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Facilitated Communication and Autism Ranking: Mildly Hazardous Limited negative evidence

Facilitated communicationFacilitated communication (also known as supported typing) is a form of augmentative and alternative communication in which someone physically supports another person and helps them to point at pictures or words.

Facilitated communication is based on the idea that many of the difficulties faced by communication disabled people (including some autistic people) are due to movement difficulties rather than to social or communication difficulties.

The communication partner (usually called the facilitator) physically supports the other person (usually called the aid user) so that they can point to pictures, symbols, letters and/or words using a computer keyboard or letter/picturebooks. By doing this, the aid user can demonstrate what they want to communicate.

Aid users often use facilitated communication as part of a total communication approach. For example, they may use it in combination with other methods of communication such as speech or sign language.

Please note

The National Institute of Health and Clinical Excellence (NICE) made the following recommendations: "Do not provide facilitated communication for adults with autism". (NICE, 2012)

The International Society for Augmentative and Alternative Communication (ISAAC) stated that “ISAAC does not support FC as a valid form of AAC, a valid means for people to access AAC, or a valid means to communicate important life decisions. The weight of evidence does not support FC and therefore it cannot be recommended for use in clinical practice”. (ISAAC, 2014)

Our Opinion

There is a significant amount of research evidence to suggest that facilitated communication provides no benefits for individuals on the autism spectrum. All of the high quality evidence indicates that any communication is created by the facilitator, not the aid user.

There is also evidence that facilitated communication can, in a few cases, lead to significant harm. For example, there have been occasions when unsubstantiated claims of sexual abuse against family members have been made by the people facilitating the communication.

For these reasons we do not believe that it is an appropriate intervention for people on the autism spectrum. We also believe that there is no reason to carry out further studies into its use.

Disclaimer

Please read our Disclaimer on Autism Interventions


Audience

The supporters of facilitated communication believe that it is suitable for a range of people with severe communication impairments. For example, according to the Ann McDonald Centre website, accessed on 15 March 2017,

“Use of facilitated communication is not restricted to any specific age or any diagnostic group. It’s been used successfully by people with diagnoses including autism, Down syndrome, intellectual disability, cerebral palsy and acquired brain damage. We’d say it was worth trying for anybody who isn’t speaking, or who isn’t speaking roughly around the level of their peers (because we do have clients who have some speech – just not enough for their needs) who has not been able to use other communication strategies (e.g. hand signs, hand writing, electronic communication devices) fluently and effectively”.

“Facilitated communication training is most useful for people with severe communication impairments who are not able to use their hands effectively … and who need to use easily-portable communication aids”.

Aims and Claims

Aims

The aim of facilitated communication is to enable people with severe communication impairments to communicate more effectively. For example, according to the Ann McDonald Centre website, accessed on 15 March 2017,

“The immediate aim of facilitated communication training is to allow the aid user to make choices. People who can make choices can communicate in a way that was impossible before. Once they can make choices we encourage them to practice using a communication aid (a picture board, for example, or a speech synthesizer or keyboard) in a functional manner, to increase their physical skills and their self-confidence and to reduce their dependence on the facilitator. As the student's skills and confidence increase the amount of facilitation is reduced. The ultimate goal is for students to be able to use the communication aid(s) of their choice independently”.

Claims

There have been various claims made for facilitated communication. For example, according to the Ann McDonald Centre website, accessed on 15 March 2017,

“Facilitated communication training has enabled some people without functional communication to take charge of their lives, make their wishes known for the first time, and join the life of their communities. Parents have been enabled to communicate with their children. Children who have had only restricted education, or no education at all, have gone into regular classes; some have completed high school and gone on to university. For some people with challenging behaviours frustration has been relieved and behaviour has improved.

“Some people who started spelling slowly with facilitation are now typing independently. And some people who started to use communication aids with facilitation have found their speech has improved significantly”.

Key Features

Facilitated communication (also known as supported typing) is a form of augmentative and alternative communication in which someone physically supports another person and helps them to point at pictures or words.

The communication partner (usually called the facilitator) physically supports the other person (usually called the aid user) so that they can point to pictures, symbols, letters and/or words using a computer keyboard or letter/picturebooks. By doing this, the aid user can demonstrate what they want to communicate.

According to Biklen (1999), the facilitator provides support in a number of ways including:

Physical Support

Physical support may include the following:

  • assistance in isolating the index finger
  • stabilising the arm to overcome tremor
  • backward resistance on the arm to slow the pace of pointing or to overcome impulsiveness
  • a touch of the forearm, elbow, or shoulder to help the person initiate typing
  • pulling back on the arm or wrist to help the person not strike a target repetitively.

Emotional Support

Emotional support involves providing encouragement, but not direction, as the person points to communicate.

Communicative Support

Communicative support may include various forms of prompts and cues to:

  • assist the individual to stay focused in the communication interaction
  • provide feedback to the individual on the content of the message
  • assist the individual in clarifying unclear messages.

The amount of help needed varies from person to person. Some people may just need an encouraging hand on their shoulder to boost their confidence. Other people may need someone else to support and shape their hand, which allows their index finger to be isolated and extended for pointing.

According to the Ann McDonald Centre website, accessed on 15 March 2017, facilitation is a last resort.

“Facilitated communication training is difficult, limiting, time-consuming, and controversial. If you can find another satisfactory way for a person to communicate (that is, a means of communication that allows the person to generate utterances of age-appropriate length) then jump at it. If you can't, try FCT - and try to work your way out of it as soon as is feasible. And while you're using FCT, don't forget to develop independent strategies for answering yes/no questions and making choices. These may involve wide-spaced options for fist pointing or eye-pointing, cards velcroed on a carpet board for grasping, head turns - whatever suits the individual”.

Cost and Time

Costs

In theory, facilitated communication can be undertaken for free by anyone who has learnt the facilitation process. In practice, there may be costs for any training that is undertaken (which may include travel, accommodation and learning materials), and any equipment and materials used (which may include computer keyboards or letter/picturebooks.)

Time

The amount of time it takes to undertake facilitated communication is likely to depend on the needs of the people undertaking it. For example, according to the Institute on Communication and Inclusion website, accessed on 15 March 2017,

“Because each person is unique, learning to type is an individualized process. It may take a considerable time to achieve success - sometimes weeks or months. Independence depends also on the motor issues that the person faces, as well as emotional issues. While not all communication aid users will be able to type with no physical support, independent typing is the goal for all users and their families".

Risks and Safety

Hazards

Facilitated communication is a highly controversial intervention that has been the focus of reports by the American Association on Mental Retardation, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry and The International Society for Augmentative and Alternative Communication.

All are highly critical of this approach and strongly recommend that it should not be used. All the available evidence indicates that communication is created by the facilitator, not the communication disabled person. There is also evidence that facilitated communication can, in a few cases, lead to significant harm.

The International Society for Augmentative and Alternative Communication (2014) noted that:

“The use of FC appears to be in violation of several articles of the United Nations Conventions on the Rights of Persons with Disabilities (i.e., Articles 12, 16, 17, and 21) as it has been shown to prevent individuals without sufficient spoken language from using their own “voice.” With the use of FC, the messages may be attributed to facilitators. For persons with limited or no functional speech, the use of FC risks the loss of valuable assessment and intervention efforts, time, and resources that might otherwise have been expended to implement AAC systems and strategies that are empirically validated and do not leave doubt about authorship”.

Contraindications

There are some contraindications (something which makes a particular treatment or procedure potentially inadvisable) for facilitated communication. For example, according to the Ann McDonald Centre website, accessed on 15 March 2017,

“Facilitated communication training generally isn’t considered as an option for an individual if they:

  • have fluent functional speech
  • have a fluent alternative communication strategy
  • have the potential to acquire manual signing or handwriting skills easily
  • can clearly and unambiguously select sequences of items from communication displays in order to create sentences
  • are able to use other direct or indirect access options such as headpointers or scanning systems effectively (some people can’t use these means because of physical control problems, some can’t use them for practical reasons - people who walk instead of using wheelchairs, for example, have trouble carrying a scanning system around with them)".

Suppliers and Availability

Suppliers

A facilitator can be a teacher or other professional, a family member or a friend.

Credentials

There are no formal, accredited qualifications for people who act as the facilitators.

However the Institute on Communication and Inclusion at Syracuse University in New York does publish a document called Best Practice in Communication Support. This is designed to set out best practice in the use of facilitated communication.

History

Facilitated Communication began in Australia in the 1970s. Rosemary Crossley, an aide at an institution for people with severe multiple disabilities, encouraged a young woman who had cerebral palsy to communicate by acting as her facilitator.

Crossley went on to establish the DEAL Communication Centre in Melbourne in 1986 which aimed to “assist people with no speech or with dysfunctional speech to find alternative means of communication”.

Interest in FC quickly spread to other countries – in particular the USA, Canada and Denmark and the UK. FC was widely promoted in the US by Professor Douglas Biklen who published many reports in the 1990’s claiming that FC could lead to “Communication Unbound”.

Current Research

We have identified more than 50 studies of facilitated communication for people on the autism spectrum which have been published in English-language, peer-reviewed journals.

These studies included more than 500 aid users aged from 3 years old to adult, some of whom had significant learning disabilities. The facilitators included teachers, researchers, other professionals and family members. The facilitation took place in a range of settings including the classroom, clinic and/or family home.

The majority of the studies investigated facilitated communication as a standalone technique. A small number of the studies compared facilitated communication to other interventions, such as PECS:

  • The majority (more than two thirds) of the studies reported that facilitated communication was ineffective, that is, it was demonstrated that it was the facilitator creating the communication, not the aid user
  • A minority (less than one third) of the studies reported that facilitated communication enabled the aid users to communicate more effectively. However most of these studies were of very low scientific quality.
  • A small number of studies reported that, where facilitated communication was compared with another form of augmentative and assistive communication (such as PECS), facilitated communication was ineffective but the other intervention was effective.
  • A small number of studies reported adverse effects when using facilitated communication. For example, Bebko and Perry (1996) reported that the participants became more passive communicators when facilitated communication was used.

Status Research

Studies

There are a number of limitations to all of the research studies published to date. In part this could be explained by the fact that the majority of the studies took place in the1990’s, a time when some authors were less rigorous in how they reported their work. For example, many of the studies we identified did not provide sufficient data about the participants in the study (such as age and gender, whether they had a formal diagnosis of autism etc.).

There were a number of other significand limitations to the studies. For example:

  • The majority of the studies included less than 10 participants. Some of the studies included three or less participants.
  • The majority of the studies used single-case design methodologies (such as multiple baseline, reversal design or simple case series).
  • A minority of the studies used an open label trial format but no comparison control group. The two studies that did have a control group did not use randomisation or blinding.
  • Some of the studies were undertaken by researchers who were not independent of the intervention being studied. Those researchers may therefore have been biased towards the intervention, however unconsciously.

For a comprehensive list of potential flaws in research studies, please see ‘Why some autism research studies are flawed’

Reviews

There have been a number of research reviews of facilitated communication published in peer-reviewed journals. We agree with the review by Mostert (2001) which concluded:

“The results of the review support and confirm the conclusions reached by previous reviewers of the empirical FC literature. The divide between the results of studies incorporating control procedures find very little to no support for the efficacy of FC, studies employing fewer control procedures produce mixed results, and studies ignoring control procedures almost universally find FC to be effective. In the cases of the few, tentative positive results emerging from studies reporting some form of control procedures, as in the cases of Cardinal et al. (1996) and Weiss et al. (1996), these results are much more likely the artifact of methodological problems than an accurate representation of persuasive evidence. However, should researchers so choose, there is still much work to be done related to FC, both theoretically and experimentally. Theoretically, many questions remain related to FC proponents’ stance on anecdotal versus scientific evidence, the critique of Green and Shane (1994) and Biklen and Duchan’s (1994) response notwithstanding. As this review makes clear, the correspondence of evidence or lack thereof appears correlated to the methodological means of obtaining that evidence. Any hope of establishing credibility for FC, as unrealistic as that may be, can only come from increased experimental rigor. At a more philosophical, level, Hudson’s (1995) challenge to the weak theoreticl underpinnings of FC should be addressed by FC proponents given that current theoretical perspectives of FC are, at best, unformed”.

Ongoing Research

We have been unable to identify any studies into facilitated communication that are currently underway. If you know of any other studies we should include please email info@researchautism.net with the details.

Future Research

Summary of Existing Research

There is a significant amount of research evidence to suggest that facilitated communication provides no benefits for individuals on the autism spectrum. All of the high quality evidence indicates that any communication is created by the facilitator, not the aid users.

There is also evidence that facilitated communication can, in a few cases, lead to significant harm. For example, there have been occasions when unsubstantiated claims of sexual abuse against family members have been made by the people facilitating the communication.

A number of advisory and professional bodies have recommended that facilitated communication is not used. For example:

  • The National Institute of Health and Clinical Excellence (NICE) stated “Do not provide facilitated communication for adults with autism." (NICE, 2012)
  • The International Society for Augmentative and Alternative Communication (ISAAC) stated that “ISAAC does not support FC as a valid form of AAC, a valid means for people to access AAC, or a valid means to communicate important life decisions. The weight of evidence does not support FC and therefore it cannot be recommended for use in clinical practice”. (ISAAC, 2014)

Recommendations for Future Research

There is no reason to carry out further studies on facilitated communication. However, we agree with the review by Mostert (2001) which concluded

"Specifically, more attention in future research could be paid to subjects (n and disability label), their age, the physical act of facilitation itself, issues around the settings for experiments, the motivations and beliefs of the facilitators, the inefficacy of FC over time, and an even greater emphasis of quantitative over qualitative methods for verification".

 

Studies and Trials

This section provides details of scientific studies into the effectiveness of facilitated communication for people on the autism spectrum which have been published in English-language, peer-reviewed journals. If you know of any other studies we should include please email info@researchautism.net with the details.

Please note that we are unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Related Studies and Trials


Other Reading

This section provides details of other publications on facilitated communication. If you know of any other publications we should include please email info@researchautism.net with the details. 

Please note that we are unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Related Other Reading


Personal Accounts

This section provides details of personal accounts of the use of facilitated communication for people on the autism spectrum.

Personal accounts can be useful sources of information about the intervention but are not as scientifically valid or reliable as research trials. This may be especially true where the accounts are published by an organisation which might gain a financial advantage from the take-up of the intervention.

Please note that the views expressed in these personal accounts do not necessarily represent the views of Research Autism.


The Institute on Communication and Inclusion website has published a number of positive personal accounts of facilitated communication for people on the autism spectrum.

Boynton (2012), on the other hand, has provided an account of how, as a facilitator, she persuaded herself that Betsy, her aid user, was using facilitated communication to tell her that she had been sexually abused. She explains how the allegations of abuse were proved to be false and that she therefore had to accept that she had, however unwittingly, been creating those false allegations herself.

Additional Information

According to Lilienfeld et al (2012)

“… FC is a striking case of the ideomotor effect, which had been known in psychological circles since at least the mid-nineteenth century. This effect, illustrated by such purported paranormal phenomena as Ouija boards, automatic writing, table tipping, dowsing, and the Chevreul Pendulum, refers to the propensity of people’s thoughts to influence their movements without their awareness. By means of mutual operant shaping, the facilitator and subject gradually learn to adjust to each other’s subtle movements. Over time, facilitators become convinced, and frequently insist, that they are merely offering resistance to the child’s hands, not actively guiding them. Yet, the data on FC clearly demonstrate that they are in control, even though they are typically unaware of their inadvertent authorship of the messages. This problem of unconscious bias and signaling has sometimes proven difficult to manage even for researchers trying actively to minimize it".

Related Additional Information


Updated
31 Oct 2017
Last Review
01 May 2017
Next Review
01 May 2020