Brief report: a case study assessing the validity of facilitated communication

Autism spectrum disorder: Consensus guidelines on assessment, treatment and research from the British Association for Psychopharmacology

An expert review of the aetiology, assessment, and treatment of autism spectrum disorder, and recommendations for diagnosis, management and service provision was coordinated by the British Association for Psychopharmacology, and evidence graded. The aetiology of autism spectrum disorder involves genetic and environmental contributions, and implicates a number of brain systems, in particular the gamma-aminobutyric acid, serotonergic and glutamatergic systems. The presentation of autism spectrum disorder varies widely and co-occurring health problems (in particular epilepsy, sleep disorders, anxiety, depression, attention deficit/hyperactivity disorder and irritability) are common. We did not recommend the routine use of any pharmacological treatment for the core symptoms of autism spectrum disorder. In children, melatonin may be useful to treat sleep problems, dopamine blockers for irritability, and methylphenidate, atomoxetine and guanfacine for attention deficit/hyperactivity disorder. The evidence for use of medication in adults is limited and recommendations are largely based on extrapolations from studies in children and patients without autism spectrum disorder. We discuss the conditions for considering and evaluating a trial of medication treatment, when non-pharmacological interventions should be considered, and make recommendations on service delivery. Finally, we identify key gaps and limitations in the current evidence base and make recommendations for future research and the design of clinical trials.

Facilitated Communication as an Ideomotor Response

Forty college students were taught facilitated communication via a commercially available training videotape. They were then asked to facilitate the communication of a confederate, who was described as developmentally disabled and unable to speak. All 40 participants produced responses that they attributed at least partially to the confederate, and most attributed all of the communication entirely to her. Eighty-nine percent produced responses corresponding to information they had received, most of which was unknown to the confederate. Responding was significantly correlated with simple ideomotor responses with a pendulum and was not affected by information about the controversy surrounding facilitated communication. These data support the hypothesis that facilitated communication is an instance of automatic writing, akin to that observed in hypnosis and with Ouija boards, and that the ability to produce automatic writing is more common than previously thought.

Facilitated communication and authorship: a systematic review

Facilitated Communication (FC) is a technique whereby individuals with disabilities and communication impairments allegedly select letters by typing on a keyboard while receiving physical support, emotional encouragement, and other communication supports from facilitators. The validity of FC stands or falls on the question of who is authoring the typed messages--the individual with a disability or the facilitator. The International Society for Augmentative and Alternative Communication (ISAAC) formed an Ad Hoc Committee on FC and charged this committee to synthesize the evidence base related to this question in order to develop a position statement. The purpose of this paper is to report this synthesis of the extant peer-reviewed literature on the question of authorship in FC. A multi-faceted search was conducted including electronic database searches, ancestry searches, and contacting selected authors. The authors considered synopses of systematic reviews, and systematic reviews, which were supplemented with individual studies not included in any prior reviews. Additionally, documents submitted by the membership were screened for inclusion. The evidence was classified into articles that provided (a) quantitative experimental data related to the authorship of messages, (b) quantitative descriptive data on the output generated through FC without testing of authorship, (c) qualitative descriptive data on the output generated via FC without testing of authorship, and (d) anecdotal reports in which writers shared their perspectives on FC. Only documents with quantitative experimental data were analyzed for authorship. Results indicated unequivocal evidence for facilitator control: messages generated through FC are authored by the facilitators rather than the individuals with disabilities. Hence, FC is a technique that has no validity.

Facilitator control as automatic behavior: A verbal behavior analysis

Several studies of facilitated communication have demonstrated that the facilitators were controlling and directing the typing, although they appeared to be unaware of doing so. Such results shift the focus of analysis to the facilitator's behavior and raise questions regarding the controlling variables for that behavior. This paper analyzes facilitator behavior as an instance of automatic verbal behavior, from the perspective of Skinner's (1957) book Verbal Behavior. Verbal behavior is automatic when the speaker or writer is not stimulated by the behavior at the time of emission, the behavior is not edited, the products of behavior differ from what the person would produce normally, and the behavior is attributed to an outside source. All of these characteristics appear to be present in facilitator behavior. Other variables seem to account for the thematic content of the typed messages. These variables also are discussed.

Look Who's Pointing Now

This article focuses on three factors related to the use of facilitated communication (FC), all of which constitute possible reasons for caution by speech-language pathologists who are considering this technique for individuals with severe communication impairments. First, problems with the theoretical bases of FC are discussed, especially those attributing the success of this method to its ability to target individuals' underlying difficulties with apraxia, word finding, and social-emotional challenges. A case is made that there is insufficient evidence to support claims that FC overrides such problems. The notion of the method unlocking communication and related skills from otherwise competent individuals is also questioned. Next, the subject of candidacy is discussed. Special attention is called to the absence of criteria for initiating, maintaining, modifying, and terminating this approach. Finally, outcomes of the method are summarized. Discrepancies between qualitative and experimental investigations are summarized, along with some possible explanations for these differences. Suggested parameters for evaluating individuals' uses of FC are discussed, along with the continuing need for speech-language pathologists to make informed decisions concerning the role FC will play in their interventions with individuals who exhibit severe communication impairments.

Allegations of sexual abuse by nonverbal autistic people via facilitated communication: testing of validity

OBJECTIVE

The aim of the paper is to offer a comprehensive approach to establishing the validity of allegations of sexual abuse by nonverbal autistic children and adults produced through facilitated communication (FC). This approach is offered as an alternative to existing methodology that relies exclusively on the "message passing" task, and has been used to advantage in the courts.

METHOD

Three components to the battery are included: (a) specialized psychometric testing; (b) a variant of the message passing task; and (c) systematic analysis of the allegations themselves. Through the juxtaposition of the data from the different sources, conclusions can be reached as to the allegations' authorship.

RESULTS

The results of a series of studies addressing the issue of validity of FC in general are briefly presented. Then a case presentation is offered to demonstrate how the technique can be employed to clarify allegations of sexual abuse. Elements of two other cases are also briefly discussed.

CONCLUSIONS

Facilitated communication has been heralded as a breakthrough, allowing nonverbal people with autism to express themselves. It relies on manual guidance by a facilitator. Its proponents' resistance to allowing the technique's validation relying on the paradigm of normal science has resulted in its broad dissemination without support. In the case of sexual abuse allegations thus far the "message passing" task has been used to assess their verity. The present methodology is offered as a more comprehensive alternative to "message passing," with relevance to other populations of nonverbal individuals.

The role of touch in facilitated communication

Imagine that one day a nonverbal autistic child suddenly starts to type messages, such as "I am not retarded," using a computer keyboard while being touched by an assistant. Facilitated communication (FC) appears to create this miracle around the world. To understand how this works, experiments were conducted involving a "telepathy game" using a rod with an attached strain gauge. A force from the assistant, which controlled what was spelled through physical support, was measured. It was thus completely possible for any message to appear to be typed with FC regardless of the autistic child's actual knowledge or language ability.

Research into practice in special education

In this article the authors outline a number of disparate reactions to the Gersten et al. (this issue) piece. Gersten et al. rightly point out that researchers' reluctance to draw conclusions from ambiguous data is at odds with educators' daily demands and serves to reduce the impact of research. In contrast, the authors argue that on those occasions when educators have confronted the application of undocumented practices, they have done society a great service. The lack of middle-level scientist/practitioners in the education field is discussed. This situation puts much more of a burden on educational practitioners and researchers to stretch themselves to communicate with each other. Issues of source credibility become paramount, and widespread dissemination of scientific criteria for evaluating claims is critical. Finally, it is argued that researchers and educators are kindred spirits at the epistemological level, because both are grounded in a "what works" epistemology.

Treatment of autistic disorder

OBJECTIVE

To present an overview of a variety of treatment approaches in individuals with autistic disorder.

METHOD

Selected studies and articles are reviewed.

RESULTS

In the past three decades, great progress has been made in the treatment of autistic disorder, particularly in the area of education and parental involvement, with the objective to transfer to home and in other situations learning acquired in school. A role for psychoactive agents, when combined with psychosocial treatments, has been identified.

CONCLUSIONS

Although considerable advances have been made in a variety of interventions-educational, psychosocial, and biological-knowledge about the comparative and combined efficacy of the various treatment modalities is lacking. From the parents' perspective, particularly, support and continuity of services require improvement.

Failure to confirm the word-retrieval problem hypothesis in facilitated communication

Two hypotheses were raised and empirically tested to account for the failure of previous controlled validation studies to find evidence of literacy in nonspeaking persons with autism using facilitated communication: (a) The naming tasks used in other studies have triggered specific "word retrieval" problems, or anomia, and (b) a perceptual problem, visual agnosia, prevents subjects from recognizing objects without touching them. Three nonspeaking autistic children who had used facilitation for at least 2 years were evaluated with four experimentally controlled tasks, over a period of 5 months. In descriptive and object handling tasks, and in a traditional picture identification task, subjects failed to type correct answers when facilitators were blind; one subject, however, occasionally engaged in signing and vocalizations that were context-appropriate. Results reflected a generalized language deficit, rather than isolated word-finding or perceptual difficulties, and were consistent with many previous studies revealing facilitator cuing. Questions are raised about inconsistencies in pseudo-correct scores, a measure of facilitator influence, reported here and in previous research.

Successful use of facilitated communication with an oral child

A 6 1/2-year-old child's oral and spelled utterances were compared over a 3-month period as he was trained to use Facilitated Communication (FC), a method of augmentative and alternative communication. The child's language with FC was significantly better than his oral language in length of utterances, novelty of utterances, and syntactic complexity. His language with FC also contained more function words and over time was more intelligible and required less verbal scaffolding than his oral communication. Evidence that he was authoring his own messages during his facilitated spelling was found in his idiosyncratic use of language and his ability to convey verifiable information that was unknown to the facilitator. The strongest evidence came later with his ability to type messages without physical support. The results suggest the potential for using FC with children who have some functional oral skills but cannot express themselves fully in the oral modality. The method can serve as a means of investigating language potential and as a transition to literacy and independent typed communication.

An experimental analysis of facilitated communication

We evaluated the authorship of messages produced through facilitated communication by 7 adults with moderate or severe mental retardation and their facilitators. The clients had been reported to be communicating fluently through facilitated communication. We controlled the facilitators' access to information to be communicated in two evaluation formats, naming pictures and describing activities. In both formats we conducted three conditions: (a) the facilitator and client had access to the same information, (b) the facilitator did not have access to the picture or activity, and (c) the facilitator was given false information about the picture or activity. The results showed that the clients typed the correct answer only when the facilitator had access to the same information, never typed the correct answer when the facilitator had no information or false information, and typed the picture or activity presented to the facilitator when it was different from the one experienced by the client. These results provide unequivocal evidence for facilitator control of typing during facilitated communication.

A naturalistic approach to the validation of facilitated communication

By manipulating the facilitator's knowledge of a student's just-completed activity, facilitated communication ability and the extent of guiding were assessed. Seven students diagnosed with mental retardation and their facilitators participated in the study. All 7 students were purported at the start of the study to be communicating via facilitation at levels far above what was previously thought possible given their level of intellectual ability. A large degree of facilitator guiding was revealed for each of the 4 facilitators. Minimal evidence of facilitation was found for 4 of the 7 students. One of the 7 students demonstrated validated facilitated communication on two trials.

Belief in and use of a questionable technique, facilitated communication, for children with autism

23 educators and therapists of children with autism were surveyed about their beliefs and use of Facilitated Communication, a technique previously shown to have questionable scientific validity. 65.2% or 15 use the procedure often or very often in their work with children. Some factors that appeared related to this choice were beliefs consistent with those of proponents of Facilitated Communication, less education, belief in the notion that individuals with autism were more intelligent than their behavior indicated, and lack of belief in science as a source of explanation of human behavior. It was concluded that supervisors need to be more informing about the scientific validity of techniques used by their employees.

Facilitated communication: the effects of facilitator knowledge and level of assistance on output

Investigated facilitated communication with 10 adults with autism, and specifically examined the effects of facilitator influence and level of assistance as a function of facilitator knowledge of experimental stimuli. Six men and four women with autism served as subjects, ranging in age from 14 years to 51 years of age. Each subject had 6 experimental sessions, 2 with no help, 2 with partial assistance, and 2 with full assistance. Within each session, the facilitator had knowledge of the experimental stimuli in one half of the trials. Results revealed no cases of correct responding independent of facilitator knowledge of correct answers. Additionally, facilitator control was apparent in numerous cases in which typed output matched stimuli to which the facilitator, not the subject, had been exposed. Results suggest that clinical and educational use of the procedure should be curtailed pending further experimental investigation.

Language acquisition after mutism: a longitudinal case study of autism

This longitudinal case study challenges the assumption that individuals with autism who have severely restricted speech and language skills have a poor prognosis for further development of expressive oral language. The study follows the development of a woman with autism from mutism at age 10 to acquisition of a range of spoken and written language skills at age 26. The intervention in which the woman participated and her skills pre- and post-intervention and at two follow-up assessments are documented. The results support the hypotheses that speech and language development may proceed after mutism associated with limited verbal imitation and phoneme production skills, that some skills may plateau or decline, and that both spoken and written language may become viable forms of communication.

Facilitated communication: a failure to replicate the phenomenon

Twenty-one subjects participated in a study of Biklen's and Crossley's hypothesis that persons with autism show unexpected literacy and improved communication ability through the process of facilitated communication (FC). Repeated measures of literacy were conducted at (a) a baseline test of communicative ability before FC; (b) a pretest with facilitation; and (c) a posttest with facilitation after 20 hours of training. At both the pretest and posttest, the facilitators were screened from hearing or seeing the questions or pictorial stimuli. Although some facilitators reported newfound communicative abilities during training sessions, no client showed unexpected literacy or communicative abilities when tested via the facilitator screening procedure, even after 20 hours of training. Separate analyses indicated that some facilitators influenced the communicative output of their clients.