Abstract
This chapter discusses a discredited but frequently used language intervention in minimally speaking autism: facilitated communication (FC). Its variants include the rapid prompting method (RPM) and spelling to communicate (S2C). The chapter discusses the multiple organizations that advise against the use of FC and the dozens of studies that show how facilitated messages are directed by the facilitator rather than by the person that the facilitator is supposed to be merely facilitating. It also notes the growing resistance to well-controlled authorship testing and how this has translated into a dearth of rigorous research examining the validity of the latest variants. It explains how FC relies on scientifically unfounded theories of autism, language learning, and the acquisition of academic skills, and how using FC in place of evidence-based learning interventions translates into significant opportunity costs for those individuals with autism who are subjected to it.
TopIntroduction
The previous chapter reviewed a variety of strategies for augmenting and assisting communication in non-speaking and minimally speaking autism. These strategies range from gestures (sign language), to picture exchanges (PECS), to screen-based technologies (speech generating devices and word prediction software). For those who need additional assistance, say because of difficulties with fine motor control, there are large switches and eye trackers. For all this variety, AAC has one common denominator: once the individual learns how to use the AAC tool at hand, the following conditions hold:
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The tool does not need to be held up by someone else.
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The user does not require someone to touch her while she uses the tool.
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She is able to use it with an unlimited range of different communication partners.
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She does not require a specific person to be present, within her line of sight or range of hearing, in order to use the tool successfully.
In other words, the user does not depend on a designated helper to assist with the communication process.
In facilitated communication (FC), the subject of this chapter, such independence is completely lacking. FC, also known also as supported typing and typing to communicate, and including such variants as the Rapid Prompting Method (RPM) and Spelling to Communicate (S2C), is distinguished from all other forms of communication by one key ingredient:
The facilitator, also called a helper, assistant, interpreter, communication partner, or communication and regulations partner, facilitates communication in ways that end up undermining both the communication process and the individual being facilitated (henceforth, the “facilitatee”). The problem, as we will discuss, is that all of variants of FC lend themselves to cueing of the facilitatee by the (typically unwitting) facilitator: cueing that, via tactile, auditory, or visual signals, guides the typed-out messages, substituting the communicative intent of the facilitatee with that of the facilitator.
Despite this key distinction between AAC and FC, some FC proponents claim that AAC includes all types of aided communication, such that FC qualifies as a subtype (see, e.g., Nancy Lurie Marks Foundation, n.d.; United Nations, n.d.). As Mirenda (2014) reminds us, however, even though many forms of AAC are aided, the aid comes from devices that are external to the individuals who use them; not from other human beings. The one exception is what is called “partner assisted scanning,” where another person points to or speaks out loud or otherwise scans through the words to be selected, but even here it is unequivocally the AAC user who controls what is selected.
As we will discuss, FC was debunked multiple times in the early 1990s. In the U.S., it has been deemed ineffective and/or non-evidence-based by multiple medical, psychiatric, and disability organizations: the American Speech-Language-Hearing Association, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, the American Association on Intellectual and Developmental Disabilities, the American Psychological Association, the Association for Behavior Analysis International, the Association for Science in Autism Treatment, the National Council on Severe Autism, the International Society for Augmentative and Alternative Communication, and the National Institute for Health and Care Excellence. Below are three recent position statements.
From the American Academy of Pediatrics (Hyman et al., 2020):
Current scientific evidence does not support the use of facilitated communication in which a nonverbal individual is guided to communicate. This differs from AAC, in which the individual is taught to communicate independently.
From the American Association on Intellectual and Developmental Disabilities (American Association on Intellectual and Developmental Disabilities, 2019):
In the case of FC, there is no scientific evidence supporting its validity, and there is considerable evidence that the messages are authored by the facilitator rather than by the individual with a disability. In the case of RPM, there is lack of scientific evidence for its validity, and concerns about message authorship similar to those for FC have been raised.
Key Terms in this Chapter
Message-Passing Test: A test in which the facilitator does not know the answer to the question being asked of the person they are facilitating. Message-passing tests are the only reliable way to determine who is directing the messages during facilitated communication. In all rigorous message-passing tests that have been published, it has turned out that the facilitator was the author of the facilitated messages.
Minimally-Verbal: Both minimally-speaking and similarly limited in writing and/or sign language, and also exhibiting only minimal comprehension of oral, written, or signed language.
Ideomotor Effect: The tendency of people to make subconscious movements under certain circumstances, for example when rooting for a particular outcome, and to be unaware that they are the causes of these movements.
Presume Competence: The notion that people should assume that minimally-speaking and non-speaking individuals are communicatively and intellectually competent. For many proponents of this notion, presuming competence means presuming that communications generated via FC are coming from the individual being facilitated.
Non-Speaking: Unable to articulate words, perhaps because of Apraxia of Speech or other oral-motor difficulties, or perhaps because of lack of access to speech sounds (e.g., because of hearing loss). Non-speaking individuals may be able to use alternative linguistic media like sign language or written language. In autism, however, non-speaking often means non-verbal.
Cueing: Signals, often subconscious, that can influence another person’s conscious or subconscious behavior.
Nonverbal: Unable to produce language in any linguistic medium: speech, sign language, or written language. Approximately 20% of autistic individuals are thought to be nonverbal.
Facilitator: A person who provides physical support and/or emotional encouragement and/or verbal prompts and/or prompts involving letterboard movements while the person they are facilitating (the facilitatee) types out a message. Facilitators are also known as “assistants,” “communication partners,” and “communication and regulations partners.” A large body of evidence suggests that they unwittingly direct the messages that their facilitatees type out.
Minimally-Speaking: Speaking, but only in a limited way: only able to produce a few words and phrases, and/or mostly echoing words without understanding their meanings. In autism, minimally-speaking tends to mean minimally-verbal. Many of those subjected to facilitated communication are minimally-speaking.