Consent remains an essential part of different elements of life including clinical practice. In the world of applied behavior analysis (ABA), it can be quite tricky. Most clients may have little to no capacity and as such caregivers, parents or certain stakeholders may need to make important decisions about their care. Also, clients are from a vulnerable population and need to be protected from coercion. However, behavior analysts must recognize these clients are human and even though they may not have full capacity, their body language and other factors can be used to determine if they agree with interventions or not. This is where assent comes in. Even though there is no legal requirement with assent, it helps build trust between clients and behavior analysts as clients feel like they are part of decision making regarding their care. This reflection will be on ethical review and guidance on assent in ABA and positive behavior support, the importance of therapeutic assent and informed consent in clinical practice and ABA.
The article by Breaux and Smith (2023) discussed the legality of consent in ABA services and other medical practices (p.112). This is very essential and ensure clients and their parents and care givers are active participants in their care. It also provides an avenue for clients, parents and caregivers to let behaviour analysts know if they fully understand what intervention is being carried on. Similarly, this was also supported by the article by Flowers and Dawes (2023) which reiterated the need for a behaviour analyst to have checklist for informed consent (p.914). It is important to note that a checklist helps behaviour analysts to be systematic and prevents him or her from missing important information. Additionally, it helps assess clients, parents or caregivers on the content of the informed consent as it provides an avenue for asking questions and clarifying any confusion with what is being said. An example is when I was working as a dentist, after explaining any procedure, I would ask my clients to tell me how they understood what I said. After the explanation they give if there is anything missing in translation, I would clarify it immediately and ask them to repeat again. After, I would ask if they had any further questions before I would proceed. Most of my clients found it to be helpful and it was also my way of ensuring they were actively involved in their care. The article by Breaux and Smith (2023) clearly defined assent and consent adding both cannot be coerced and can be withdrawn at any time (p.112). This statement is crucial in ABA. As behaviour analyst, we need consent or assent whichever is applicable from clients, parents and caregivers before any intervention is started. I remember a male client who visited my dental clinic and needed a composite restoration. After the procedure, risks and benefits were explained he said he understood what had been said and requested to use the bathroom before we could proceed. After 2 hours, he returned looking worried and the procedure, risks and benefits were explained again. He then said, “Doctor did you say I cannot eat anything that contains colour for 48 hours?”. I responded, yes then he said scratching his head, “when I left to the bathroom, my wife called. She said she would be preparing palm nut (coloured fruit that stains everything it touches) soup and I know her if I do not eat her food, she would think I am cheating so please can we reschedule to another day?”. I immediately said of course because he had rescinded his decision to continue with the procedure. Furthermore, the article by Breaux and Smith (2023) also highlighted the influence of culture on assent (p.114). In some cultures, a child should be seen and not heard so trying to get any form of assent may be a bit hard.
According to Flowers and Dawes (2023) researchers should provide participants the risks, benefits and their rights (p.913). This makes clients, parents and caregivers more willing participants as they know what to expect especially in behavioural interventions. It also helps them make decisions on whether to participate or not. This article got me thinking of the little Alberts experiment. I am unsure if parents were aware of the risks involved to allow the experiment to go ahead. Also, I know Albert was a baby, but I am wondering if any form of assent was taken into consideration especially when he started crying after seeing first fury animal right after the conditioning had occurred. Even though now it is seen as unethical, I am just wondering why he was still introduced to other fury things right after he had started crying. The article also introduced the word dissent and how it can be used by behaviour analysts and clients to indicate a need for a break (p.916). This is a necessity as it reduces non-compliance and gives the client power to stop an intervention whenever they feel uncomfortable or tired. The article also highlighted the importance of behaviour analysts to familiarize themselves with their clients (p.917). This will help behaviour analysts to identify cues of when a client rescinds their decision to assent especially for clients that are non-verbal. It is the role of the behaviour analyst to know all details of their client no matter how small the information is to better serve them efficiently and effectively.
Graber and Maguire (2024) emphasized on the need for the person who gives informed consent to be clear-sighted mentally and emotionally (p.390). This is because some interventions may have harmful effects, and it needs to be thought through carefully before it is considered. Choosing a medical proxy is very crucial especially when it comes to people in the vulnerable population as these decisions can lead to best or worse care. For example, there was an elderly stroke patient in the ward when I was completing my medicine rotation back in university. He had an ex-wife and was married to a new wife 2 years prior. When he was admitted, his new wife brought a legal document stating she was the medical proxy and was the only one that could make medical decisions. Throughout the one month he was at the hospital, we hardly saw the new wife and it was always the ex-wife coming to his bed side to care for him. We would call the new wife about his medications, but we would hardly get her on the phone. He eventually ended up on life support and the new wife requested he is taken off. Ex-wife was very upset but there were little doctors could do as there was a legal document obligating them to take it off. This was the first time I heard of medical proxy.
In all three articles, they clearly discussed the importance of seeking consent before initiating any form of interventions. Flowers and Dawes (2023) also highlighted some gaps in research on consent and assent and the need for more research especially for those clients that are non-verbal. The articles also clearly defined consent and assent which made it easy to read. The only criticism I have is that in Graber and Maguire (2024) I was expecting an example from ABA about legal cases of consent as this would have made it more practical.
In conclusion, consent and assent help behaviour analysts actively involve their clients, parents and caregivers in their care. It also protects clients from harm. Moreover, there should be more laws in place about consent and assent to protect all clients with autism and developmental disabilities.
References
Breaux, C.A., & Smith, K. (2023). Assent in applied behaviour analysis and positive
behaviour support: Ethical considerations and practical recommendations.
International Journal of Developmental Disabilities, 69(1), 111-121.
Flowers, J., & Dawes, J. (2023). Dignity and respect: Why therapeutic assent matters.
Behavior Analysis in Practice, 16, 913-920. https://doi.org/10.1007/s40617-023-00772-6
Graber, A., & Maguire, A. (2024). Clinical informed consent and ABA. Behavior
Analysis in Practice, 17, 389-400. https://doi.org/10.1007/s40617-023-00902-0
