Consent, Assent, and a Restrictive Procedure
A residential program serving adults with intellectual disabilities proposes a response-blocking and brief physical-guidance procedure for a 27-year-old man who engages in hand-to-mouth behavior that staff describe as potentially harmful (placing non-food items in his mouth). The man can express preferences verbally but has a legal guardian. The behavior analyst has a signed consent from the guardian for the behavior plan. The man has said "no" and pulled away during two prior attempts at physical guidance. The team argues the procedure is necessary for safety and that guardian consent is sufficient. The analyst must decide whether to proceed, modify, or decline.
1. Analyze the consent and assent issues. What must the analyst do before any restrictive procedure is implemented?
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Guardian consent is necessary but not sufficient. Behavior analysts must also seek the client's assent, especially when the client can communicate preferences, and must respect indications of dissent. The man's verbal "no" and pulling away are clear dissent signals.
Before proceeding, the analyst must:
- Confirm the risk is real and documented: has he actually ingested dangerous items, how often, and with what consequences? "Potentially harmful" is not enough to justify restraint-like procedures.
- Conduct a functional assessment to determine why the behavior occurs (attention, automatic/sensory, access). If the function is sensory, less restrictive alternatives such as competing stimulation or enriched environment may suffice.
- Review less restrictive options first: environmental arrangement, supervision, offering safe chew items, teaching an alternative response.
- Revisit consent: ensure the guardian's consent was informed about the specific procedure, risks, and alternatives, and that the client's dissent was communicated to the guardian.
- Document the assent process and the dissent.
If less restrictive options are untried or the risk is not well documented, the analyst should not proceed with physical guidance. If risk is severe and alternatives fail, the analyst should pursue a formal review (human rights committee, peer review) and a plan that minimizes restriction and builds in frequent reassessment.
2. The team says guardian consent settles the matter. How should the analyst respond, and what would justify declining to implement the plan?
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The analyst should respond that consent is a process, not a signature. Guardian consent authorizes the guardian's decision-making role, but it does not override the analyst's ethical obligations to the client, to use the least restrictive effective procedure, and to honor expressed dissent where possible.
The analyst should explain, in plain terms to the team:
- The procedure is restrictive and carries risks (injury, escalation, damage to therapeutic relationship).
- The client has communicated "no" twice, which must be taken seriously and documented.
- Less restrictive alternatives have not been shown to fail.
- A functional assessment has not established the function of the behavior.
Grounds for declining to implement:
- Insufficient evidence of serious harm.
- Untried less restrictive alternatives.
- Inadequate functional assessment.
- Client dissent not addressed or resolved.
- Absence of required review by a human rights or peer review committee.
Declining is not abandonment: the analyst should offer to design and supervise a less restrictive plan, help the team pursue review if needed, and document the decision and rationale. If the team proceeds without the analyst, the analyst should follow organizational and regulatory reporting procedures. The guiding principle is that the client's safety and dignity, not administrative convenience, drive the decision.