Running Head: Science and Controversy in Facilitated Communication

Science and Controversy in Facilitated Communication

David Charlon

National University
Running Head: Science and Controversy in Facilitated Communication

Introduction and History of Facilitated Communication

Facilitated communication is an instructional methodology first put into practice in

Australia in the early 1970s by Rosemary Crossley, a teacher at St. Nicholas Hospital in

Melbourne. Since that time it has become a source of significant controversy in the field

of developmental disability and the larger scientific community, even reaching into the

sphere of public policy (Biklen, 1990; Gorman, 1999; Hudson, 1993; Jacobson, Mulick,

& Schwartz, 1995; Melita, & Arnold, 1993; Moore, et al., 1993; Moore, Donovan, &

Hudson, 1993; Montee, Miltenberger, & Wittrock, 1995; Mostert, 2001, 2010; Regal,

Rooney, & Wandas, 1994; Simon, Whitehair, & Toll, 1996; Wombles, 2010). This

controversy became more pronounced following the introduction of FC in the United

States in 1989 when Douglas Biklen, a sociologist and professor of special education at

Syracuse University began to use the technique with individuals diagnosed with autism.

The perceived and dramatic success in enabling previously nonverbal individuals to

communicate through typewritten messages with the aid of a facilitator attracted the

attention of those in the speech, disability and special educational fields. The practice

was rapidly promoted and widely disseminated through trainings and workshops across

the country to professionals, students and families of people with severe disabilities,

eventually gaining the attention of the national media (Simpson & Myles, 1995).

Much of the controversy regarding facilitated communication historically centers on the

notion of authorship of the communications produced by individuals with previously

limited or nonexistent verbal communication skills when working intimately with a

facilitator. This question of authorship – i.e. whether these communications are indeed

the true utterances of the participant, the intended or unintended statements of the
Running Head: Science and Controversy in Facilitated Communication

facilitator, or something in-between – was thrust into the mainstream of public

awareness in 1990s when allegations of physical and in some cases sexual abuse were

made against family members of several severely disabled, non-verbal individuals as a

result of statements produced during facilitated communication training sessions. The

results of these accusations, now part of the public record through civil and criminal and

court proceedings, served to cast further doubt on both the authenticity of statements

produced through facilitated communication and by extension the scientific validity of

the instructional methodology itself, as well as raising serious ethical questions

regarding basic civil rights (Gorman, 1999). The scientific community responded with a

dramatic increase in scientific studies and analysis designed to evaluate the

effectiveness and in some cases the legitimacy of facilitated communication as a viable

treatment. The results of these studies were overwhelmingly negative (Mostert, 2001,

2010).

Proponents of facilitated communication continued to defend the practice, arguing that it

was the scientific method itself, with its unfamiliar clinical settings and rigorous control

procedures, that impeded the process of facilitated communication, effectively

inoculating FC against even the possibility of either verifying or invalidating the

procedure in whole or part though traditional scientific means (Simpson & Myles, 1995;

Jacobson, et al., 1995). Nevertheless, researchers continued to experimentally

evaluate facilitated communication, this time adopting the more qualitative measures

prescribed by FC practitioners while attempting to maintain sufficient control procedures

(Wheeler, et al., 1992; Hudson, et al., 1993). The results, while marginally more

favorable again failed to replicate the results demonstrated in typical FC training

Running Head: Science and Controversy in Facilitated Communication

sessions when measures were taken to control for facilitator influence.

While studies continued to be conducted on some select facets of facilitated

communication into the new century, by 2001 the scientific community largely

considered the matter settled (Mostert, 2010), pointing to the overwhelming lack of

empirical evidence to support the claims and findings of FC and the preponderance of

evidence indicating facilitator influence as the most likely variable responsible for the

unexpected language abilities in individuals with no history of such ability.

Facilitated communication continues to be practiced and promoted throughout the

United Stated and elsewhere in spite of a near absence of qualitative, peer-reviewed

studies to support its claims.

Description of Facilitated Communication, Its components and behavior-analytic

principles

As defined by Simpson and Myles (1995), Facilitated communication is “…an

augmentive communication method that permits individuals with severe disabilities such

as autism to demonstrate unanticipated, and in some instances extraordinary,

communication skills” (p. 1). It involves a facilitator who provides the participant with

physical support at the hand, wrist, elbow, or shoulder in order to stabilize their

movements while the nonverbal person types letters, words or sentences on a keyboard

or similar communication device.

These general features of FC have remained largely unchanged since its initial practice,

and are founded on the observations and subsequent writings of Crossley (1997) with
Running Head: Science and Controversy in Facilitated Communication

later theoretical extrapolations provided by Biklen (1990), most notably the

unsubstantiated contention that speech and language delays, as exhibited by

individuals diagnosed with autism, are a function of an unspecified neurophysiological

condition that manifests as apraxia. It is this supposed underlying condition that

prohibits the individual from communicating freely and independently, and which is

ameliorated through the physical and emotional support provided by the facilitator.

While adherence to the general principles of FC remains mostly consistent where it is

practiced, significant variability exists in the rudiments of the technical and mechanical

implementation of the treatment. There are number reasons for this, chief among them

being the contention that, due to variability in “…behavior, disability, style of interaction,

personality, and other factors” the approach to teaching FC is necessarily non-uniform

(Biklen, 1990). While this degree of individuation is not unique to FC, and perhaps

even laudable given the range of ability exhibited by those with autism, it nevertheless

lacks the necessary theoretical basis of more established teaching strategies that are

firmly situated within a larger framework backed by a body of scientific research,

experimentation and methodological rigor. A condition that is conspicuously absent in

the case of Facilitated Communication.

Biklen (1990) outlines seven attitudinal dimensions and 18 practices, which comprise

the underlying principles of Facilitated communication. The attitudinal dimensions are

broken down into two categories, Presentation/Intention and Assumptions/Beliefs and

include such guidance as “Don’t patronize people…Be candid” “Be apologetic about the

assessment procedure… it involves asking questions that are too simple for the person

being queried” and “Assume the person’s competence” (Biklen, 1990, p. 306). The 18
Running Head: Science and Controversy in Facilitated Communication

practices are similarly subcategorized under the headings: Physical Support, Being

Positive, Other Support, Achieving Communication/Overcoming Problems, and

Curriculum. From these general principles and other literature are derived the specific

teaching methods of facilitated communication. Of the methods described in FC

literature and training documents, four key components stand out of having a loose

(though undocumented) association with certain behavior-analytic principles. These

components are a) graduated prompt fading from hand to wrist, arm, elbow and

shoulder with the intention being to b) fade facilitation to the point at which the aide user

types or communicates independently without the need for physical contact, c)

consistent practice with the teaching strategy in order to increase accuracy and speed

(i.e. fluency), and d) planned ignoring of problem behavior (extinction) such as

“stereotyped utterances,” “screeches,” “hand slapping on desk,” “pushing desk away,”

and “getting up by asking, for example, ‘What’s the next letter you want?’” (Biklen, 1990,

p. 307). It is important to note that there is no stated or documented adherence to

behavior-analytic principles, merely that a correlation exists. As such, while assessing

these components through the lens of a separate discipline may be presumptuous; it

nevertheless serves a useful comparative function, given ABA’s history of strict

adherence to experimentation and scientific methodology.

Defined in behavioral terms, prompts are “supplementary antecedent stimuli used to

occasion a correct response in the presence of an discriminative stimulus that will

eventually control the behavior” (Cooper, Heron & Heward, 2007, p.403). More

precisely, the technique used in FC is a procedure for systematically transferring

stimulus control from the response prompt (i.e. the physical guidance of the facilitator)
Running Head: Science and Controversy in Facilitated Communication

to the naturally existing stimulus (the keyboard). Key differences between these two

procedures exist. Whereas in Behavior Analysis, stimulus prompts are only used during

the “acquisition phase of instruction” (Cooper, et al., 2007, p. 403), in the practice of

facilitated communication contact can be maintained beyond the time that the behavior

demonstrates reliable occurrence if it is in service to the individual’s capacity to

communicate more fluently (Biklen, 1990, p. 307). Another key difference is that in

facilitated communication, the “facilitation” of the behavior of typing is, in theory, not

considered a prompt in that the individual continues to initiate and hold primary authority

over the response.

Behavioral fluency, defined by Binder (1996) as the “fluid combination of accuracy plus

speed that characterizes competent performance” (p. 164) is closely related to the

philosophy of Precision Teaching. A prominent feature of fluency is that its measured

effects tend to be retention, maintenance, and endurance of the skill even in the

presence of distracters. Insofar as rate of behavior increase is the standard measure of

behavioral fluency, it stands to reason that frequent and consistent responding is

necessary to increasing fluency. This practice is supported in the facilitated

communication literature in its recommendation to “establish a regular schedule by

which the practice of pointing through facilitation can develop” (Training Standards,

Syracuse University), as well as item 13 in the Facilitated Communication Practices,

“Encourage lots of practice; practice builds accuracy and speed!” (Biklen, 1990).

Finally, under the subsection Achieving Communication/Overcoming Problems, Biklen

(1990) recommends that facilitated communication trainers stop stereotyped utterances

and other problem behaviors (listed above) by “ignoring them and focusing on the task
Running Head: Science and Controversy in Facilitated Communication

of manual communication” (p. 307). In Behavior Analysis, this procedure is known as

extinction (Cooper, et al., 2007, p. 457), specifically the procedural variation, as

differentiated from the functional variation. Historically, the procedural form of extinction

was often demonstrated to be ineffective (Cooper, et al., 2007). With the development

of functional assessment, and the capacity to identify the maintaining contingencies for

a given behavior (i.e. the function of the behavior), it became possible to withhold

maintaining reinforcers, and therefore more effectively reduce occurrences of problem

behavior. While it is unlikely that practitioners of facilitated communication will conduct

functional assessments of problem behaviors, it is encouraging that FC principles

acknowledge these behaviors and provide some means of addressing them when they

occur.

The Problem of Validity: Evidence and Limitations of Empirical Effectiveness

As stated, an overwhelming body of scientific literature and research reviewing the

efficacy of Facilitated Communication has consistently demonstrated an inability to

replicate the qualitative and anecdotal findings of FC when quantitative measures are

implemented, including specific procedures for controlling facilitator influence (Cummins

& Prior, 1992; Mostert, 2001; 2010). The causes put forth for to account for the

incredible results and “unexpected literacy” of formerly minimally communicative

individuals and the subsequent failure of experimentation to validate these outcomes,

constitute a collection of explanatory fictions, which further obscures analysis of the

procedure. In addition, the body of literature that serves as a vehicle for these

rationalizations consists almost entirely of promotional materials, case studies, and

other anecdotal accounts published in popular magazines and other non-peer reviewed,
Running Head: Science and Controversy in Facilitated Communication

non-experimental source material (Jacobson, et al., 1995, p. 754).

Perhaps the most pernicious of these explanatory constructs is the claim that the

success of the teaching strategy requires trust and faith between the user and facilitator

in order to be effective (Biklen, 1990; Jacobson, et al., 1995). Therefore, requirements

to validate the authenticity of an aid users FC output (an empirical necessity) violate the

relationship between the aid user and facilitator, disturbing the process, and by

extension the results of that interaction. Instead, proponents of FC “…have identified 14

conditions which increase the likelihood that facilitated communication users will be able

to demonstrate their authorship” (Biklen & Cardinal, 1997). Setting aside for the

moment the criteria of “increased likelihood” these conditions are as follows:

1. extensive experience with facilitation by both facilitator and facilitated communication

user;

2. practice using multiple trials;

3. consultation with facilitated communication user on test and format;

4. familiar facilitators;

5. monitoring for facilitated communication user's style;

6. no-risk, or low-risk testing;

7. building of confidence; with limits on opportunities to fail

8. naturally controlled conditions;

9. ongoing feedback on performance;

10. minimization of word retrieval tasks;

11. presentation of information through multiple modalities;

12. age appropriate content;

13. personally relevant content; and

14. extensive time to respond to questions.

Running Head: Science and Controversy in Facilitated Communication

With regard to Items I, 2 and 14, it is certainly logical and necessary to ensure that the

user is familiar with the strategy and competent in its application, as well that the user is

allowed sufficient time to respond, given that ineffective motor functioning and poor

motor planning is a prominent rationalization for the use of FC in various population

groups. For the remainder of these items it is difficult to determine in what way such

conditions would contribute to the scientific validation of authorship. To the contrary,

conditions such as “consultation with the user,” “familiar facilitators,” and “ongoing

feedback” may lead to the possibility of contaminating the outcome by altering facilitator

knowledge, this being of primary concern considering the preponderance of analysis

demonstrating facilitator influence as the determining factor in facilitated communication

output (Cummins & Prior, 1992; Jacobson, et al., 1995; Wheeler, et al., 1992). To a

lesser degree using “personally relevant content” may prove problematic as well when

considered in relation to other factors such as the familiarity between facilitator and FC

user, and the duration of training and longevity of contact between them. Familiarity

and rapport being, incidentally, a “best practices” principle as outlined by Biklen.

These conflicting variables at best create a degree of uncertainty that must be mitigated

through extensive revision and clarification of the listed conditions. At worst, the

procedures for demonstrating authorship listed above in fact decrease the likelihood of

validating authorship unless additional mechanisms are established to control for their

influence, not unlike the various control procedures described in the texts cited

throughout this document.

As stated in Item 10 in the list above, facilitated communication practitioners seek to

minimize the use of “word retrieval tasks” particularly as they relate to tests for validity
Running Head: Science and Controversy in Facilitated Communication

and authorship. This statement alludes to the claim in much of the FC literature that

children with autism suffer from difficulties with stating specific words on demand, with

the assumption that this etiologically unspecified deficit prevents them from doing so

(Crossley & Remington-Gurney, 1992). While the literature on this indicates some

occurrence of word finding problems (Jacobson, et al., 1994), as well as deficient recall

of recent events (Boucher, 1981) and general pragmatic language impairment, these

studies involve either “higher-functioning” individuals with significant vocal

communication, or word-retrieval problems with respect to verbs (Boucher, Jacobson et

al., respectively). In all but one of the studies conducted prior to 1995 that tested for

authorship using adversarial testing (i.e. requiring a specific response) under controlled

conditions the stimulus used, whether vocal, text or pictorial could be categorized as a

noun. In addition, later studies allowed for considerable interpretation of the FC user’s

output in determining the intent, and thus the correctness of the response.

Despite this and other concessions permitted to accommodate the demands of FC

proponents, and the attendant threats to internal validity, the findings presented in these

studies are consistently unfavorable to facilitated communication.

Assumed literacy, one of the foundational principles of facilitated communication, is a

principle that within the evolving theoretical framework of facilitated communication, has

attenuated over time. According to the Training Standards document available through

the Syracuse University School of Education web page (Training Standards), “It is

especially important that difficulties with communication not be taken as evidence of

intellectual incompetence”. This is a dramatic change from previous positions, which

held that this was one of the “essential components” of FC (Eberlin, McConnachie, Ibel,
Running Head: Science and Controversy in Facilitated Communication

& Volpe, 1993). Nevertheless, this assumption whether explicit or implied, is central to

the belief that exhibited verbal behavior is not correlated with actual ability and that

certain individuals possess a “hidden literacy” that can be revealed through proper

training. This belief is contraverted by an expansive literature demonstrating a strong

correlation between observed behavior and covert ability (Jacobson, et al., 1995),

however the assumption of a developmental dyspraxia remains a cornerstone belief of

FC. The persistence of this belief, despite a significant lack of supportive evidence, is

perhaps due to a peculiar logical fallacy inferred by the many anecdotal reports

demonstrating the effectiveness of FC: The hidden ability possessed by severely

disable, nonverbal individuals exists because individuals using facilitated

communication have stated it. Further, the very existence of their statements proves as

much. While this type of circular reasoning clearly poses a threat to the overall validity

of facilitated communication, of greater concern is that “evidence” such as this is and

has been widely disseminated to the public as proof of FC’s dramatic claims. And the

adoption of this technique by those impacted by autism and other developmental

disabilities, in the absence of context and experimental validation poses significant

ethical considerations.

Ethical and Other Considerations

As stated in the Training Standards document for facilitated communication, “The right

to communicate is both a basic human right and the means by which all other rights are

realized” (Training Standards). While it would be difficult to argue with this statement,

perhaps a more salient concern – and more significant violation of basic human rights –

is the misattribution of one’s statements. Wheeler et al., having demonstrated the

Running Head: Science and Controversy in Facilitated Communication

inadequacy of circumstantial evaluation methods stated that such methods “…could

lead to inadvertent, unknowing, albeit benevolent, misrepresentation of individual

preferences” (1992). When such communications are acted upon “…as indications of

preference, personal belief, necessary treatments, and supports” (Wheeler, et al.,

1992), the consequences of such action have the potential to be detrimental to the

individual if these statements prove to be inaccurate.

To date, all of the relevant studies conducted concerning the effectiveness of facilitated

communication either fail to demonstrate a functional relation between the treatment

strategy and its observed outcome, demonstrate a relationship but are invalidated due

to methodological flaws revealed under critical examination, or were conducted using

qualitative or ethnographic analysis with no procedures in place to control for facilitator

influence – of primary concern considering the controversy regarding authorship.

Concerning studies that fall into the category of qualitative analysis, such as those of

Biklen (1990), Biklen and Cardinal (1997), Crossley (1997), Crossley and Remington-

Gurney (1992) and others, the absence of adequate description in terms of

methodology and evaluation of the case studies, specifically baseline measurements of

expressive speech and language capabilities prior to treatment, constitutes an

additional failure to validate and supports the findings.

Summary

In light of the analysis presented in this paper, it should be noted that not every

component of facilitated communication fails the scientific test. Indeed, certain

principles and practices previously discussed appear, in theory if not always in practice,
Running Head: Science and Controversy in Facilitated Communication

to be grounded in accepted scientific discipline. The difficulty is that where FC fails the

test of science, it fails on the first principles of empiricism and validity. As such, all

positive claims, findings and analysis must be considered with an eye toward prudence

and skepticism. Unfortunately, the resistance among proponents and practitioners of

FC to thoroughly question its findings, the reliance on anecdotal and ethnocentric

analysis, and most significantly the dismissal of qualitatively derived scientific findings

questioning the validity of FC, place this strategy more suitably in the realm of

pseudoscience.

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