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[00:00] Intro & About the Podcast

Host (Kyle):
Welcome to the Cooperate Learning Podcast! I’m excited you’re here for our very first episode. We’re kicking off a subject matter expert series on rights, ethics, and behavior analysis when providing services to adults.

This episode was recorded live with our team at Sparks Behavioral Services. If you don’t know us, Sparks is a team of behavior analysts serving the state of Michigan. We provide Behavioral Science services across a range of settings, including:

• Adult foster care homes

• Adult residential placements

• Group homes

We work with adults regardless of the nature or severity of their needs. If you’re a BCBA or behavior technician interested in joining the team, you can learn more at sparksbehavioralservices.com.

Today’s topic: assent.

[01:00] Guest Introduction

Host:
I’m thrilled to have our first guest be someone with a ton of insight into assent and client involvement.

• Dr. Cody Morris

  • Assistant Professor & Graduate Programs Director of Behavior Analysis

  • Chair of the IRB at Salve Regina University

  • Research focus: client involvement in therapeutic decisions, assessment and treatment of challenging behavior, and organizational practices

  • Editorial board member for Behavior Analysis in Practice and Journal of Applied Behavior Analysis

  • Executive Board Director for the Rhode Island Association for Behavior Analysis

  • Executive Producer & Host of Behavior Analysis in Practice: The Podcast

Cody, thanks for being here.

Cody:
Thanks for having me—excited to be here and connect with folks from Michigan and the Midwest.

Yes, I’m at Salve Regina University in Rhode Island. The campus really does look like the photos: we’re in historic Gilded Age mansions right on the Atlantic Ocean. If I lean back in my chair, I can literally see the water.

[03:00] What Is Assent (and How Is It Different From Consent)?

Host:
Let’s start with definitions. Most of us are familiar with consent, but not always with assent. How do you define assent, and what drew you to this topic?

Cody:
Good place to start. I’ll briefly define consent first.

• Consent is an affirmation from someone who is legally authorized to make decisions for themselves (or for someone they’re a guardian of) to participate in a procedure, after receiving adequate information about that procedure.

• Assent is also an affirmation to participate—but it comes from a person who is not legally authorized to provide consent for themselves.

  • This might be:

    • A child

    • An adult under guardianship or conservatorship due to developmental disability, serious mental illness, etc.

The working definition I use is:

Assent is when a client who cannot legally consent indicates their willingness to participate in a procedure via a choice arrangement, after receiving adequate information about that procedure, with the clear expectation that they can withdraw assent at any time.

There are a lot of important pieces in there: choice, information, and the right to withdraw. We can unpack those as we go.

[05:00] How Cody Became Interested in Assent

Host:
Was there a particular experience that pushed you into focusing on assent?

Cody:
Yes—very much tied to adult services, which is the world most of you are in.

When I first started graduate school, within my first couple of weeks of clinical experience, I was sent to a group home for a treatment team meeting for an adult with developmental disabilities.

Here’s what happened:

• The client had a court-appointed guardian who had already reviewed and signed off on a fairly long written treatment plan.

• A social worker led the meeting.

• The social worker spent maybe under three minutes summarizing a multi-page plan.

• Then she slid the plan across the table to the client, handed him a pen, and said something along the lines of “sign here.”

• He scribbled on the paper. She took it back and said, essentially, “Great, we have consent from the guardian and assent from the client.”

Then the client just kept scribbling on napkins and pieces of paper at the table.

I remember thinking—even as a brand-new grad student—“That can’t be what assent is supposed to look like.” It felt like:

• He wasn’t actually informed.

• He didn’t really have a meaningful choice.

• Nobody checked whether he understood what he was “agreeing” to.

That moment was a big spark for me. From there, I started digging into:

• The history of assent in behavior analysis

• How assent has been handled in developmental disability services more broadly

• And also what’s happening outside behavior analysis—in medicine, pediatrics, mental health, etc.

[08:30] Key Components of Assent

Host:
You mentioned earlier that there are critical components to assent. Can you break those down, especially in a way that makes sense for day-to-day practice?

Cody:
Sure. I’ll first say: assent isn’t just “a signature” or “not saying no.” There are multiple layers:

1. Is assent even applicable here?

   • There are situations where assent is essential.

   • Other situations where it cannot be the primary driver (for example, urgent health and safety).

2. Does the client have the skills needed to assent or withdraw assent?

   • Communication skills

   • Choice-making

   • Understanding cause-and-effect around their choices

3. How are you arranging the assent process itself?

   • Are you only relying on written or spoken language?

   • Or are you building adapted procedures that work for people with limited or no speech?

4. How often and in what moments are you checking for assent?

   • You can’t stop and formally assess assent to every tiny decision all day.

   • You need a practical, prioritized approach.

To get more concrete, I often draw on the work of the American Academy of Pediatrics, who have been thinking deeply about assent for decades. Translating their model into behavioral language, there are four core components when we’re seeking assent:

1. Acquaint the client with the options

   • They need to know what they’re choosing between—not just “yes or no,” but what “yes” or “no” actually lead to.

2. Provide clear discriminative stimuli for each option

   • Visuals, words, or other cues that reliably represent each option.

3. Provide a clear response option for each choice

   • A way for the client to say “yes” or “no” or select option A or B:

     • Spoken response

     • A gesture

     • A card to hand over

     • A button to press

4. Test that those cues actually control the behavior

   • Make sure the way they’re responding really maps onto their preferences (i.e., the SDs are functioning as SDs).

That’s the formal side: how we present options and accept assent.

But there’s another equally important side…

[13:30] Assent Withdrawal vs. “Noncompliance”

Host:
You mentioned that identifying assent withdrawal is a separate process from assessing assent in the first place. Can you talk about that?

Cody:
Yes, they’re distinct but related.

• Assent = “I’m willing to participate.”

• Assent withdrawal = “I was willing, but now I no longer am.”

A really important point that often gets missed:

The absence of assent withdrawal does not equal assent.

You can’t say, “Well, they didn’t try to leave or protest, so they must assent.” That’s not safe reasoning, because:

• Many clients have long histories of punishment for noncompliance.

• They may have learned that resisting, saying “no,” or walking away leads to bad outcomes.

• So “going along” might mean helplessness or compliance history, not genuine willingness.

We also have decades of research showing that behaviors like:

• Noncompliance

• Disruption

• Aggression

…can serve many different functions (attention, escape, access to tangibles, automatic reinforcement, etc.). So you cannot simply say, “Whenever someone is noncompliant, that means they’re withdrawing assent.”

If we discover that some behavior does function as “let me out of this treatment”:

• Great—now we’ve learned an important function.

• Then we can teach a clearer, less ambiguous, more functional communication response to stand in for that behavior.

Host:
Right, and sometimes staff will say “Oh, when he does this tiny thing, that’s his sign that he wants to stop.” But a new staff person has no idea what that means.

Cody:
Exactly.

• It’s excellent when teams learn those idiosyncratic cues.

• But they are often ambiguous and fragile for new staff or in new environments.

So we want to:

1. Honor those idiosyncratic cues when we know them.

2. Also teach more explicit, universally understandable assent-withdrawal responses (e.g., a card that says “Stop,” a button, a clear sign).

[18:30] What Happens After a Client Withdraws Assent?

Host:
Okay, so let’s say we’ve set up clear ways to detect assent withdrawal. A client uses them. They’re saying, “I don’t want to participate right now.” What do we do next? What do we tell staff?

Cody:
It depends on what kind of procedure we’re talking about, but a few guiding steps:

1. Treat assent as dynamic.

   • Assent is not a one-time event at intake.

   • It’s something that can be granted, pulled back, and revisited over time.

2. Understand why they’re withdrawing assent.

   • Is the procedure aversive?

   • Do they not understand it?

   • Do they not see it as relevant to their own goals?

3. Rebuild the therapeutic relationship and context.

   • Sometimes we need to step back and build rapport again.

   • Example: I was once introduced to a client in a group home as “the guy who’s going to make you shower.”

     • Unsurprisingly, she wanted nothing to do with me.

     • So I left, came back another day, brought her favorite snack (licorice), and just talked with her.

     • I learned her goals, preferences, and what she wanted out of services.

4. Center the client’s own goals.

   • The staff’s goal was “get her to shower.”

   • Her goals were broader—things like comfort, dignity, social opportunities.

   • My job was to connect her goals to the behavior (showering) in a way that made sense to her.

Assent withdrawal doesn’t mean “never work on this again.” It often means:

Pause. Reassess. Rebuild alignment between treatment and the client’s values and goals.

[22:30] Dignity of Risk vs. Duty of Care

Host:
This seems related to the idea of balancing the dignity of risk with our duty of care. How do you think about that?

Cody:
Great connection.

There are times when:

• A client genuinely does not want a procedure.

• But the procedure is necessary for their health, safety, or basic welfare.

A classic example:

• Blood draws.

• Almost no four-year-old is excited about a blood draw, even if you explain the long-term health benefits.

• Many adults aren’t either, especially if they don’t have the coping skills.

If a procedure is medically or legally necessary (e.g., life-saving medication, seizure meds, mandatory education), then:

• We may not be able to honor assent withdrawal by stopping the procedure entirely.

• But we’re still responsible for doing it as compassionately and respectfully as possible.

What we absolutely cannot do is stretch “necessary for welfare” so far that it covers everything we personally think would be “nice” or “easier”:

• “They have to wear the yellow shirt; it’s better for them.”

• “They have to stop swearing because I don’t like it.”

That’s not genuine duty of care. That’s controlling behavior for our own comfort or cultural bias.

I always tell students:

Our core job is to help clients achieve maximum independence and autonomy.

So whenever we’re deciding whether a behavior is fair game for intervention, we should ask:

• Does changing this behavior actually move them toward more independence and autonomy?

• Or is it just making them easier to manage, or more palatable to someone else?

[30:00] Changing Social Norms & Social Validity

Host:
Social norms change fast. Something people asked us to target 10 years ago might feel inappropriate now. How do we handle that?

Cody:
That’s a reality we live with as behavioral scientists and as members of a culture.

• Our science evolves.

• Our ethics evolve.

• Society’s understanding of disability, mental health, identity, and acceptable behavior evolves.

You gave a perfect example: swearing.

• I once had a team ask me to target an adult client’s occasional mild swearing.

• She wasn’t threatening anyone. She was just an adult using adult language sometimes.

• To me, that’s not a meaningful, autonomy-relevant target. That’s policing someone’s personality.

When I’m making decisions about whether to work on a behavior, I ask:

1. Does this behavior actually limit their access to:

   • Community

   • Relationships

   • Employment

   • Safety

2. Would changing this behavior increase their independence?

If the answer is no, I’m very cautious about making it a treatment goal.

And yes, what counts as “limiting” or “independent” can change over time. In 50 years, people may look back on some of what we’re doing today and say, “That was off.” That’s part of growth. Our job is to do the best we can with the information and values we have right now, guided by client voices and community perspectives.

[42:00] When Guardians and Clients Disagree

Host:
In adult services, guardians play a huge role. Sometimes guardians and clients disagree—for example, about what goals are important or what behaviors should change. How do you navigate that?

Cody:
I’ve been in that situation many times.

My main strategy is to:

Center the conversation on treatment goals first—not on specific procedures.

Typically:

• Guardians might say, “I want him to be perfectly behaved,” or have very specific ideas about “good” behavior.

• The treatment team might be focused on independence, safety, communication, access to the community.

• The client might have their own goals—maybe working, dating, having more privacy, etc.

If we try to debate procedures first (“Do we use this intervention?” “Do we allow this behavior?”), we get stuck quickly.

Instead, I try to:

1. Get consensus on goals.

   • “Can we agree that the big goal is more independence and safe access to the community?”

   • Or, “Can we agree that the goal is for them to live in a less restrictive setting?”

2. Explore why guardians want what they want.

   • Sometimes “perfect behavior” is really about fear:

     • Fear of rejection

     • Fear of the client being mistreated

   • If you can link it back to autonomy, inclusion, and safety, you can often find common ground.

3. Then evaluate proposed procedures against those agreed goals.

   • “Does making her stop swearing actually help her live more independently?”

   • “Does this restriction help or hurt her ability to function in the real world?”

It’s not always easy. But if everyone cares about the client (and most people do), you can often reframe things around shared long-term outcomes.

[50:00] Open Research Questions About Assent

Host:
You’ve written and spoken a lot about assent. What still needs research? What questions aren’t answered yet?

Cody:
So many.

Behavior analysis has always had, at its heart, an emphasis on:

• Social validity

• Client welfare

• Countercontrol and power dynamics (think Skinner and others)

We’ve always talked about centering the client—but we still need more practical, well-researched procedures for actually doing that, especially with people who:

• Have limited communication

• Are under guardianship

• Live in congregate care settings

Some open areas:

1. Assent procedures for clients with limited or no speech

   • How do we “acquaint” them with procedures without relying only on explanations?

   • One option: brief forced exposure to a procedure, so they know what it is before they’re asked to assent.

     • That raises ethical tension but may ultimately increase autonomy by enabling informed assent.

2. Alternatives to forced exposure

   • Use modeling or role-play with another person (peer or staff) while the client observes.

   • If the client has an observational learning repertoire, they may be able to understand procedures indirectly.

3. Better tools for tracking ongoing assent

   • Not just at intake, but across sessions, across components of treatment, across different environments.

4. How assent, social validity, and happiness measures all fit together

   • They’re related but distinct.

   • We need to clarify when each is most appropriate and how they can complement one another.

I don’t think we’ll ever “finish” this work. But that’s good—it means we keep getting better at centering clients and sharing control.

[52:00] Court Orders, NGRI, and When Assent Isn’t Optional

Steve (Audience):
Let me throw a tough one at you. Some of our consumers have very severe histories—even homicide—and may be found Not Guilty by Reason of Insanity. The state sometimes expects us to implement treatment regardless of client assent. How does assent fit in there, if at all?

Cody:
This is where we have to be very clear about necessity.

If:

• There is a court order

• Or a legal mandate

• Or an intervention is clearly necessary for safety and public welfare

…then assent may not be applicable in the usual way.

Some pediatric ethics literature says:

When a procedure is ethically and legally non-optional, it may actually be inappropriate to present it as a “choice” requiring assent.

In those cases, a more honest, respectful approach is:

1. Explain that it’s not optional.

   • “You have to take this medication.”

   • “You do have to participate in this safety procedure.”

2. Apologize and validate.

   • “I know you don’t want to do this. I get that. I don’t like it either, but it is required.”

3. Offer choices around the edges.

   • If they must take a seizure medication:

     • Can they choose:

       • What they drink it with?

       • The time of day (within medical limits)?

       • Where they sit?

       • What they do right before or after?

   • Even small choices can preserve a sense of control and dignity.

So in those contexts:

• Assent doesn’t control whether the procedure happens at all.

• But we can still:

  • Seek input.

  • Build rapport.

  • Maximize autonomy within the constraints.

  • Make the experience as humane as possible.

That’s still meaningful, and it still aligns with our values as behavior analysts.

[56:00] Closing

Host:
We’re up on time, so we’ll wrap here. Cody, thank you so much for joining us for our first episode. This was incredibly helpful and thought-provoking.

Cody:
Thank you for having me. It was great seeing you again, Kyle, and connecting with Steve and Taylor and the rest of the team. I hope we get to do this again soon.