FAQs: Practice Implications for ASHA's Position Statements on Facilitated Communication (FC) and the Rapid Prompting Method (RPM)

About the FC and RPM Position Statements and the ASHA Ad Hoc Committee

ASHA's Ad Hoc Committee on Facilitated Communication (FC) and the Rapid Prompting Method (RPM) developed these Frequently Asked Questions (FAQs) to help clinicians serving individuals with severe communication disabilities. The FAQs provide supplemental information to increase understanding about ASHA's Position Statement on FC (ASHA, 2018a) and Position Statement on RPM (ASHA, 2018b). This resource includes information for use in all settings; however, members and certificate holders must consider all applicable local, state, and federal requirements when applying the information in their specific work setting. This information does not constitute legal advice.

The ASHA Ad Hoc Committee on FC and RPM was established by the ASHA Board of Directors in 2017.

Committee Charge:

  1. Review the scientific literature regarding the use of FC since 1994
  2. Update the 1995 ASHA Position Statement on FC
  3. Review the scientific literature regarding RPM
  4. Develop resources to guide members on the use of RPM

Dates: August 1, 2017, to August 31, 2018

Committee Members: Meher Banajee, chair; Bronwyn Hemsley; Russell Lang; Ralf W. Schlosser; Howard C. Shane; and Diane Paul, ex officio. Sandra Gillam, Vice President for Speech-Language Pathology Practice (2015–2017) served as the ASHA Board of Directors (BOD) liaison from August 1, 2017, to December 31, 2017. Marie Ireland, Vice President for Speech-Language Pathology Practice (2018–2020) served as the BOD liaison from January 1, 2018, to August 31, 2018.

ASHA's Board approved the FC and RPM position statements—that FC should not be used and that RPM is not recommended—in August 2018. Video messages, links to the position statements, a press release, and other resources are available on the ASHA Press Room web page.

It is customary practice for the policy positions of professional associations to evolve based on the growing knowledge base and advancements in scientific research. ASHA's current positions on FC and RPM reflect the latest research findings. Considering the high stakes involved—including from practice, human rights, and ethical perspectives—these positions were undertaken with the highest regard for scientific evidence. More than 95% of the certified speech-language pathologists (SLPs) and audiologists who participated in peer review supported the position statements. ASHA's FC and RPM positions align well with positions of other associations with members serving individuals with disabilities. To date, at least 19 organizations in the United States and in other countries have issued similar cautions about the use of FC (Behavior Analysis Association of Michigan, n.d.) and RPM (Irish Association of Speech & Language Therapists, 2017; Speech-Language & Audiology Canada, 2018; Speech Pathology Australia, 2012).

Ethical, Licensure, and Certification Implications

As indicated in the ASHA Position Statement on FC (ASHA, 2018a) and ASHA Position Statement on RPM (ASHA, 2018c), "Speech-language pathologists (SLPs) are autonomous professionals who are responsible for critically evaluating all treatment techniques in order to hold paramount the welfare of persons served in accordance with the ASHA Code of Ethics." The Code indicates that ASHA members and certificate holders "shall abide by established guidelines for clinical practice." As the Preamble to the Code explains:

The Code is designed to provide guidance to members, applicants, and certified individuals as they make professional decisions. Because the Code is not intended to address specific situations and is not inclusive of all possible ethical dilemmas, professionals are expected to follow the written provisions and to uphold the spirit and purpose of the Code.

The Code provides the framework to preserve the "highest standards of integrity and ethical principles." All ASHA members and certificate holders are bound to practice in accord with the fundamental principles and rules set forth by the Code and are "subject to the jurisdiction of the Board of Ethics for ethics complaint adjudication."

SLPs should be mindful of their own legal and ethical responsibilities and risks; they are obliged to "provide services or dispense products only when benefit can reasonably be expected" and not do harm (ASHA, 2016a). The Code speaks to the obligations of SLPs to inform "persons served about possible effects of not engaging in treatment or not following clinical recommendations."

According to the Practices and Procedures of the Board of Ethics, "Alleged violations shall be reviewed by the Board in such manner as the Board may, in its discretion, deem necessary and proper. There is no statute of limitations with respect to the timeframe for the filing of an ethics complaint." Board determinations are based on "facts established by a preponderance of the evidence/information submitted to the Board" (ASHA, 2018b).

In accord with Principle IV, Rule R: "Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice." ASHA has an Issues in Ethics statement that is pertinent to state licensure (ASHA, 2016b).

Many members and/or certificate holders of ASHA hold licenses or certificates issued by a state licensure board or a teacher certification agency, allowing them to practice in that state. These boards or agencies may also require adherence to an ethical code or code of conduct. Consequently, ASHA members and certificate holders often come under the jurisdiction of separate and independent codes of professional conduct that, although generally similar in intent and in principle, may vary in their specific provisions, requirements, and prohibitions. It is the responsibility of professionals to familiarize themselves with all applicable codes and regulations.

ASHA provides Ethics Resources to assist its members and certificate holders. School-based SLPs also may want to discuss ASHA's Code of Ethics with school administrators or with their human resources department. SLPs should maintain thorough documentation of all concerns shared. SLPs may contact the ASHA Ethics Office to discuss unique situations.

Responses to FAQs

Responses to FAQs are provided below in two distinct categories: Considerations for Evidence-Based Practice and Considerations for Service Delivery.

Considerations for Evidence-Based Practice

Considerations for Service Delivery

Considerations for Evidence-Based Practice

What are effective communication interventions for individuals with severe communication disabilities?

The ASHA position statements on FC and RPM each refer to current scientific evidence in the field of augmentative and alternative communication (AAC). AAC includes a range of systems and strategies—including speech or vocalizations, gestures, manual signs, and aided communication (e.g., keyboards, alphabet/letter/ picture boards, speech-generating devices)—and incorporates the individual's full and multimodal communication abilities (ASHA, n.d.-b; National Joint Committee for the Communication Needs of Persons With Severe Disabilities, n.d.). For more information on AAC-related assessment and interventions, see the ASHA Practice Portal (ASHA, n.d.-b). There is a well-established body of scientific evidence for the use of many types of AAC (e.g., see systematic reviews, Allen, Schlosser, Brock, & Shane, 2017; Holyfield, Drager, Kremkow, & Light, 2017; Logan, Iacono, & Trembath, 2017; Lynch, McCleary, & Smith, 2018; Mandak, Light, & Boyle, 2018; Therrien, Light, & Pope, 2016; Wong et al., 2013) and there are proven strategies for communicating with individuals who have severe communication disabilities (see ASHA Evidence Maps; ASHA, n.d.-a).

The goal of AAC is to enable independent access to AAC systems and functional communication strategies. This contrasts with prompt dependence, which is characteristic of FC (Travers, Tincani, & Lang, 2014) and RPM (Mukhopadhyay, 2008). AAC may also involve communication partner support and, as in all communication interactions between two or more people, AAC relies on the co-construction of meaning. In AAC, any involvement of the communication partner in producing the message is acknowledged.

Clinicians should use interventions that are demonstrated to support an individual's independent access to communication, shown to be of benefit, and shown to be of no harm.

The SLP should address barriers to the use of AAC systems that may have occurred or might be occurring. Examples of barriers include lack of communication partner involvement in design of AAC systems or other interventions, lack of generalization from one setting to another, and negative societal attitudes. The International Classification of Functioning, Disability and Health (World Health Organization, 2001) and the Participation Model for AAC (Beukelman & Mirenda, 2013) provide useful frameworks for teams to address barriers and enhance communication success using empirically-supported interventions.

What is an SLP's responsibility to follow evidence-based practice when there is little or no scientific research to support a technique?

See ASHA's Position Statement on Evidence-Based Practice in Communication Disorders (ASHA, 2005):

"It is the position of the American Speech-Language-Hearing Association that audiologists and speech-language pathologists incorporate the principles of evidence-based practice in clinical decision making to provide high quality clinical care."

According to ASHA, the goal of evidence-based practice is the integration of

  1. clinical expertise/expert opinion;
  2. external scientific evidence; and
  3. client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve"(ASHA, n.d.-c).

Here are some considerations pertaining to the use of FC and RPM within this evidence-based practice framework:

Clinical expertise/expert opinion. Clinicians need to evaluate and document whether a treatment works for a particular client. SLPs should not assume that FC or RPM reflect the communication of the person with a disability. Authorship testing should be conducted independently and in a controlled manner. The ASHA Code of Ethics (2016a) requires the use of approaches that "hold paramount the welfare of persons they serve professionally" and that SLPs (and audiologists) "shall abide by established guidelines for clinical practice." As the Preamble to the Code explains, 

"The Code is designed to provide guidance to members, applicants, and certified individuals as they make professional decisions. Because the Code is not intended to address specific situations and is not inclusive of all possible ethical dilemmas, professionals are expected to follow the written provisions and to uphold the spirit and purpose of the Code."

External scientific evidence. There is no scientific evidence validating the use of either FC or RPM as communication methods. There is substantial evidence against FC. There is no firm scientific or theoretical foundation to either FC or RPM.

Client/patient/caregiver perspectives. The SLP should recognize the interests of individuals and families and integrate those interests with the best current scientific and clinical expertise. Clients and families should be informed about the lack of scientific research for FC and RPM, the scientific evidence against FC, the similarity of RPM to FC, the harms of FC, and the lack of confidence in the authorship of messages produced using these techniques. Ultimately, people who need or use AAC and/or persons responsible for decisions on behalf of individuals with communication disabilities who need or use AAC choose whether or not to follow recommendations made by an SLP.

In evidence-based practice, client perspectives and clinical expertise/expert opinion are considered along with external scientific evidence. Evidence-based effective treatments should be considered as an integral component of the process of evidence-based practice (Chambless & Hollon, 1998; Schlosser & Sigafoos, 2008). Client requests for a specific treatment have to be balanced with an SLP's responsibility to provide safe, effective, and scientifically based interventions. Furthermore, SLPs should exercise due diligence and be appropriately cautious when considering data from treatment sessions or anecdotal reports of techniques or practices that are not supported by empirical research. SLPs should consider and address (a) other possible reasons for improved or reduced performance, and (b) all possible biases in their analysis and interpretation of results.

Examples of common biases include the tendency to

  • interpret data in a way that confirms a person's own preconceptions (e.g., attributing authorship to an individual without validation or controlled authorship trials to confirm; also referred to as "confirmation bias");
  • avoid conflict with others (e.g., not sharing information and research about methods that conflict with the request for an intervention); and/or
  • allow expectations to affect perception of results (e.g., acting on observations without a deeper or "critical" examination of other potential influences on performance; also referred to as "expectation bias").

What do SLPs need to know about pseudoscience in relation to features of FC and RPM?

Pseudoscience is a system of theories, assumptions, and methods erroneously presented as scientific (Finn, Bothe, & Bramlett, 2005; Gardner, 1957). Pseudoscience often is (a) characterized by contradictory, exaggerated, or untestable and unfalsifiable claims; (b) reliant on bias rather than rigorous attempts at use of scientific rigor; (c) lacking openness to evaluation by other experts; and (d) lacking in systematic practices for developing theories.

RPM and FC fit these four characteristics of pseudoscience:

  1. Make contradictory, exaggerated, or falsifiable claims: Recent analyses of FC (Lilienfeld, Marshall, Todd, & Shane, 2014) and RPM (Lang, Tostanoski, Travers, & Todd, 2014) indicate (a) no evidence of independent communication in the use of FC and RPM, and (b) evidence of facilitator influence over the messages produced. Contrary to claims of independence, double-blind studies demonstrate facilitator influence for FC-generated responses (e.g., Moore, Donovan, Hudson, Dykstra, & Lawrence, 1993; Shane & Kearns, 1994).
  2. Rely on bias rather than rigorous attempts at use of scientific rigor: Studies supportive of FC and RPM lack scientific rigor and use study designs that do not control adequately for bias (e.g., Biklen, 1993; Emerson, Grayson, & Griffiths, 2001). Proponents of FC and RPM often refer to these studies to defend the use of FC or RPM.
  3. Lack openness to evaluation by other experts: Proponents of FC and RPM contend that subjecting the techniques to empirical examination, including data collection, causes the phenomenon responsible for the perceived success of FC and RPM to dissipate (e.g., Biklen & Cardinal, 1997; Crossley, 1997; Emerson et al., 2001; Helping Autism for Learning and Outreach [HALO], n.d.; Jacobson, Mulick, & Schwartz, 1995).
  4. Absent systematic practices for developing theories: Neither FC nor RPM follow a consistent set of procedures or techniques that relate to the theories proposed to underpin the techniques. No formal assessments are used to determine the skills and abilities of the clients to determine their suitability for the techniques.

Finn et al. (2005) provided a tutorial titled Science and Pseudoscience in Communication Disorders: Criteria and Applications, describing 10 criteria to assist SLPs in distinguishing between scientific and pseudoscientific treatment claims to navigate controversial topics. Science-Based Practice and the Speech-Language Pathologist (Lof, 2011) further examines the role of the SLP with regard to the need for (a) skeptical thinking to differentiate science from pseudoscientific practices and (b) the use of the scientific method to determine legitimate treatment approaches.

Considerations for Service Delivery

What should an SLP do if asked to use FC or RPM?

Students, caregivers, parents, teachers, administrators, or employers may not know or understand the true opportunity costs of using FC or RPM—in terms of lost time, lost money, lost energy, and lost opportunities at practicing skills for independent access to an AAC system and other communication strategies. SLPs receiving requests to teach or use FC or RPM should share and explain all of the following information:

ASHA's Code of Ethics (2016a), Principle I, Rule H speaks to the need for SLPs to "obtain informed consent from the persons they serve about the nature and possible risks and effects of services provided . . . . This obligation also includes informing persons served about possible effects of not engaging in treatment or not following clinical recommendations." The Code also provides, under Principle I, Rule K, "Individuals who hold the Certificate of Clinical Competence shall evaluate the effectiveness of services provided . . . and they shall provide services . . . only when benefits can reasonably be expected." In terms of the public, Principle III, Rule E explains, "Individuals' statements to the public shall provide accurate and complete information about the nature and management of communication disorders . . . and about research . . . . ," and Principle III, Rule F refers to such public statements as needing to adhere to "prevailing professional norms."

What should an SLP do if FC or RPM is already included on a student's individualized education program (IEP)?

School-based SLPs must implement the IEP as written and may not change a student's IEP without an IEP team meeting. The SLP's concern and information about using FC or RPM should be shared with the IEP team—including evidence, ASHA position statements, the potential for harm, and the opportunity costs.

There are several important factors for school-based SLPs and IEP teams to consider in relation to FC and RPM. SLPs should have sufficient student-specific assessment data (formal and informal) to justify their position and recommendations as a member of the IEP team. Furthermore, in light of ASHA positions and resources on FC and RPM, SLPs working in a school setting have a responsibility to

  • inform development and revisions of children's IEP goals (i.e., that they do not include FC or RPM) and
  • ensure that the student's goals can be targeted and addressed through evidence-based interventions and AAC approaches, in accordance with their legal and ethical responsibilities to offer a free and appropriate public education (FAPE) as required by the Individuals with Disabilities Education Improvement Act (IDEA, 2004).

Although IDEA mandates that decisions are made by the student's IEP team, the Americans with Disabilities Act (ADA), Title II Supplementary Information (U.S. Department of Justice, 2010) states the following:

"In determining what types of auxiliary aids and services are necessary, a public entity shall give primary consideration to the requests of individuals with disabilities."

The U.S. Department of Justice and the U.S. Department of Education (2014, p. 6) further explain this obligation as follows:  

"Title II requires covered entities, including public schools, to give 'primary consideration' to the auxiliary aid or service requested by the student with the disability when determining what is appropriate for that student."

"The public school must honor the choice of the student with the disability (or appropriate family member) unless the public school can prove that an alternative auxiliary aid or service provides communication that is as effective as that provided to students without disabilities. If the school district can show that the alternative auxiliary aid or service is as effective and affords the person with a disability an equal opportunity to participate in and benefit from the service, program, or activity, then the district may provide the alternative."

School-based SLPs should work closely with school administrators because the interplay between IDEA and Title II is complex. The U.S. Department of Justice and the U.S. Department of Education provide additional guidance on this matter in the jointly authored documents, Dear Colleague Letter on Effective Communication [PDF] and Frequently Asked Questions on Effective Communication for Students with Hearing, Vision, or Speech Disabilities in Public Elementary and Secondary Schools.

SLPs should maintain thorough documentation of all concerns shared about the use of FC or RPM in an IEP. School-based SLPs also may want to share ASHA's Code of Ethics with school administrators and their human resources department in raising professional responsibility considerations about the use of these techniques in delivering services.  

May SLPs adapt IEP goals to align with ASHA's position on FC and RPM or their own clinical judgment?

Once an IEP is signed, it cannot be changed without a properly constituted IEP meeting. An SLP may not change a student's IEP without an IEP team meeting. The school-based SLP who has concerns about any goals specifying FC or RPM should request an IEP meeting to share concerns and provide information to others. 

See Questions 1 and 2 in Considerations for Service Delivery for additional information about informing students, caregivers, parents, teachers, administrators, or employers and about discussing concerns.

If the IEP team will not change or remove FC or RPM from the IEP, then the SLP may choose to take one or all of the following actions:

  • Document disagreement with any IEP team decisions to use FC or RPM.
  • Share concerns with their supervisor, other administrators, and (if appropriate) their human resources office or school board attorney.
  • Recommend an alternative communication aid or service that is effective in providing a valid form of communication, and document this recommendation. This is consistent with Title II of the ADA.
  • Seek information, guidance, and support about their particular circumstances related to RPM or FC from school administration, State Education Agency staff, ASHA (including ASHA Special Interest Group 12: AAC), and colleagues in their wider professional community, including state associations and others.

What should SLPs do if they are concerned about harm related to the use of FC or RPM?

SLPs are mandated reporters and are required to contact authorities whenever there is a suspicion of abuse or neglect in vulnerable populations, such as children, persons with disabilities, or elderly individuals. Specific standards vary by state. The documentation of concerns in relation to suspected harms of FC or RPM might be similar to documentation of recommendations and service notes. It is recommended that SLPs take the following actions if they suspect abuse or neglect:

  • Report concerns to the person responsible for decisions related to service provision and communication methods.
  • Inform workplace supervisors of the concerns.
  • Document specific concerns. Provide a copy of this documentation to the parents/guardians involved and to any other parties as appropriate or required within the confines of the confidentiality requirements of the setting.
  • Document all individuals that the SLP informed—specify names, dates, and outcomes.

What are appropriate ways to use prompts for communication in clinical practice?

It is common practice for SLPs to use prompts when teaching someone to communicate using AAC (e.g., hand-over-hand prompting, verbal prompts, and/or gestural prompts to point or to activate a speech-generating device using direct or indirect methods). When identifying appropriate prompts to use, SLPs should consider linguistic, cognitive, sensory, and motor needs of the individual. The communication goal in using prompts should be independent communication, not prompt-dependent communication.

SLPs should be familiar with prompting hierarchies and documentation methods that verify fading of prompts and increasing independence in communication (Cooper, Heron, & Heward, 2007; Martin & Pear; 2014). As an example, Cooper et al. (2007) discuss the use of response prompts (verbal instructions, modeling, physical guidance) and stimulus prompts (movement, position, and redundancy cues). They also emphasize the need to "transfer stimulus control from the response and stimulus prompts to the naturally existing stimulus" (pp. 402–403). The SLP should acknowledge and document

  • which prompts are being used (e.g., type, timing, frequency);
  • how the prompts will be "faded" (i.e., systematically removed); and
  • the prompter's influence over the message produced—that is, the SLP should acknowledge that the prompter may influence the person's action, even if the prompt is faded or changed (e.g., changing to a different prompt location or to a different type of prompt).

References  

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