Technical Report

Facilitated Communication

Subcommittee on Facilitated Communication of the Ad Hoc Committee on Auditory Integration Training and Facilitated Communication


About this Document

This technical report was prepared by the American Speech-Language-Hearing Association's (ASHA) Subcommittee on Facilitated Communication of the Ad Hoc Committee on Auditory Integration Training and Facilitated Communication: Stephen Calculator (subcommittee chair), David Fabry (committee chair), Sharon Glennen, Barry Prizant, Anoja Rajapartirana, Annegret Schubert, Diane Paul-Brown (ex officio), Diane Eger (vice president for professional practices in speech-language pathology, 1991–1993) and Crystal Cooper (vice president for professional practices in speech-language pathology, 1994–1996). The committee acknowledges the assistance of Louise Zingeser in the development of the technical report.

October 4, 1994. A minority of the appointed committee who do not agree with the majority have expressed their views in a separate statement. [The minority statement follows this report—ED].



Introduction

Facilitated communication (FC) is a technique in which physical, communication, and emotional support is provided by a facilitator to an individual with a communication disorder (communicator). With assistance, the communicator points to symbols such as letters, pictures and/or objects. ASHA established an Ad Hoc Committee on Auditory Integration Training and Facilitated Communication in 1992. A subcommittee on facilitated communication was charged with preparing a technical report on facilitated communication as an intervention for persons with autism and other severe communication disorders. The primary purpose of this report is to define and describe facilitated communication, present current research findings in facilitated communciation, and offer suggestions for its use in clinical practice. It was not ASHA's intent to issue a position statement at that time, since such a course of action was considered premature in light of the contradictory and conflicting results of the investigations that attempted to assess the merits of this technique. Instead, committee members were charged with describing research findings to date; addressing the impact of facilitated communication on the scope of practice of speech-language pathologists; reviewing standards for implementation, preservice, and in-service education of speech-language pathologists; discussing ethical issues; and proposing future research needs. The committee was composed of speech-language pathologists, parents, and researchers who represented diverse opinions and positions concerning the validity and efficacy of this method. Individual thoughts were continuously challenged and sometimes modified through interactions with other committee members.

The committee was formed in response to inquiries from ASHA members, health care and education professionals, consumers, administrators, and others seeking information about facilitated communication. Professionals, parents, and others have reported unexpected communication and literacy skills from individuals considered to have severe communication impairments. Some of these individuals had also been diagnosed as severely to profoundly intellectually disabled. Professionals and others have questioned the extent to which such outcomes reflect the actual abilities of individuals using this method (communicators) and not the unwitting contributions of individuals (facilitators) who are supporting them physically, emotionally, and communicatively during interactions. The committee's intention is to present a balanced portrayal of facilitated communication based on our current and evolving understanding of this method. The committee hopes that this document will promote further discussion about facilitated communication and, in time, will lead to a clear statement of policy from ASHA regarding this method.

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Responses of Other Professional Organizations

Several professional organizations have elected to publish position statements on facilitated communication. These statements have consistently recommended caution in applying this controversial method of communication. The American Psychological Association (APA) Council of Representatives issued a press release through their Public Affairs Office on August 24, 1994, that concluded with the statement, “THEREFORE BE IT RESOLVED that APA adopts the position that facilitated communication is a controversial and unproved communicative procedure with no scientifically demonstrated support for its efficacy.” The APA raised concerns about possible violations of civil and human rights associated with use of this method. These included actions toward others following unsubstantiated facilitated accusations of abuse and mistreatment, actions based on messages generated by facilitated communication that are perhaps mistakenly perceived as individuals' personal preferences and wishes, and providing instruction and counseling based on results obtained through facilitated communication.

The American Academy of Child and Adolescent Psychiatry policy statement, approved by Council on October 20, 1993, states that “studies have repeatedly demonstrated that FC is not a scientifically valid technique for individuals with autism or mental retardation. In particular, information obtained via FC should not be used to confirm or deny allegations of abuse or to make diagnostic or treatment decisions.” This same policy has been endorsed by the American Academy of Pediatrics.

Finally, the American Association on Mental Retardation (AAMR) Board of Directors approved the following resolution at their 1994 annual meeting: “A substantial number of objective clinical evaluations and well-controlled studies indicate that Facilitated Communication … has not been shown to result in valid messages from the person being facilitated. Therefore, be it resolved that the Board of Directors of the American Association on Mental Retardation does not support the use of this technique as the basis for making any important decisions relevant to the individual being facilitated without clear, objective evidence as to the authorship of such messages.” (Note: authorship relates to who is creating the message: the communicator, the facilitator, or both).

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Other Sources of Controversy

Facilitated communication has been surrounded by controversy since its inception. The notion of hidden, unexplained literacy skills that seem to appear when facilitated communication is used has contributed to skepticism about the validity of the method, as echoed in the aforementioned position/policy statements. Charges of abuse and other messages with social implications have been communicated using the technique, prompting additional concerns about who is authoring messages — facilitators and/or communicators?

The popular media has further fueled debate about the efficacy of this method by presenting varying reports of the technique's benefit. Early media reports portrayed facilitated communication as a valid method of communication for individuals with autism (Prime Time Live, 1992; New York Times Magazine, 1991; Washington Post Magazine, 1992; CBS News, 1991). Conversely, more recent accounts have indicated that all messages generated through the technique are the sole product of the facilitators (Frontline, 1993; 60 Minutes, 1994; 20/20, 1994).

Widely divergent public opinions regarding facilitated communication have raised ethical concerns by parents and professionals about use of the technique. Others have expressed equal levels of concerns about withdrawing the method. This controversy has created polarized views that cause each side to exhibit a lack of interest in or appreciation of the other's perceptions and the bases for these perceptions (e.g., qualitative vs. quantitative research procedures). This technical report attempts to summarize both viewpoints without ignoring the controversies surrounding the use of facilitated communication.

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Organization of This Technical Report

The technical report begins with a brief review of the history of facilitated communication. Next, the method is described in detail. The role of the facilitator in promoting progressively more independent communication is explained. Populations with whom the method has been employed are described, along with information pertaining to proposed candidacy criteria. The report then reviews legal implications that have arisen in conjunction with facilitated communication, as these have been a primary source of controversies surrounding the method.

Next, extensive reviews of qualitative/naturalistic and quantitative/experimental research are presented, including contradictory outcomes of research related to methodologic and other factors. This is followed by a discussion of concerns and suggestions about current practices related to facilitated communication. The report concludes with recommendations for future research, clinical applications, and suggested principles on which to base the development of a subsequent ASHA position statement for the use of this method.

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History of Facilitated Communication

Before the recent public interest in facilitated communication, there were reports of success with methods involving physical support for communication (Eastham, 1985; Goodwin & Goodwin, 1969; Johnson, 1989; Nolan, 1987; Oppenheim, 1974; Schawlow, 1985; Zoeller, 1989). Rosemary Crossley, an Australian educator and founder of the Dignity Through Education and Language (DEAL) Communication Center in Melbourne, Australia, was the first person to use this method widely. Her initial work, with persons with cerebral palsy, caught public attention through the publication of Annie's Coming Out (Crossley & McDonald, 1980). She later applied the technique to people with a wide variety of disabilities.

Douglas Biklen, professor of special education and currently director of the Facilitated Communication Institute at Syracuse University, studied Crossley's work and then introduced the method in the United States in 1989. His first investigation into facilitated communication was published in the Harvard Educational Review (Biklen, 1990). Subsequent qualitative studies (Biklen, 1990, 1993; Biklen et al., 1991; Biklen, Morton, Gold, Berrigan, & Swaminathan, 1992; Biklen & Schubert, 1991) provided more accounts of children and adults who were using facilitated communication. Responses to these findings from other investigators and the general public varied from enthusiastic to cautiously optimistic to skeptical.

The method has continued to evolve since Biklen's first study (1990). Facilitated communication has been described as an effective technique for individuals with physical disabilities, autism, Down syndrome, multiple handicaps, and mental retardation of various etiologies (Biklen, 1990; Crossley, 1992; Crossley & Remington-Gurney, 1992). It is impossible to estimate the number of individuals who are now using this method; thousands of parents, teachers, speech-language pathologists, paraprofessionals, and others have attended workshops about the technique (Calculator & Schubert, 1993, personal communication). Similarly, it is imposssible to address how facilitators are using and adapting this method; it is unknown how many have discontinued use of the technique.

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Facilitated Communication: The Technique

It should be pointed out that neither the reliability nor the validity of techniques associated with FC, as described below, has been demonstrated at this time. Techniques are based on instructors' clinical experiences and hypotheses.

Facilitated communication requires that facilitators provide varying levels of physical, communication, and emotional support to communicators. Physical support, in the form of backward pressure and resistance, is not intended to guide the communicator's movements but instead to assist the communicator in planning and executing movements. However, there remains disagreement as to the validity of this claim (Datlow-Smith, Haas, & Belcher, 1994). Results of experimental investigations indicate that facilitators can unknowingly influence communicators' typing when using this method of applying backward resistance and support to communicators. Some argue that movements by the communicator that are preferred by the facilitator are not resisted and therefore are permitted, encouraged, and guided, whereas movements that are not preferred by the facilitator are resisted.

Physical support has been cited as essential to overcome hand function and motor planning and thus enable communicators to access their communication systems (Biklen, 1990; Crossley & Remington-Gurney, 1992; Higginbotham, Sonnenmeier, & Duchan, 1993). Such support may range from helping the communicator isolate an index finger, to diminishing degrees of contact at the wrist, elbow, and shoulder. Ultimately, the goal is independent communication in which communication proceeds without physical support from the facilitator (Biklen, 1990; Crossley & Remington-Gurney, 1992; Eastham, 1992; Karp, Biklen, & Chadwick, 1993; Oppenheim, 1974; Schalow & Schalow, 1985).

Schubert (1992) proposed the following features to describe progress toward independent communication:

  1. Diminished levels of physical support.

  2. Decreased communication support (from facilitators) for clarification and verification.

  3. Effective communication with a number of facilitators.

  4. Increased abilities by communicators to initiate interactions.

  5. Use of communication skills in a variety of settings.

In addition to providing physical support, facilitators are expected to provide communication and emotional support. Briefly, communication support may take the form of facilitators phrasing or rephrasing questions to lead to clarification (e.g., by asking yes/no and multiple choice questions, rather than open-ended questions). Schubert (1992) described different types of set work, set play, and set conversation that would foster successful interactions. Set work, set play, and set conversation activities in which the conversational content is predictable and the level of predictability can be adjusted by the facilitator as needed by the communicator. As communicators' abilities to interact effectively progress, the need for conventions that encourage predictability may diminish and conversations then become more open-ended.

Emotional support from facilitators to communicators takes many forms: encouraging, being patient, maintaining high expectations, and assuming that the communicator is competent (Biklen, 1990; Crossley, 1988; Schubert, 1992).

Crossley (1992) described facilitated communication as a technique by which communicators' neuromotor problems (e.g., limited hand function) are addressed systematically. She suggests an alternate term, facilitated communication training (FCT), to describe this method. Crossley defined facilitated communication training as a teaching strategy used with people with severe communication impairment who require augmentative and alternative communication (AAC), who are unable to access a communication aid independently, and for whom such access with their hands is a realistic and desirable goal.

Mirenda (1993, personal communication) placed facilitated communication within the broader framework of AAC when she referred to this method as a form of assisted direct selection. As such, it may be described as a means by which communicators can access a variety of AAC systems (Crossley & Remington-Gurney, 1992; Higginbotham, Sonnenmeier, & Duchan, 1993).

Equipment for facilitated communication users typically has involved the use of simple picture and alphabet communication boards, typewriters, microcomputers, or special typing devices such as the Abovo PCD, Canon Communicator, and the Franklin Speaking Ace (Higginbotham et al., 1993; Schubert, 1992). Considerations for selecting devices include portability, durability, the presence of paper copy, voice output, and visual displays. Other considerations are key size, the force necessary to activate keys, and cost (Higginbotham et al., 1993). Higginbotham and associates suggested that assessment of the communicator's needs, abilities, and preferences should be completed before using any AAC system.

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Populations Using Facilitated Communication

Facilitated communication has been used with individuals with autism and with individuals who exhibit a wide variety of other types of disabilities, including cerebral palsy, Down syndrome, Rett syndrome, and cri du chat syndrome (Biklen, 1993; Crossley, 1992; Crossley & Remington-Gurney, 1992). The method has been applied to diverse age groups (preschoolers through adults), some of whom have been diagnosed as severely to profoundly intellectually disabled and have exhibited minimal or no literacy skills. To date, characteristics of people who benefit from this technique have not been delineated clearly. This point is discussed further in the following section.

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Candidacy for Facilitated Communication Training

General guidelines describe potential users of this method (see below); more specific candidacy criteria are not available at this time. Nor are there specific guidelines that predict those individuals with whom the method will be most useful. As information is collected about the relative success of facilitated communication or lack thereof with various groups of people, it may be expected that more specific candidacy profiles will emerge.

Biklen (1993) stated that candidates for facilitated communication include “people who cannot speak, or whose speech is very limited and who cannot point independently or reliably.” The method has been used with speaking as well as with nonspeaking individuals. It has been used with individuals who are able to point independently (e.g., to objects, pictures, and other types of symbols), and those who are not.

It has been suggested that facilitated communication may be particularly useful for persons who have demonstrated limited ability to communicate through other modes (Biklen, 1993; Crossley, 1992; Schubert, 1992). Crossley (1992) stated that facilitated communication is not the method of choice if other means that are more efficient for the user are available. Other methods include continued efforts to increase spontaneous spoken language, use of sign language or other naturally occurring gestures, use of aided augmentative communication strategies including picture communication boards, and electronic voice output communication aids.

It has also been proposed that there are no prerequisite developmental, educational, or literacy skills for implementing facilitated communication successfully (Biklen, 1993; Crossley, 1992; Schubert, 1992). The method has been introduced to individuals who have been diagnosed as severely to profoundly mentally retarded. Although pre-existing literacy skills have been reported in some of the people who responded positively to the method, Crossley (1993) states that such skills are not a prerequisite to facilitated communication. She contends that such skills may be difficult for the communicator to demonstrate without a viable communication system. Also, she suggests that literacy skills may be taught or that communicators may employ pictures in place of letters and words.

Rather than evaluating individuals' potential to use facilitated communication, clinicians have instead recommended introducing the method and then modifying supports (physical, communication, emotional) as needed by the communicator (Schubert, 1992).

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Facilitator Characteristics and Training

Facilitators, like communicators, comprise a heterogeneous population. They include parents, siblings, peers, teachers, speech-language pathologists, personal care assistants (aides), and others. The need for training facilitators is a prevalent theme in the facilitated communication literature (Crossley, 1992; Schubert, 1992), and several resources are now available to acquaint facilitators with the method (Barker, Leary, Repa, & Whissel, 1992; Berger & Kilpatrick, 1992; Biklen, 1993; Crossley, 1994; DEAL Communication Centre, 1992; Lehr, 1992; Schubert, 1992).

New facilitators are frequently trained at workshops. Workshops often include discussions about interaction strategies (e.g., employing a positive attitude), supports (physical, communication, and emotional), and methods of progressing toward independent communication. On other occasions, training is conducted on-site through technical assistance from experienced facilitators to new facilitators. At this time there are no standardized procedures available for training facilitators, nor are there any certification or licensure requirements for facilitators or for trainers of facilitators.

Core facilitator skills have been identified by Biklen (1990). These include components of presentation/intention (e.g., avoid patronizing people, be apologetic about the assessment process); attitude (e.g., be positive attitude, provide error-free learning opportunities; be direct, firm, and encouraging); assumptions/beliefs (e.g., assume competence, convey the importance of communication); physical support (e.g., attend to person and equipment positioning, provide minimal physical support); other support (e.g., monitor and work toward directing gaze to the equipment, clarify communication breakdowns by narrowing response options, ignore stereotypes, redirect when behavior becomes challenging); and curriculum (e.g., give choices; use age-appropriate, nonoffensive materials; wait for initiation; encourage facilitated communication users to work in groups).

The facilitator is trained to make certain that the communicator is consistently looking at the facilitator (Biklen, 1992a; Crossley & Remington-Gurney, 1992; DEAL Communication Centre, 1992). Facilitators have been encouraged to gradually decrease physical support to increase independence (Chadwick, 1993; Crossley & Remington-Gurney, 1992); to create a communication profile (see Chadwick, 1992, pp. 70–72) or portfolio (Kliewer, 1993) for validation purposes; as well as to teach protest strategies (“No, that is not what I meant!”), verify messages, and avoid anticipating communicators' messages (Schubert & Biklen, 1993). Attention to these issues is noteworthy in light of present controversies surrounding the validity of facilitated communication.

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Legal Implications

Allegations of abuse have received the most attention in the press and other media in terms of legal issues arising with the use of facilitated communication. Senn (1988) estimated the incidence of abuse experienced by people with developmental disabilities to be up to 32% in men and 80% in women. A recent report by a physician responsible for medical examinations following abuse allegations indicated that of 1,096 allegations she followed in a 2-year time span, 13 were made via facilitated communication. There was corroborating evidence for 11 of these allegations (of the 11, 7 were found to have medical evidence of abuse), suggesting that many of these children had been sexually abused (Botash et al., in press). The authors emphasized that these findings neither supported nor refuted the validity of facilitated communication for these individuals.

It is difficult to determine how many allegations of abuse have been made through facilitated communication, or, of such allegations, how many were subsequently corroborated or refuted. There is also no way to estimate the impact of these allegations on the accused parties. Alleged perpetrators have sued facilitators, school districts, and other agencies. No facilitator or agency has been convicted of wrongdoing.

Several safeguards for accused parties have been recommended. Facilitators have been advised to attempt to confirm the allegation with a different, naive, experienced facilitator (Biklen, 1992a; Borthwick, Morton, Crossley, & Biklen, 1992; Morton, 1993; QRFC, 1993). It has also been recommended that for everyone's protection facilitators must understand their role in allegations. This includes monitoring their potential influence on messages conveyed and knowing their legal obligations (Borthwick et al., 1992). Because so many lives are affected in such critical ways when allegations arise, Borthwick and colleagues stated that it is the responsibility of those knowledgeable in facilitated communication to assure that the proper authorities are well educated with regard to the specific individual's ability to communicate and the specific issues that facilitated communication presents.

Professional organizations have offered more stringent guidelines for handling allegations of abuse, and other sensitive matters, when conveyed through facilitated communication. The American Psychological Association recommended that information obtained via facilitated communication should not be used to confirm or deny allegations of abuse (APA, 1994). The American Association on Mental Retardation does not support using facilitated communication in these circumstances in the absence of clear, objective evidence as to the authorship of messages (AAMR, 1994). These guidelines are contrary to the findings of the New York State Court Appelate Division: Second Department, which ruled that “the court … should adequately establish whether this is a reliable and adequate means of communication,” thus leaving it up to individual courts to determine the validity of an individual's communication through facilitated communication (Matter of P. (anonymous), Luz).

The courts have handled the question of authorship in two ways. On some occasions, the rules of the Frye Hearing (Frye v. United States, 293 F. 1013 [D.C. Cir. 1923]), have been applied. Here, a method must be considered scientifically validated before evidence produced by its use can be admitted into court. On other occasions, specific communicators' uses of facilitated communication have been subjected to validation testing (Crossley & McDonald, 1984; Kansas v. Warden, March 30, 1993; New York v. Webb, March 26, 1993; P. [Anonymous] Luz, 595 N.Y.S.2d 541 [App. Div. 1993].

Some cases have been dismissed because message authorship could not be ascertained. Others, however, have led to indictment, adjudication; or conviction (Kansas v. Warden, New York v. Webb; Gwinnett Cty. GA Juvenile Ct. #9931-B36; Walker Cty. GA Juvenile Ct #146 936-071A; Moriarty, 1990).

Although some reports of abuse lead to court cases, others are resolved through confessions by accused perpetrators or dismissals by the potential plaintiffs. As in all allegations of abuse, it is difficult to establish the truth, regardless of the communication mode. Limited ability to communicate (in terms of depth and elaboration) and questions of message authorship complicate the issue with facilitated communication users.

One recent allegation was dismissed when a child's parents demonstrated that she had repeated phrases using facilitated communication exactly as she had overheard them while wandering in their bedroom, without actually being abused. These were phrases that the facilitator did not know about (Heckler, 1994). This reinforces the fact that, as in all kinds of allegations, those claimed to have been made through facilitated communication also must be investigated carefully, and need further corroborating evidence.

Legal implications associated with facilitated communication have extended beyond matters involving alleged abuse. In several cases rights were awarded to use facilitated communication as a means of communication (Jerry & Diane B. v. Le Mars Community School District et al., 1992; P.K. v. Plainfield Board of Education, 1992), and to use facilitated communication within a more inclusive school setting (L. v. Public Schools, 1991). Adult communicators have been granted the right to speak for themselves rather than through a guardian or parent (Crossley & MacDonald, 1984) and to manage their own finances (Silberfeld, Corber, Madigan, & Checkland, 1993). The committee is not aware of any situations that have progressed to the courts in which facilitators have been accused of purposely controlling the output of facilitated communication users to make educational decisions, control their finances and/or speak for them, or of misleading others about who was the author of such messages.

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Facilitated Communication Research

Facilitated communication has been examined using a variety of research paradigms. Qualitative and naturalistic studies have described the method and proposed significant facilitator and communicator behaviors (Biklen, 1990; Biklen et al., 1991; Biklen, Morton, Gold, Berrigan, & Swaminathan, 1992; Biklen & Schubert, 1991; Olney, in press; Sabin & Donnellan, 1993). They have also addressed issues related to validation (QRFC, 1993), independence (Biklen, 1990; Crossley & Remington-Gurney, 1992), movement disorders (Crossley & Remington-Gurney, 1992; Hill & Leary, 1993; Olney, in press), word finding problems (Crossley & Remington-Gurney, 1992), and demographic characteristics (Vicker, 1993).

Experimental research has focused almost exclusively on issues related to validation and authorship (Bligh & Kupperman, 1993; Calculator & Hatch, in press; Calculator & Singer, 1992; Eberlin, Ibel, Volpe, & McConnachie, 1993; Hudson, Melita, & Arnold, 1993; Intellectual Disability Review Panel [IDRP], 1989; Moore, Donovan, Hudson, Dykstra, & Lawrence, 1993; Shane & Kearns, in press; Smith & Belcher, 1993; Szempruch & Jacobson, 1993; Vazquez, 1994; Wheeler, Jacobson, Paglieri, & Schwartz, 1993). These studies relied heavily on blind procedures in which communicators were asked to convey information in ways that precluded facilitators from influencing message content.

Results of experimental investigations consistently fail to support the validity of facilitated communication, and provide repeated examples of facilitators unknowingly influencing the content of messages that they believed were conveyed by the facilitated communication user. Skills demonstrated with this method under controlled conditions were limited to single word responses to pictures (Vazquez, 1994), and a receptive task requiring subjects to point to pictures rather than letters (Calculator & Singer, 1992). Vazquez (1994) also reported on a subject who was able to type sentences about a video that was not seen by the facilitator. Finally, the Intellectual Disability Review Panel (1989) reported three individuals who were successful on a message passing task that required them to convey the identity of a gift to a facilitator who lacked this information.

Results of experimental studies have led many investigators, clinicians, and others to question the validity and value of this method of communication. They have also precipitated policy and position statements from professional organizations, as noted earlier. However, other investigations (qualitative and naturalistic) of facilitated communication contradict conclusions drawn from experimental research and question the validity of the methodologies through which such data have been derived.

The following sections present results from qualitative and naturalistic studies. These findings are then contrasted with results from experimental research. A summary of all research reviewed by the committee is presented in the Appendix. Unless otherwise indicated, investigations appearing in the Appendix are limited to published and in press research reports that have or will appear in peer-reviewed scientific journals.

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Qualitatitive and Naturalistic Studies

Methodology

Investigators have described and attempted to explain the process of facilitated communication through naturalistic studies involving facilitators and communicators. Qualitative research examines phenomena as they occur naturally, generates hypotheses, and attempts to provide insights into what is occurring (Becker, 1969; Glaser & Strauss, 1967). Methodologies have included:

  1. Systematic observations (often videotaped).

  2. Interviews and discussions with facilitators, communicators, and others.

  3. Review of communicators' records, and other techniques drawn from qualitative research (Biklen, 1990; Biklen et al., 1991; Biklen, Morton, Gold, Berrigan, & Swaminathan, 1992; Biklen & Schubert, 1991).

Using these research paradigms, investigators have corroborated facilitators' reports of communicators' skills through a process known as triangulation. In this process the investigator may compare communicators' typed output across different facilitators who may or may not possess prior knowledge about the content conveyed by the communicator. In other situations, typed output is compared with information from other sources such as daily logs, diaries, and so forth.

As consistent as experimental studies have been in failing to support communicators' skills using this method, qualitative and naturalistic results have been compelling in the opposite direction. All of these studies have reported positive changes in the communication skills of individuals following the introduction of facilitated communication. Communication skills for some of these individuals have been reported to involve accurate pointing, with support, to pictures. Other individuals have been found to communicate in more complex ways: yes/no responses to questions or spelled words, phrases and sentences (Attwood, 1992; Biklen, 1990; Biklen & Schubert, 1991; Crossley, 1988; Crossley & Remington-Gurney, 1992).

Research activities in five areas are reviewed below and summarized in the appendix. Qualitative research has examined (a) the role of facilitators, (b) issues of validation, and (c) evidence of independent communication. It has also attempted to provide insight into how facilitated communication could be so useful to individuals who had earlier exhibited marginal success with alternate methods of communication. Two primary hypotheses have been explored in this regard: (d) movement disorders, and, (e) word finding problems.

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Role of Facilitators

As previously described, qualitative studies of facilitated communication have included suggestions for facilitators on how to support the communicator most effectively. More recently, investigators (Duchan, 1993; Sabin & Donnellan, 1993) have begun to analyze interactions between facilitators and communicators, with an emphasis on the role of facilitators as collaborators in the communication process. Based on these observations, they have proposed a model that suggests that facilitated communication, like any other method of communication, involves participants assisting one another with message construction (e.g., facilitators interpret and clarify messages). Others argue that the analogy to a collaborative process is inappropriate in the absence of evidence that the communicator is contributing to the construction of messages (see Shane, 1994).

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Issues of Validation in Qualitative Research

Facilitators have expressed concerns about unwittingly influencing the messages of communicators (Biklen, 1990). Investigators have reported several ways in which facilitators and others have attempted to validate communicators' messages naturally:

  1. Documenting communicators' facial expressions, noises (e.g., laughter), and other behaviors and showing how these correspond with partners' messages and their own typed output (Biklen, 1990; Olney, in press).

  2. Noting changes in communicators' behavior when their facilitated messages are interpreted correctly (Olney, in press).

  3. Unique phonetic spellings or typographical errors (Biklen & Schubert, 1991).

  4. Oral spelling of written messages.

  5. Self-corrections.

  6. Using idiosyncratic expressions without explanations (Olney, in press).

  7. Unusual or unexpected expressions (e.g., swearing, disagreeing with facilitator; Biklen & Schubert, 1991; Olney, in press).

  8. Opposing the facilitator's corrections (Olney, in press).

  9. Displaying similarities with different facilitators (in terms of personality conveyed in messages, content and form of messages, manner in which communicators are facilitated).

  10. Messages and other outcomes vary as the same individual facilitates different communicators (Biklen, Kliewer, & Saha, 1993; Biklen & Schubert, 1991; Olney, in press).

  11. Spontaneous message passing, in which it is claimed and later verified that communicators relate information that was previously unknown to the facilitator (Biklen, 1990; Biklen & Schubert, 1991; Olney, in press; QRFC, 1993). For example, 13 (65%) of the 20 persons involved in the 1-year clinical study conducted by Attwood and Remington-Gurney (QRFC, 1993) were reported to be able to convey unknown information during open conversation; and half (some of whom were different subjects than those above) were able to pass messages in a multiple-choice format. The investigators reported that 17 subjects (87.5%) had their communication validated through either structural or content analysis.

  12. Message passing tasks: Sheehan (1993) found that communicators' abilities to relate unknown information varies from day to day and appears to improve when the content is relevant to them. These findings are consistent with other reports (Biklen et al., 1993; IDRP, 1989).

  13. Parent perceptions: Information pertaining to parents' perceptions of success was provided by Vicker (1993) in a preliminary survey of 233 parents of children with autism. Of these parents, 80 indicated that they were either using or considering facilitated communication for their children; 17 others had used facilitated communication and stopped. For the 42 children who were using facilitated communication at the time the survey was disseminated, 36.9% of their parents associated its use with changes in their perceptions of their children; 31.7% reported changes in their children's communication abilities; and 14.8% of the respondents reported that it was still too early to see changes.

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Evidence of Independence

Independence generally connotes an absence of physical contact between the facilitator and communicator. As such, investigations into this factor are also germane to questions of authorship and validation, as it can be argued that the communicator who is able to type without physical contact from the facilitator is indeed the author of his or her messages. Progress toward independence has been defined as including multiple factors.

Biklen (1992b) described an individual with autism who failed a validation test of his communication in an experimental condition (IDRP, 1989), and then went on to type independently. Evidence of independent typing was also reported by Crossley and Remington-Gurney (1992), who defined independence (in facilitated communication training) as sentence-length typing without physical support. These investigators reported that 30 of 118 individuals who were labeled as severely intellectually impaired and autistic eventually typed independently, some within 6 months, others taking up to 6 years.

Other studies have reported that facilitated communicators are making progress toward independent typing. Progress is connoted by diminished levels of physical support (e.g., with a hand on the shoulder, leg, thread of sleeve, or other location) required from facilitators. Biklen (1990) noted that 12 of 21 students he observed exhibited such changes, and 6 of these students communicated independently much of the time with two or more different facilitators.

Attwood and Remington-Gurney (QRFC, 1993) pointed out that many of their clients seemed to be unsure if they wished to type independently. This finding indicates to some that achieving independence requires social-emotional support as well as motor skills. Despite this reported reluctance, communicators have been cited as making progress toward independent typing in the QRFC and other studies (Biklen, Saha, & Kliewer, 1993; Karp, 1993; Sabin & Donnellan, 1993).

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Movement Disorder Hypothesis

Some researchers have hypothesized about why facilitated communication may be helpful to individuals who earlier had derived comparably little benefit from other types of communication instruction. Perhaps more than any other reason, movement difficulties have been implicated as a possible factor to explain discrepancies in communication performance with and without facilitated communication (Hill & Leary, 1993; Oppenheim, 1974).

Support for a movement hypothesis comes from a variety of sources. Several individuals with autism who have written or co-authored autobiographies discuss their difficulties controlling movement (Barron & Barron, 1992, p. 60–63, 200, & 237; Grandin & Scariano, 1986, p. 22, 30; McKean, 1994, p. 45; Williams, 1994, p. 29). This difficulty is echoed in the writings of people who use facilitated communication, such as Nolan (1987, p. 56), Eastham (1993, p. 60) and informants in qualitative studies (Biklen et al., 1991, 1992; Olney, in press).

Biklen's (1990) observations, and his review of earlier work conducted by Maurer and Damasio (1982), led him to theorize that facilitation may compensate for movement disturbances (dyspraxia) that otherwise prevent individuals from independently accessing communication displays. Similarly, Sabin and Donnellan (1993) hypothesized that facilitation may be “an individualized accommodation [by facilitators] to a movement disturbance” (p. 208).

Hill and Leary (1993) suggested the presence of movement disturbances in individuals with autism in their review of the literature on movement disturbance in recognized neurological disorders such as Tourette syndrome, Parkinson disease, and catatonia, and a subsequent review of the literature on autism. They found considerable overlap in movement-related symptoms, with 24 of 36 movement characteristics as described by Rogers (1992) on the Modified Rogers Scale also applying to autism.

Crossley and Remington-Gurney (1992) reported that more than 90% of the 430 individuals with autism or intellectual impairments assessed at their center showed a variety of motor difficulties involving hands. Olney (in press) described an individual who typed with a jabbing motion when perseverating and a tentative, light motion when he produced novel information. A similar variation was noted in this individual's speech, which varied from loud, high, and monotone when using perseverative speech, to soft and low when producing meaningful speech.

In concluding this section, it should be pointed out that movement hypotheses are possible explanations for unexplained phenomena. Their significance in explaining communication performance and/or the ability of specific individuals to benefit from facilitated communication instruction (as opposed to other methods of AAC) has not been demonstrated. This is an area in need of further research before conclusions may be drawn.

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Word-Finding Problem Hypothesis

Some have hypothesized that, in addition to movement disorders, individuals who use facilitated communication may be experiencing word-finding problems. This has been cited (Biklen, 1993; Crossley, 1992) as a potential explanation for individuals' inabilities to perform successfully on formal, experimentally controlled validation tests, particularly those that involve confrontation naming and similar tasks.

Although none of the qualitative studies to date have addressed this issue, relevant information has been reported from qualitative analyses of experimental research as well as from clinical studies. Subjects in the IDRP (1989) study gave semantically related answers (e.g., black for blue), with the specific answer evident only after probing and verification by the facilitator.

Crossley & Remington-Gurney (1992) indicated that individuals' word-finding problems (as noted in perseverating on specific letters or words) were generally less severe in their written than in their spoken language. They also identified individuals who used written language to cue their speech (e.g., by typing the first letter they appeared more able to retrieve a corresponding spoken word). Attwood (1992) reported similar findings. Vazquez (1994) indicated that a student was able to label items under controlled conditions when a game format was used. This format was designed to diminish the levels of anxiety associated with confrontation naming tasks. When reviewing the task, however, there seems to be little difference between it and various experimental tasks involving naming, as noted in the following section.

It is possibe that word-finding problems can contribute to the communication problems of some people with autism or other disabilities who use facilitated communication, but no more so than for individuals using other methods of communication. Word-finding problems should be examined in conjunction with other components of a complete AAC assessment. Where such evidence is identified, accommodations should be made in conducting and interpreting the assessment battery. Again, this consideration applies for users of facilitated communication and other individuals with communication disorders.

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Summary of Qualitative Research

In reviewing results displayed in the appendix, qualitative and naturalistic studies have reported unexpected literacy and communication skills in facilitated communication users. These skills have been associated with a variety of positive outcomes, including enhanced perceptions by others (Vicker, 1993), increased success including these students in regular education classes and curriculum (Biklen et al., 1992), positive changes in behavior (Biklen et al., 1992; Calculator & Singer, 1992; Olney, in press), and generalized use to other forms of communication (Olney, in press).

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Experimental Research

The validity of outcomes from qualitative research has been questioned by contradictory findings from quantitative, experimental research. While qualitative investigations cite progressions toward independent pointing (i.e., diminished needs for physical support) as a measure of success, quantitative investigators argue that any contact between the facilitator and communicator raises the possibility of facilitator influence or unwitting authorship of the communicators' messages.

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Experimental Methodology

Experimental studies have used three primary research designs to assess the validity of facilitated communication. One design uses message-passing tasks in which the communicator is asked to describe an object or relate an event that the facilitator has little or no information about. An alternative procedure, referred to as a blind procedure, requires the communicator to respond to stimuli that are not shared with the facilitator. For example, the communicator may be asked to label a picture that the facilitator did not see, or answer a question that the facilitator was prevented from hearing through the presentation of white noise, music, or removal from the testing area.

A third procedure accompanies a blind with various distractor conditions in which the facilitator and communicator are provided the same or different information. Neither participant is aware of the stimulus being presented to the partner. When communicators respond by conveying content shared only with the facilitators (and not them), the authorship of the message is questioned. Conversely, when communicators convey content to their facilitators that they alone know about, the belief that communicators are authoring their own messages is supported.

Results of experimental investigations (summarized in the appendix) have been highly consistent and indicate that communicators are typically unable to respond accurately unless their facilitators have access to the same information. When facilitators and communicators are presented different stimuli, communicators are often found to type out responses to the stimulus viewed only by their facilitator, rather than what they themselves saw. When communicators are presented with stimuli and facilitators are not, communicators are typically unable to respond correctly. Conversely, communicators respond correctly in these same experimental tasks when exposed to the same stimuli as their facilitators.

Bligh and Kupperman (1993) found that a child was unable to respond to questions that were presented in written form unless the facilitator viewed the same question and knew the answer. Situations in which the facilitator had no knowledge of the correct answer, and those in which the facilitator was not shown the question presented to the child, resulted in incorrect responses by the child.

Similar results to visual stimuli have been reported by other investigators (Datlow-Smith, Haas, & Belcher, 1994; Klewe, 1993; Regal, Rooney, & Wandas, 1994; Shane & Kearns, 1994; Szempruch & Jacobson, 1993; Wheeler, Jacobson, Paglieri, & Schwartz, 1993). In these investigations communicators were consistently unable to name or describe visual stimuli unless these same stimuli were presented to their facilitators. The investigators related numerous incidents that led them to conclude that facilitators were influencing communicators' typing. These typically involved situations in which communicators labeled pictures viewed only by their facilitators. Again, communicators had little difficulty naming pictures that were viewed concur rently by their facilitators. These results led the respective investigators to the same conclusions: There was no evidence that communicators authored their own messages; to the contrary, it appeared that all messages attributed to communicators were instead authored unknowingly by their facilitators.

Procedures involving the auditory presentation of stimuli have yielded similar results. For example, Moore, Donovan, Hudson, Dykstra, and Lawrence (1993) reported that communicators were unable to answer questions when their facilitators were blocked from hearing these same questions by presenting music to them through headphones. Comparable findings occurred when facilitators received different questions, or did not know the answers to questions that were presented to communicators (Hudson, Melita, & Arnold, 1993; IDRP, 1989).

When communicators have demonstrated communication skills under experimentally controlled conditions, investigators have reported that such findings were neither surprising nor unexpected, given the backgrounds (e.g., educational background, previous assessment results) of these individuals before facilitated communication was introduced. For example, Eberlin, Ibel, Volpe, and McConnachie (1993) required their 21 subjects to identify pictures, define words, provide yes/no answers, and then respond to progressively more abstract responses to open-ended questions about their personal preferences and feelings (e.g., “How do you feel about school?”). The 2 (of 21) subjects who answered questions successfully through facilitated communication were also more capable when responding to questions with their own speech. Both of these subjects had exhibited typing, reading, and writing (literacy) skills prior to the introduction of facilitated communication and had also displayed relatively strong language abilities, in comparison with subjects who were unsuccessful in these tasks.

Smith and Belcher (1993) compared communication skills using facilitated communication and communication skills without facilitated communication. Facilitators asked progressively more open-ended questions of eight communicators. Typed responses were found to be consistent with subjects' verbal output. Communicators who had no speech abilities typed letters randomly. Those who typed intelligibly with facilitated communication had prior independent reading and writing skills.

Similarly, Calculator and Hatch (in press) found that their subject's responses reflected literacy skills and semantic problems that were consistent with what might be expected given existing information about previous test results and the communicator's prior educational experiences. Their subject was able to name pictures orally yet unable to type the names for these same pictures (Note: facilitators were auditorily blocked from hearing the subject's speech).

A review of the experimental studies in the appendix indicates a preponderance of evidence that refutes the validity of facilitated communication. In studies reviewed by the committee of the 143 subjects involved in validation testing, 11 have exhibited unexpected levels of literacy and communication skills using facilitated communication. It should be pointed out, however, that of these 11 subjects (a) four exhibited their skills in a receptive task involving picture pointing. This task did not require any spelling or other expressive communication by the subjects (Calculator & Singer, 1992); (b) three subjects exhibited evidence to validate their use of facilitated communication, but were unable to demonstrate their skill across different tasks (Heckler, 1993; Vazquez, 1994); (c) four subjects exhibited valid communication, yet were still found susceptible to facilitator influence in that their facilitators were determined to unwittingly author messages for them on other occasions (IDRP, 1989).

Calculator and Singer (1992) reported that four of five subjects performed significantly better on a test of receptive vocabulary—the Peabody Picture Vocabulary Test-Revised (Dunn & Dunn, 1981)—when facilitated than when asked to respond to items independently. Facilitators wore ear plugs, received white noise through headphones, and were asked to look away as the examiner presented test items. In the IDRP (1989) study, the investigators concluded that four of the six individuals who were tested were able to formulate their own messages when facilitated. One individual was successful in using a procedure in which different stimuli were presented to facilitators and communicators via headphones. Three other individuals exhibited skills in a message-passing task in which they had to divulge information about a gift they received from the experimenters in the absence of their facilitator. The investigators argued that these results indicated several subjects communicated through facilitated communication. However, they also noted that all six individuals were susceptible to facilitators influencing the message content.

Vazquez (1994) described two communicators who showed inconsistent abilities to convey novel information to their facilitators in another message passing task. Communicators viewed videotapes and then described them to their respective facilitators. One communicated through facilitation with support at the shoulder that a videotape about canoeing was about sailing. In another task, a different communicator was able to name 9 of 10 objects that were hidden from the facilitator's view. The subject often verbally named objects during the task. However, the investigator noted that the subject responded without facilitator influence on five of the trials. On three of these five trials, the subject, who had previously required support at the wrist, pushed the facilitator away and typed independently.

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Summary of Experimental Research

Experimental research has provided minimal support for the validity of facilitated communication. Eleven of 143 subjects have “passed” validation tests. Yet none of these subjects has exhibited levels of communication skill that are consistent with their facilitators' reports. This may be due in part to the nature of these tasks, which have relied heavily on one word responses, sentence completion tasks, and other simple responses. In one apparent exception to the use of a single word task, Calculator & Hatch (in press) required the subject to maintain a conversation with the examiner while his facilitator's hearing was intermittently blocked. The task was designed so as to not constrain the complexity or novelty of the communicator's responses. The subject responded contingently and accurately when his facilitator heard input directed to the subject. However, when the facilitator's hearing was blocked responses were consistently off-topic.

Finally, experimental investigations have not only failed to validate facilitated communication, they have also repeatedly documented instances of facilitators unwittingly authoring messages for communicators. Authorship issues continue to be a major concern of qualitative as well as experimental research.

Just as the positive results of qualitative researchers have been questioned, so too have the preponderance of negative outcomes arising from experimental research. In particular, various methodologic concerns have been raised: (a) the use of confrontation tasks that may exacerbate word finding difficulties, (b) insufficient time for subjects to become familiar with tasks presented, (c) use of unnatural settings, (d) unfamiliar examiners, (e) stressful nature of the testing context, (f) use of conditions, such as distractors, that alter the facilitated communication process, (g) inappropriate use of the technique by facilitators, (h) failing to allow subjects sufficient time to respond, (i) lack of information about subjects' pre-existing communication and related skills, (j) lack of experience with test taking, and (k) failed confidence (Biklen & DuChan, in press; Biklen, 1993, Crossley, 1994). Future investigations should make every effort to address these issues.

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Summary of Research

Disagreements about the usefulness of facilitated communication relate directly to how success is defined. Results may be interpreted differently when success rests on demonstrations of communication effectiveness under experimentally controlled conditions, without consideration of other changes in behavior and quality of life.

Entering into this debate is the question of authorship. Few would disagree that independent pointing or typing validates authorship. However, progress toward independence is also viewed by some as an indicator of success. Authorship remains an issue both in persons who do and those who do not pass formal validation tests. Validation of authorship in one situation does not automatically verify communicator authorship of every message that follows. Similarly, a failure to validate in one situation does not preclude an individual's ability to author messages in other situations. Certainly, communicators' skills, like those of all individuals, are expected to vary to some extent in different contexts and settings (Biklen, 1993; Calculator & Singer, 1992; Calculator & Hatch, in press; Duchan, 1993; Hudson, Melita, & Arnold, 1993). This was illustrated by the case of an individual who failed an experimental validation test (IDRP, 1989) and yet went on to type independently (Biklen, 1993).

Experimental research and qualitative research offer different perspectives on facilitated communication, especially with regard to validation. It is thus perhaps not all that surprising that results of investigations in these respective realms have consistently contradicted one another and, in the process, confused the public and professionals looking for clear direction.

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Concerns Related to Current Practices and Corresponding Suggestions

Concerns about facilitated communication relate largely to efficacy. Additional attention focuses on the role of facilitated communication relative to AAC, candidacy, and developing a generally accepted definition of the method. Each of these areas is examined below.

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Efficacy

Many research and application questions remain open with the facilitated communication technique. Some researchers involved with failed validation studies conclude that there is no merit to the technique and it should be abandoned, others agree on the need for more research into how and why this technique works or fails. People with disabilities as well as professionals will clearly benefit from further research, and will benefit even more if researchers in all traditions stay abreast of each other's results and integrate what others have found in their own research questions and designs. Qualitative studies should continue to focus on concerns such as increasing levels of independence, literacy skills, and the effect of multiple facilitators. Experimental researchers should continue to strive to develop designs that do not disrupt the process (facilitated communication) that they seek to understand.

Although positive behavioral changes have been reported following the introduction of facilitated communication (Saxe, 1993; Vicker, 1993), it is not yet known how long such effects persist. There have also been reports of increased behavioral problems (Vicker, 1993), as well as shutting down and becoming more withdrawn after a short period of success (Prizant, personal communication, 1994). This is an area that needs further investigation.

Issues of authorship and facilitator influence have paramount significance here as well. The previous review of research indicates that all results, quantitative and qualitative, require close inspection, cautious interpretation, and reticent generalization.

The committee is aware of efforts around the country to develop position statements and policies related to the introduction and continued use of facilitated communication. As policies are considered, it is critical that consumers' voices are heard (and/or represented by others) and considered. Regardless of media or other pressures, the decision to use or to terminate facilitated communication can be expected to have a major impact on peoples' lives. Speech-language pathologists and others are encouraged to base decisions on professional ethics.

The process of evaluating functional communication outcomes is a vital aspect of any treatment plan, including treatment methods involving facilitated communication. Crossley and Remington-Gurney (1992) state that communicators who are not making progress toward independent communication should be re-evaluated, with consideration of other communication methods. Methods of evaluating functional outcomes can encompass both qualitative and quantitative techniques. Qualitative indicators of success, discussed previously, include conveying novel information to facilitators, message passing, or requiring decreasing levels of physical support from facilitators. Quantitative tasks may include sentence completion, message passing, conversations (with and without blinds) and a variety of other procedures discussed earlier. Special modifications and provis ions associated with testing individuals with severe communication disabilities (e.g., assuring that individuals are familiar with tasks and materials that are presented, allowing sufficient time to respond, relying on naturalistic assessments that reflect daily experiences, and so forth) should be applied to research involving facilitated communication users, just as they are with individuals who rely on other methods of AAC.

Attempts to verify independent communication free from facilitator influence need to be evaluated through objective methods that can be replicated within the clinical setting. Ideally, a combination of quantitative and qualitative data should be gathered in the process of evaluating functional communication outcomes. This approach may help resolve disagreements regarding the efficacy of facilitated communication in individual cases (Calculator & Hatch, in press).

Potential users, family members, and other consumers should be apprised of the ongoing research on facilitated communication, including the results of validation work to date. Potential risks should be outlined and informed consent should be obtained before proceeding with this method, as is consistent with the Code of Ethics (ASHA, 1994).

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Role of Facilitated Communication Relative to AAC

Facilitated communication may be best viewed and introduced in the broader context of AAC. The introduction of facilitated communication should not preclude other methods of communication. To the contrary, all methods of communication should be promoted, and individuals should be encouraged to use multiple modes of communication. If facilitated communication support is withdrawn for whatever reason, other communication options should be available for children as well as adults. The search for effective methods of communication should be an ongoing practice that accommodates changes in technology, clients' abilities, and other relevant factors.

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Candidacy

Some may argue that candidacy procedures are unnecessary until the method of facilitated communication is validated. In other words, no one is a candidate for a procedure that lacks validity. A less extreme position may call for well-delineated practices and procedures related to candidacy selection. These activities might begin by defining facilitator and communicator behaviors that are associated with positive and negative outcomes.

As was indicated earlier, there are few guidelines concerning candidacy for this method. To begin developing these guidelines, investigators and others should not only share success stories but also accounts of individuals with whom the method has been marginally successful or unsuccessful. If information is shared only on extreme successes or failures, parents and other consumers have incomplete data to identify candidates for facilitated communication training.

Many of the definitions and much of the research in facilitated communication reflect work with spelling and literacy, neglecting the use of facilitated communication with pictures, objects, or other symbol systems. Emphasizing broader communication perspectives might improve candidacy selection and application of the method.

One tenet of facilitated communication is assuming competence. This tenet is never clearly defined in the literature on facilitated communication, and has been applied in ways that range from assuming intact social and cognitive abilities and comprehension to the more conservative position of assuming the potential for more sophisticated communication ability than has previously been attributed to an individual. The lack of clarity in this underlying principle may lead well-intentioned facilitators to unwittingly influence typed output or apply rich interpretations to difficult-to-decipher messages. Conversely, assuming incompetence may lead professionals or families to exclude individuals from access to facilitated communication or other intervention.

Given the current controversy surrounding authorship and independence, it might be argued that facilitated communication should only be considered when other ways to improve expressive communication abilities have been unsuccessful. Debate continues on how to validly measure individuals' potential to communicate using facilitated communication. Some argue that such potential may not be fully revealed until after the introduction of facilitated communication training. The decision to use facilitated communication remains a matter of individual choice made by professionals, families, and the communicator.

Candidacy decisions for facilitated communication should be based, in part, on the results of a complete speech and language evaluation that is conducted by professionals trained to work with individuals with severe communication impairments. The use of facilitated communication as a potential intervention method should be systematically evaluated within the broader context of evaluating a prospective client's use of independent AAC strategies. The use of a multimodal approach allowing the expansion of independent communication skills cannot be stressed enough. Independent communication is always preferable to assisted communication, as long as the independent skills allow the person to meet his or her communication and cognitive potential.

ASHA has developed a competency list that reviews the range and scope of skills necessary for providing services to nonspeaking persons (ASHA, 1989). These competencies include:

  1. Evaluating an individual's current communication abilities.

  2. Determining the need for augmentative communication.

  3. Determining specific augmentative communication strategies to maximize functional communication.

  4. Developing AAC intervention plans and evaluating functional communication outcomes of those plans.

It is the committee's contention that if facilitated communication is to be viewed in the broader context of AAC, persons involved with this method require expertise in AAC and facilitated communication. Speech-language pathologists should be involved in the decision making and implementation process.

Facilitated communication training should extend beyond overviews of basic information and issues, many of which have been discussed in this report. Prospective facilitators should be trained to implement the method and continually expand their training as knowledge in the area grows and becomes more refined. Facilitators who lack skills in AAC should work in conjunction with professionals who possess this knowledge.

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Research Recommendations

Continued research is essential in light of the various concerns that have arisen in relation to facilitated communication. Some areas to pursue are discussed below.

Further research must address the questions of message authorship and validation, with particular emphasis on understanding or confirming communicators' lack of success in experimental validation studies to date. It must be determined to what extent these failures are representative of communicators' abilities to communicate outside experimental settings vs. artifacts of testing in contrived situations. Assessment protocols should be designed with particular attention to internal validity.

Researchers in the experimental and qualitative traditions are encouraged to collaborate in order to design valid, mutually agreed-on procedures for probing validation. Also, individuals and groups must ask themselves what types and amounts of evidence are necessary in order to accept results of validation testing, and then act accordingly.

Further descriptive research examining the communication process that takes place during facilitated communication is warranted. Studies might examine the facilitator-communicator dyad in facilitated communication, and compare this to other methods of AAC and spoken communication. Such research might also be helpful in delineating the qualities of “good” facilitators. Once again, such a determination will depend on researchers' definitions of facilitated communication and successful outcomes, and their choice of methodology.

An area of particular interest concerns the methods by which facilitators may inadvertently cue communicators during message transmission, resulting in authorship by facilitators. How can we explain the facts that (a) influence occurs without facilitators' awareness, and, (b) communicators who may have been relatively uninfluenced by prompts and cues during previous forms of instruction are able to act in response to such subtle resistance from facilitators? Are there ways of providing feedback to facilitators, through instruction, to advise them when they are inadvertently influencing communicators by leading them to particular locations on letter boards and other visual displays?

Research detailing changes that occur in people's lives following the introduction of facilitated communication, in terms of communication, behavioral, lifestyle, medical and financial changes, and so forth would be useful. As indicated earlier, the direction (positive and/or negative) and longevity of such changes are critical questions. It may also be of interest to examine the impact of validation testing, relative to the outcomes of such testing on facilitators', communicators' and others' lives.

Detailed subject descriptions are necessary, regardless of which research methodology is chosen, if we are to begin to differentiate which persons could be most helped by facilitated communication. Minimally, information should be provided about subjects' language and communication abilities, prognosis for speech, previous medical and educational diagnoses (and the basis for such diagnoses), previous communication training and its effectiveness, previous literacy training and its effectiveness, and education. Descriptions of facilitators' training and experiences, and the duration and manner in which facilitated communication was introduced and progressed would also be helpful in interpreting and generalizing from the results of future investigations.

Based on the apparent success of facilitated communication with some individuals, questions have been raised regarding the validity of previous research and knowledge about autism and related disabilities. For example, some authors have stated that autism should no longer be viewed as a disability that primarily affects social relatedness and communication knowledge and skills, a position currently accepted as the core symptoms of the syndrome (APA, 1994).

If classic descriptions of autism and other types of disability are inaccurate, it is critical that they be modified based on new empirical data. For example, what support is there for the central hypothesis on which facilitated communication rests (Biklen, 1993): that its users, and people with autism in general, are impaired in movement rather than social cognition and social relatedness? To advance such a hypothesis in the absence of supporting data is premature at best, and certainly not useful in efforts to develop appropriate services and supports for individuals with severe disabilities. This hypothesis has been offered without addressing persons with autism who are better able to communicate through speech, and whose primary difficulties appear to be in the areas of social cognition and relatedness rather than movement.

Definitions of what constitutes success with facilitated communication vary from one investigator to the next and one facilitator to the next. When the definition of success goes beyond communication to include changes in attending, on-task behavior, others' perceptions of individuals, decreased incidents of challenging behavior, and so forth, we may be comparing different phenomena as we attempt to reconcile differences in results across investigations as well as different interpretations of the same investigation. Researchers need to be explicit in stating how they define and measure success.

Research should address both successes and failures in the use of facilitated communication. The conditions under which each result is achieved should be described in detail.

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Final Recommendations

This technical report is intended to promote further public discussion about facilitated communication and, in time, a policy statement from ASHA regarding this method.

Neither the reliability nor the validity of techniques associated with facilitated communication have been demonstrated satisfactorily at this time. Techniques are based on trainers' clinical experiences and hypotheses.

Facilitated communication may be best viewed and introduced in the broader context of AAC. The introduction of facilitated communication should not preclude other methods of communication. To the contrary, all methods of communication should be promoted, and individuals should be encouraged to use multiple modes of communication.

If facilitated communication support is withdrawn for whatever reason, AAC and other communication options should be available to consumers. The search for effective methods of communication should be an ongoing practice that accommodates changes in technology, clients' abilities, and other relevant factors.

It is important to note that this technical report is based on published and in press research that was available to the committee through April 1994. Given the flurry of activity in this area, it is reasonable to assume that significant new findings that challenge statements made in this document may appear in the near future. Clinicians and others are encouraged to keep apprised of the latest findings concerning facilitated communication.

Based on research available at this time, it is the recommendation of this committee that speech-language pathologists and others who are or will be engaged in providing facilitated communication instruction should:

  1. Receive state-of-the-art training in this method and also possess competency across the various aspects of AAC.

  2. Be aware of the latest research related to facilitated communciation, and the legal, social, educational, and emotional implications of these findings to consumers and others.

  3. Take measures to assure that consumers are aware of the potential benefits and risks associated with this method, and obtain informed consent from consumers, legal guardians, and others prior to proceeding.

  4. Systematically evaluate functional communication outcomes of individual communicators, using a combination of qualitative and quantitative indicators of success. Communicators who are not making progress toward independent communication should be re-evaluated with consideration given to other methods of communication. This is particularly important for individuals who rely on facilitated communication as a primary mode of communication.

  5. Rely on multiple sources of information in making educational and other major life decisions, rather than relying on content conveyed solely by facilitated communication. Be certain to assure communicators' active involvement in all decisions effecting them, and hold paramount these individuals' rights to communicate.

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Crossley, R. (1992). Getting the words out: Case studies in facilitated communication training. Topics in Language Disorders, 12(4), 46–59.

Crossley, R. (1993). Literacy and facilitated communication training. Facilitated Communication Digest, 1(2), 12–13.

Crossley, R. (1994). Facilitated communication training. New York: Teachers College Press.

Crossley, R., & Remington-Gurney, J. (1992). Getting the words out: Facilitated communication training. Topics in Language Disorders, 12(4), 29–45.

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Higginbotham, D.J., Sonnenmeier, R.M., & Duchan, J.F. (1993). The impact of technology on facilitated communication. Technology and Disability, 2(3), 68–78.

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Karp, E. (1993, May). Strategies for increasing independent typing. Presented at the 2nd annual Facilitated Communication Conference, Syracuse University, Syracuse, NY.

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Moore, S., Donovan, B., & Hudson, A. (1993). Brief report: Facilitator-suggested conversational evaluation of facilitated communication. Journal of Autism and Developmental Disorders, 23(3), 541–552.

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Wheeler, D.L., Jacobsen, J.W., Paglieri, R.A., & Schwartz, A.A. (1993). An experimental assessment of facilitated communication. Mental Retardation, 31, 49–60.

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Appendix 1. Facilitated Communication Research Results of Peer Reviewed Quantitative Studies

Table 1.

Source Classification of Participants n Subjects Prior Communication Skills Described Method Outcome
Bligh & Kupperman (1993). Journal of Autism and Developmental Disorders. Severe mental retardation and legally blind 1 yes Ten questions were presented across four conditions. In some conditions the facilitator was asked not to look at the keyboard while the child responded. Other conditions included blocking the facilitator's ability to hear auditory questions. When the facilitator was not looking at the keyboard, all responses were random typing. When the facilitator could look at the keyboard but was blinded to the questions, linguistic messages were typed that were unrelated to the questions being asked.
Cabay (1994). Journal of Autism and Developmental Disorders. Autism, severe mental retardation 4 Communicators answered questions during “set work” activities in a message passing task. No valid communication was noted.
Calculator & Hatch (in press). American Journal of Speech-Language Pathology. Moderate to severe mental retardation, autism 1 yes An assessment battery consisting of six standardized and nonstandardized procedures sampled communication across different input and output modalities. Results were compared with and without blinds across tasks. General guidelines for assessing validation of facilitated communication are proposed. No valid communication was noted. Facilitators influenced message content, and also influenced misspellings, idiosyncratic phrases, and other responses, that in the absence of controls, could have been attributed to the subject.
Calculator & Singer (1992). Topics in Language Disorders. Mental retardation, autism 5 yes Subjects were given the PPVT-R while facilitators wore headphones to block hearing test questions. Facilitators could not look at the examiner during testing. Three of the five subjects significantly improved their performance when facilitation was used. Test scores with facilitation were within the normal range. A fourth subject who did not initially show improvement was reassessed several days later using the same procedures and then showed significant improvement on the second trial.
Datlow-Smith, Haas, & Belcher (1994). Journal of Autism and Developmental Disorders. Autism 10 yes Subjects were facilitated in six experimental sessions following two introductory FC training sessions. Naming pictures, naming objects, and message passing tasks were used. Prior to each trial, the facilitator was given a card which indicated what the communicator had been shown or told. Tto evaluate facilitator influence, the cards were incorrect for half of the trials. Three different levels of physical support were also evaluated ranging from no support, hand support without correction for incorrect responses, and full support that included preventing errors. No valid communication was noted for any of the ten subjects when the facilitator was unaware of the experimental stimuli. Facilitator influence on subject responses as noted to be minimal when hand support was provided without error prevention procedures. When hand support was provided with error prevention procedures, facilitator influence was noted 59 times.
Eberlin, McConnaichie, Ibel, & Volpe (1993). Journal of Autism and Developmental Disorders. Autism (20) and pervasive developmental disorder (1) 21 yes All subjects were pretested using their current independent communication modes prior to beginning FC training. Test procedures were repeated using FC following 20 hours of training. Facilitators wore headphones to block auditory information and were also blocked from seeing visual stimuli. Two of the 21 subjects were able to correctly respond when using FC following 20 hours of training. However, these 2 subjects were both able to verbally answer more than 85% of the questions correctly prior to beginning training. One of these 2 subjects also was able to independently type correct answers to many questions prior to beginning training. The other subject did improve his ability to respond using written communication following the 20 hours of training, but did not improve beyond his former ability to respond verbally.
Heckler (1993). Journal of Child Abuse and Neglect. Autism 1 yes Pictures were named by the subject. The facilitator was visually blocked from seeing the pictures. Message passing by answering questions about a video, and answering questions about content unfamiliar to the facilitator was evaluated. The subject was unable to name pictures, or answer questions about the video. The subject was able to answer 3 questions about content unfamiliar to the facilitator correctly. This included an exact duplication of a parent's verbal phrase during unstructured conversation.
Hudson, Melita, & Arnold (1992). Journal of Autism and Developmental Disorders. Severe to profound mental retardation 1 no Auditory questions were presented separately through headphones to the communicator and facilitator. No valid communication was noted. Facilitator influence was noted.
Intellectual Disability Review Panel (IDRP) (1989) *** Autism and/or cognitive cdisability 3 no Auditory questions were presented separately through headphones to the communicator and facilitator. 1 of the 3 subjects exhibited valid communication. This subject was able to answer 2/4 questions correctly in the blind condition. Facilitator influence was noted across all 3 subjects.
Intellectual Disability Review Panel (IDRP) (1989) *** Autism and/or cognitive disability 3 no Message passing by describing a gift. 1 subject was able to independently type valid information about the gift. 2 others also typed valid information using facilitation. Spelling and word finding errors were noted.
Interdisciplinary Working Party (1988). (As reviewed in Cummins & Prior, 1992. Harvard Educational Review. ###
  • Comatose from head injury

  • Cerebral palsy (both using head sticks)

2 no Videotaped facilitation sessions. Movements of the subjects and communication boards were measured. The facilitator moved the communication board to produce a response for both subjects. No other valid communication was documented.
Klewe (1993). Journal of Autism and Developmental Disabilities. Mental retardation, cerebral palsy 14 no 15 pictures were named by the communicators across 3 trials. The facilitators were visually blocked from seeing the communicator's pictures across 2 of the 3 trials. No valid communication attempts were noted. Facilitator influence was noted.
Moore, Donovan, & Hudson (1993). Journal of Autism and Developmental Disorders. Cerebral palsy, mental retardation 5 yes This study was a follow-up to Moore, et. al, 1993 (see below). Methods of validating communication were designed by the subject's facilitators. Subjects participated in message passing tasks discussing hidden objects, and favorite conversational topics. Two of the 5 subjects produced related verbal responses naming the objects during facilitation. There was no evidence that any of the subjects produced valid communication suing facilitation. A lack of congruence between what was typed, and the subject's verbal and nonverbal behavior was noted in some subjects.
Moore, Donovan, Hudson, Dykstra, & Lawrence (1993). Journal of Autism and Developmental Disorders. Cerebral palsy, mental retardation 8 no Ten auditory questions were presented separately to facilitators and communicators through headphones. One subject was eliminated form the study due to slow response times. One of the remaining 7 subjects was able to correctly answer 3/10 questions in the blind condition, however the authors stated that statistically, at least 4 questions would need to be answered correctly to verify communication better than chance levels of responding.
Regal, Rooney, & Wandas (1994). Journal of Autism and Developmental Disorders. Mental retardation, cerebral palsy, autism 19 no Subjects answered 15 questions about shapes, colors, and numbers on a picture card, in a message passing task. Subjects had the option of responding with a letter board, or a multiple choice answer array. No valid communication attempts above chance levels of responding were noted for 15 of the subjects when facilitated. In the data table, 4 of the subjects responded correctly to 5/15 up to 13/15 questions. However, a figure representing the same data only reported 2 of the subjects responding correctly to 5/15, and 6/15 questions. Discrepancies in the data between the table and figure make the findings difficult to interpret.
Smith & Belcher (1993). Journal of Autism and Developmental Disorders. Autism 8 yes Facilitated communication skills were documented following 7–12 weeks of training. Four of the 8 subjects demonstrated some literacy skills prior to beginning facilitation training. Three of those literate subjects progressed to independent typing of words or phrases. The remaining subjects did not make any progress despite the use of facilitation. By the end of the training, they were simply typing random letters.
Szempruch & Jacobson (1993). Research in Developmental Disabilities. Mental retardation, cerebral palsy, autism, Down syndrome 23 minimal Message passing of picture stimuli which were viewed by the communicator. No valid communication was noted. Some subjects were able to verbally or gesturally describe the objects but were unable to correctly name them via facilitated communication.
Vasques (1994). Journal of Autism and Developmental Disorders. Autism 2 yes Both subjects named pictures. The facilitator was instructed not to look at the stimulus pictures during blind trials, but was allowed to look during other trials. One of the subjects subsequently participated in a similar object naming task. Message passing by answering questions about videos was studied for both subjects. The first subject was facilitated with hand support, and the second was facilitated at the shoulder. The first subject was able to name 3/10 pictures correctly using facilitation during blind trials. She was also able to correctly name 9/10 objects on the object naming task. During this task she simultaneously verbally named the objects correctly on 7 of the trials, and typed her responses independently on 3 of the trials. She incorrectly named one picture verbally while simultaneously spelling the correct name when facilitated. The second subject did not respond correctly in the first task, but was able to give associated responses about one of three videos viewed (i.e., he discussed “sailing” after viewing a canoeing video). In contrast, the first subject did not give any intelligible responses during the video task.
Wheeler, Jacobson, Paglieri, & Schwartz (1993). Mental Retardation. Autism with severe to profound mental retardation 12 minimal Visual stimuli were presented separately to the communicator and facilitator. No valid communication attempts were noted. Facilitator influence was noted.
Biklen (1990). Harvard Educational Review. *** Autism 21 yes Review of student records, interviews with students when facilitated and their facilitators, observations of facilitation. Unexpected literacy skills for the subjects were documented. Facilitators were aware of their influence, and variations in communication from facilitator to facilitator were noted. Independent communication was noted in 12 subjects. Other proof consisted of variations in communication across subjects with the same facilitator. Differences in outcomes across children and adults and principles of the technique are reviewed.
Biklen, Morton, Gold, Berrigan, Swaminathan (1992). Topics in Language Disorders. Autism, mental retardation 43 yes Subjects were observed in a variety of settings using facilitation and not using facilitation across a 7 to 16 month period. Multiple observers collected samples of student work, analyzed videotapes, interviewed parents, and teachers, and participated in weekly analysis sessions. The constant comparative method and grounded theory approach were used. 31 of 43 subjects were able to participate in structured grade level work when using facilitation. Some were able to produce conversational language. Typographical errors, phonetic spellings, unusual phrasing, consistency in communication across facilitators, and communication of content unknown to the facilitator were given as proof of valid communication. Behavioral improvement was noted in some subjects.
Biklen, Morton, Saha, Duncan, Hardardottir, Karna, 0'Connor, and Rao (1991). Disability, Handicap, and Society. Autism 22 yes Subjects were observed in classroom and speech therapy settings across a 12 month period. Multiple observers collected samples of student work, analyzed videotapes, and participated in weekly analysis sessions. The constant comparison method was used. 3 subjects progressed to facilitation with a touch to the elbow, 21 demonstrated literacy, 19 were able to produce sentences, and 12 students could produce grade level work. Typographical errors, phonetic spellings, unusual phrasing, and communication of content unknown to the facilitator were given as proof of valid communication. Continued behavioral difficulties for some of the subjects was noted.
Biklen & Schubert (1991). Remedial and Special Education. Autism 21 yes Subjects were observed communicating with multiple facilitators within educational contexts over a 6 month period. Observations of the students were also made when facilitation was not used. Samples of student work and videotapes were collected. Multiple observers participated in weekly analysis meetings, and used the constant comparison method. Communication skills of the subjects were described. 1 subject used picture symbols, 2 spelled single words, and 18 communicated in sentences. No students progressed to independent typing. Variability in communication across facilitators was noted. Typographical errors, phonetic spellings, unusual phrasing, fading of physical support, and communication of content unknown to the facilitator are listed as proof of communication. Differences between verbal echolalia and written communication were noted.
Olney (in press). Journal of the Association for the Severely Handicapped. Autism with moderate mental retardation 1 yes Interactions between the researcher and subject were noted through detailed field notes, interview transcriptions, and samples of student work. Grounded theory approach was used with validation through multiple outside readers. Detailed descriptions of the subjects spoken and typed communication documented communication of information unknown to the facilitator. Data suggests that facilitated communication elucidates other forms of communication and leads to increased autonomy for the communicator.
Sabin, & Donnellan (1993). Journal for the Association for Persons with Severe Handicaps. Mental retardation 2 yes Subjects were observed communicating across school and community settings for 1 year. Interviews were conducted with the subjects, facilitators, and other involved educational staff. Triangulation of information, validation through multiple outside readers, and reflective memowriting were used along with text based analysis. Facilitators described the process of facilitation with a focus on the physical characteristics of the method. The facilitator's role as a provider of support, as a decision maker, and a negotiator of meaning were reviewed.
Botash, Babuts, Mitchell, 0'Hara, Manuel, & Lynch (in press). Archives of Pediatric and Adolescent Medicine. Autism, mental retardation, cerebral palsy 13 yes Clinical case studies Clinical case studies were presented on 13 children with suspected sexual abuse who communicated with facilitation. 4 of the 13 children had corroborating evidence supporting their allegations. An additional 5 had supportive evidence. 7 of the children had non-specific physical findings, and 2 had specific suspicious findings on medical examination. The practice of using validation studies to prove or disprove suspected sexual abuse is questioned.
Crossley, (1992). Topics in Language Disorders. Cerebral palsy, phenylketonuria, Down syndrome 3 yes Clinical case studies Clinical outcomes outlined for one student's ongoing progress with facilitation. Another student's progression from wrist support to touching the shoulder when typing was documented, yet the same student was unable to testify in court. A third student's progress to using a regular academic curriculum is documented.
Crossley, & Remington-Gurney (1992). Topics in Language Disorders. Autism, Down syndrome, Retts syndrome, tuberous sclerosis, mental retardation 430 yes Broad clinical data based on initial assessments and some follow-up. All clients were initially assessed using facilitation. More than 90% demonstrated neuromotor hand impairments. The need for physical support varied. 65% demonstrated spelling skills usable for communication during the initial assessment. On follow-up, 30 of 117 autistic clients were typing independently; 4 of 8 clients who participated in validation studies were able to produce valid communication. 2 of the 4 clients who failed to demonstrate valid communication were later typing independently.
Johnson, (1989). Journal of Social Work Practice. Mental retardation 14 yes Clinical case study of institutional residents. Clients revealed literacy skills. Total communication approaches were used in addition to facilitation, which may have aided client progress.
Queensland Report on Facilitated Gommunication (1993). Autism, mental retardation, Down syndrome, cerebral palsy, multiple handicaps 24 yes Clinical case studies following a 1-year facilitated communication training program. Levels of physical support were documented. 16% were only facilitated at the level of the elbow or higher up. 50% of the clients progressed to requiring less physical support over the year. Validation of communication was confirmed for 65% of the clients, who communicated information unknown previously by the facilitator. In total, 87% of the clients were reported to have valid communication abilities when facilitated.
Silberfeld, Gorbar, Madigan, & Gheckland (1993). Canada's Mental Health. Autism 1 no Clinical case study documenting evaluation of a client to determine financial competence. The client's responses were judged to be reliable and consistent. The client was found to be competent to manage his own financial affairs.
Vicker (1993). International Conference Proceedings, Autism: a World of Options. Autism 233 yes Preliminary survey of parents registered in the Indiana Resource Center for Autism data base. 42 parents reported the use or planned use of facilitation. 17 parents reported that facilitation was started, but later stopped for their child.

[***] The IDRP is a non-peer-reviewed panel report.

[###] The Harvard Educational Review is reviewed by a panel of graduate students.

Table 2. Appendix. Review Articles on Facilitated Communication

Source Type of Review Abstract
Donnelan, Sabin, & Majure, (1992). Topics in Language Disorders. Review and discussion of research on facilitated communication. This article discussed precedents for facilitated communication in the literature. Based on previous research, the authors propose that meaningful research questions about touch, attunement, and communication through written language be developed.
Duchan (1993). Journal of Speech and Hearing Research. Review of facilitated communication research with a tutorial related to theoretical models. A collaborative view of communication is offered to substitute for prevailing views, as an explanation for discrepant research outcomes. Future research which is collaborative in nature is proposed.
Greene (1994). in Shane (Ed.), Facilitated Communication: the clinical and social phenomenon. A review of qualitative and quantitative research outcomes. This book chapter reviews both qualitative and quantitative research on the topic of facilitated communication. Evidence from published articles, and presentations are provided in a table format. The author concludes that controlled studies are necessary to evaluate the efficacy of facilitated communication. The author also states that to date, the results of controlled studies have not supported the validity or reliability of the method.
Higginbotham, Sonnenmeier, & Duchan (1993). Technology and Disability. Discussion of the impact of alternative and augmentative communication on facilitated communication. This article describes technical solutions derived from AAC in regards to issues of keyboarding, physical access, symbol encoding techniques, and device output. The need for a collaborative model between professionals with AAC experience, and professionals with facilitated communication experience is discussed.
Hill & Leary (1993). DRI Press Movin On Series. The authors review the literature on movement disorders and relate findings to autism. Movement disorders related to autism were reviewed in the literature. This information was then related to movement disorders such as parkinsonism, Tourette syndrome, and catatonia. The Modified Rogers Scale was applied to the symptoms identified; 24 of the 36 symptoms on the scale were noted in individuals with autism.
Silliman (1992). Topics in Language Disorders. Theoretical perspectives on facilitated communication. The author offers two perspectives on facilitated communication. These are 1) the plausible perspective of unexpected literacy, and 2) skeptical perspectives such as the Clever Hans phenomena. Perspectives are then provided that attempt to unravel the discrepancies between the two views. Research is suggested to incorporate innovative spelling strategies as a method of probing the issues.

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Appendix 2. Minority Statement to Technical Report on Facilitated Communication and Response from Subcommittee Chair

October 10, 1994

From: Anoja Rajapatirana, parent representative of the fc subcommittee

Annegret Schubert, practicing speech-language pathologist and facilitator on the fc subcommittee

To: ASHA Executive Board and

Readers of the Technical Report on Facilitated Communication

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Statement of Dissent from the Technical Report on Facilitated Communication

After almost 2 years of painstaking and difficult work on this committee, it was not an easy decision for us to dissent from the report we helped create. There were many times when the committee process worked well—with disagreeing parties listening openly to each other and all of us writing and rewriting until we were able to draft statements that we all felt were balanced. This never meant that we all agreed. We each worked hard at stating the facts the best we could and eliminating biases where we saw them.

Unfortunately, this meticulous process was disrupted at the last minute, when major changes were introduced to the report, giving committee members less than 24 hours to read the new report and a 3.5 hour conference call to make any final revisions. To our dismay and despite our protest, the last minute revisions led to a major shift in the content of the report. There was no committee process available to us to resolve the differences. Consequently, we have no choice but to dissent from this final report.

Our disagreements with the report center on the following issues:

1. The report consistently neglects to inform readers about positive changes that have occurred in facilitated communicators' lives. While the committee was aware of the major beneficial impact of facilitated communication on many, it chose not to report these outcomes because there had been no peer-reviewed studies on the subject. While we agreed that it was important to distinguish research from other evidence, we also continued to feel very uncomfortable with the exclusion of such vital information. There are people who were once labelled mentally retarded who have gone on to graduate from high school or college, published books, or simply encountered other more positive options in their lives while at the same time delivering proof of their ability to communicate either experimentally or over time. It was facilitated communication that was pivotal in creating such changes for these people. It is important to note that these changes have been long lasting (Crossley & MacDonald, 1980; Eastham, 1992; Zoeller, 1992).

2. The exclusion of facilitated communicators' and facilitators' experiences becomes particularly troublesome in consideration of the fact that many of the last minute changes were based on the opinions of individual reviewers of the technical report and were not based on empirical research of any kind. This is in violation of our earlier agreement that we would be basing our report on published peer-reviewed studies. In addition, the many “leave as is” comments by other reviewers were ignored. This contradictory treatment of different sources of opinion makes it impossible for us to agree with the committee's contention that this report is “balanced.”

3. The omission of the experiences of facilitated communicators is particularly disturbing at this point in the history of facilitated communication. Several controlled studies of facilitated communication (Cardinal & Hansen, 1994; Crossley, 1994; Olney, 1994; Sheehan & Matouzzi, 1994; Weiss, 1994) and book length autobiographies (Sellin, in press; Zöller, 1992) are just how coming to fruition, confirming earlier qualitative findings on the efficacy of facilitated communication. In addition, recent relevant information on persons who attained independent typing skills through the use of facilitated communication training was omitted. For example, completely independent typists were shown by Attwood (1993) and Wurzburg and Watts (1994). Sharesa Kochmeister, one of the persons on Wurzburg and Watts' videotape, now types without any supportive touch or movements by her facilitator. To re-emphasize, by ignoring these developments the report fails to take seriously the people who are most affected by the report's message.

4. The report consistently emphasizes the interpretations of facilitated communication that describe it as an invalid method of communication, even throughout the section on qualitative research. Thus it fails to represent the diverse meanings of facilitated communication research outcomes. In its tone, the report influences readers to evaluate positive facilitated communication outcomes negatively, and conversely, to accept the validity of outcomes that fail to demonstrate the method's effectiveness. We don't see the dichotomy this way. Our intent was to show the readers that each research tradition had contributed to knowledge available on facilitated communication. We wanted the readers to be able to come to their own conclusions. Unfortunately, that will be more difficult now.

5. The report understates the negative outcomes that have resulted from the introduction of guidelines, such as the APA (American Psychological Association) or the AACAP (American Academy of Child and Adolescent Psychiatry) position statements. Instead, it widely quotes from these guidelines without evaluating the resulting infringement on communicators' access to an adequate means of communication. Revealing its bias, the report neglects to include other, more supportive guidelines (i.e., Vermont Division of Mental Retardation, 1994; Facilitated communication training, practice, and validation guidelines).

Again, we acknowledge the hard work of all the committee members and the admirable attempt by ASHA to produce a balanced document when the pressure to produce a definitive statement is mounting. We commend ASHA for including people of highly diverse outlooks on this committee. We recommend strongly that when ASHA proceeds to draft a position statement, it ensure that the participants on that future committee include facilitated communicators, family members, as well as currently active facilitators. They are the ones who will be most affected by such a statement. They should therefore have major input in its creation.

Respectfully,

Annegret Schubert

Anoja Rajapatirana

References

Attwood, T. (1993). Movement disorders and autism. Presentation at the 1993 International Conference on Autism: A World of Options, Toronto, Canada.

Cardinal, D., & Hansen, D. (1994). New findings regarding the validity of facilitated communication. Presentation at the 3rd Annual Conference on facilitated Communication, Syracuse (NY) University. (Audiotape available from Gaylor MultiMedia, Inc., 904 Flintlock Place, Nashville, TN 37217 (615-361-3611).

Crossley, R. (1994). Too many tests-the search for validation. Presentation at the 3rd Annual Conference on facilitated Communication, Syracuse (NY) University. (Audiotape available from Gaylor MultiMedia, Inc., 904 Flintlock Place, Nashville, TN 37217 (615-361-3611).

Eastman, D. (1992). Silent words: A biography. Ottawa: Oliver Pate.

Olney, M. (1994). A controlled evaluation of facilitated communication: Preliminary report. Presentation at the 3rd Annual Conference on facilitated Communication, Syracuse (NY) University. (Audiotape available from Gaylor MultiMedia, Inc., 904 Flintlock Place, Nashville, TN 37217 (615-361-3611).

Sellin, B. (In press). I don't want to be inside me any more. New York: Basic Books.

Sheehan, C., & Matouzzi, R. (1994). An investigation of the factors influencing the validity of facilitated communication. Presentation at the 3rd Annual Conference on facilitated Communication, Syracuse (NY) University. (Audiotape available from Gaylor MultiMedia, Inc., 904 Flintlock Place, Nashville, TN 37217 (615-361-3611).

Weiss, M.S. (1994). Validation of facilitated communication: two case reports. Presentation to the Commonwealth of Massachusetts Disabled Persons Protection Committee, John F. Kennedy Library, Boston.

Wurzburg, G., & Watts, G. (Producers). (1994). Every Step of the Way. Facilitated Communication Institute, Syracuse University: Syracuse, NY.

Zöller, D. (1992). Ich gebe nicht auf. Bern: Scherz Verlag.

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Response from Subcommittee Chair

10/31/94

To: Louise Zingeser (Please share with committee members at your discretion)

From: Stephen Calculator

Re: Statement of dissent from Anoja Rajapatirana and Annegret Schubert

I was very disappointed with the 10/10/94 statement issued by committee members Anoja Rajapatirana and Annegret Schubert. As chair of the ad hoc committee on FC I feel a response is necessary. My comments will follow the chronological order of their statement of dissent.

Rajapatirana and Schubert suggest a “meticulous process” was disrupted at the last minute when major changes were introduced to the report. I could not, under any circumstances, agree with their characterization of the process leading up to the final draft. For 2 years, committee members struggled word by word and line by line to generate content that would be agreeable to all committee members. Certainly two committee members, Rajapatirana and Schubert, often found themselves in the role of justifying, rationalizing, persuading other committee members to share their feelings on issues we addressed. These two individuals were personally committed to the outcome of the committee in a more direct sense than other committee members. One is the parent of a young man who uses FC, herself a spokesperson to other families and professionals on FC and related issues. The other is a speech-language pathologist who is a major proponent of the method, nationally and internationally. Their task of maintaining objectivity in the committee process may have been overwhelming at times, as personal agenda often interfered with the group process. This is not to suggest that their contributions were not welcome and valued. To the contrary these committee members were absolutely integral in the development of what I felt was an outstanding Technical Report.

Final revisions to the draft followed the external review by over 40 reviewers. I incorporated reviewers' feedback into the final draft, being careful (I felt, and continue to feel) to include themes that recurred across several reviewers. The final report was reviewed line by line with Schubert on a final telephone conference call. Rajapatirana was unable to stay on the line for the entire call, and was thus able to share her comments/ concerns prior to departing.

As to our committee's failure to report on positive changes associated with FC, we all agreed to limit reporting to information that appeared in refereed journals. The section on qualitative research does note changes in the quality of life of individuals following the provision of FC. These statements may not be sufficient for Rajapatirana and Schubert, but they capture the reality of the situation—there is little documented communication benefit associated with FC. The fact is, committee members were also aware of anecdotal reports of negative impact of FC (e.g., terminating instruction in other AAC systems, ignoring vocalizations and other forms of communicative behavior, and increased frustration by individuals and their families).

Comments by FC users (reviewers identified by Rajapatirana and Schubert) were not formally addressed in the final draft since, as the report suggests, there is no way we could have known if the feedback was indeed from the FC users or their facilitators.

We are accused of omitting information about individuals who have gone on to type independently. It was Rajapatirana and Schubert, themselves, who took primary responsibility for identifying such cases and making them known to the committee. Again, we were interested in documented cases that stood up through the peer review process, as opposed to anecdotal information. The committee did not wish to further mislead the public that independence is an expected outcome of FC instruction.

As to the change that there is unequal weight given to results from qualitative and quantitative research— this is absolutely true. The former evidence is, at best, very weak and does not address the central issue of whether or not FC is a valid method of communication. Quantitative evidence refuting validity is overwhelming. We do point out limitations of the quantitative research, especially with respect to methodologic issues.

As to our widely quoting from position statements from other organizations, our reviewers rightfully and helpfully suggested that this information be included. It now covers 1.5 of the 49 pages of text. How could we not review this material in a state of the art report? Supportive guidelines (e.g., Vermont Division of Mental Retardation) by individual agencies were not included, nor were negative guidelines by states (NY) and other agencies that have taken strong positions against continued use of FC.

Finally, as to the composition of future committees, I totally disagree with Rajapatirana and Schubert's recommendations that FC users, family members, and active facilitators should be included as members. Such individuals have unique perceptions to share with a committee, just as individuals who have waged holy war to buy FC on the other end of the continuum. Inclusion of such people on this and future committees, where personal interests and agenda preclude objectivity, is not helpful in that they lead to an unnecessarily long process in which consensus may win over logic. Diversity is tremendously valued, but where opinions are motivated by emotion and personal investment the result can be troubling. Committees confronting controversial topics might consider soliciting members who are knowledgeable about the area in general, can be expected to review and interpret information from all available sources, and then render objective views based on the available evidence.

I continue to stand behind the findings of the Technical Report and hope you agree that it is a major contribution to the Association and others.

Thank you,

Stephen N. Calculator, Ph.D.

Chair, ASHA ad hoc committee on FC

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Index terms: facilitated communication

Reference this material as: American Speech-Language-Hearing Association. (1994). Facilitated communication [Technical Report]. Available from www.asha.org/policy.

© Copyright 1994 American Speech-Language-Hearing Association. All rights reserved.

Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.

doi:10.1044/policy.TR1994-00139

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