Centered Supports. Journal of Social Issues. 2025. doi:10.1111/josi.70037

11. – Centralreach.com. ABA Assent & Assent Withdrawal, Instructional Support, & Behavior Analysis. centralreach.com (2023)

12. – BHCOE. Integrating Assent-Based Thinking Into ABA. bhcoe.org (May 2022)

13. – Behavioral Health Business. Outcomes Over Output: What’s Shaping Autism Therapy Reimbursement in 2025. June 2, 2025

14. – Master ABA. Understanding Assent and Assent Withdrawal in ABA. masteraba.com

15. – BreakingNewsABA.com — March 2026