Journal of Autism and Developmental Disorders, Vol. 23, No. 3, 1993

Brief Reports

Brief Report: Evaluation of Eight Case Studies of Facilitated Communication

Susan Moore Health and Community Services, Victoria

Brian Donovan Karingal

Alan Hudson 1 Royal Melbourne Institute of Technology, Bundoora

Judith Dykstra and Jenny Lawrence Health and Community Services, Victoria

Facilitated Communication Training has been defined as "a technique that enables many speech-impaired people to have sufficient control over their pointing skills to be able to indicate their messages by pointing to letters, words, or pictures" (DEAL Communication Centre, 1991). The technique usually involves some form of physical assistance by another person, called a facilitator, to help the speech-impaired person to point accurately. An assumption is usually made that the impaired person is literate, and the assistance is to point at letters on a communication device of some sort. The letters pointed to then spell out the intended message. The communication

1Address all correspondence to Alan Hudson, Department of Psychology and Intellectual Disability Studies, Royal Melbourne Institute of Technology, Plenty Road, Bundoora, 3083, Australia.

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532 Moore et aL

device may be a high-technology general communication device such as a computer , a high-technology specific communicat ion device such as a Canon Communicator, or a low-technology communication device such as an alphabet board.

Considerable controversy has arisen as to the extent to which the communication is coming from the disabled person or from the facilitator (Biklen, 1990; Cummins & Prior, 1992; Jacobson & Mulick, 1992). A case study by Hudson, Melita, and Arnold (1993) showed that when simple short-answer questions were asked of the disabled person, correct responses resulted only if the facilitator could also hear the questions. Furthermore, if both the disabled person and the facilitator were fitted with earphones and different questions were asked of them, the answers given tended to be those to the facilitator's questions. The methodology used by Hudson et al. was essentially that recommended by the Intellectual Disability Re- view Panel (1989) in the report on its investigation into the reliability and validity of facilitated communication.

The issue of determining the origin of messages in facilitated com- munication is an important one for several reasons. First, from an ethical perspective it is imperative that communications be attributed to the correct source. While this is so for the general population, it is particularly so for people with disabilities who are less able to correct errors of attribution of this sort. Second, an accurate knowledge of a disabled person's communi- cation skills is necessary if service providers are to make the most suitable programs available to the person. Finally, the nature of the content of some critical communications is such that serious errors of justice may be asso- ciated with incorrectly attributed communications. For example, many of the disputes around facilitated communication have involved the disabled person making allegations of an offense against a family member or service provider.

The current paper reports on the assessment of the ability of each of a group of eight disabled people to communicate using facilitated communication. The people a t tended the same educational center, and were all of the students involved in the facilitated communicat ion train- ing program in that center. The assessments were carried out as part of routine program evaluation required by the State government. None of the assessments were associated with any disputes involving allegations of misconduct of any sort. The purpose of the assessments was to ensure that the most suitable educational programs were made available to the group. The assessments were conducted by a multidisciplinary team drawn from the educational center and the State government regional office. It consisted of two psychologists, a speech pathologist, and an educator.

Eight Case Studies of Facilitated Communication 533

METHOD

The general methodology was developed partially in line with the recommendations of the Intellectual Disability Review Panel (1989), but was modified as necessary to meet the needs of individuals (Hudson, 1992). For each facilitator-client pair, the facilitator was asked to provide 10 short-answer questions, each of which it was considered that the dis- abled person could answer. The facilitator also provided the expected answers, and then recorded the questions on an audio tape. Examples were: "What is the name of your dog?" or "What color is your sister's car?"

The 10 questions were asked of the subjects under three different conditions, referred to as Conditions A, B, and D. These corresponded to Conditions A, B, and D as specified in the recommendations of the Intel- lectual Disability Review Panel (1989), and as used in the Hudson et al. (1993) study. Condition A contained 5 questions randomly selected from the original 10, Condition B contained the remaining 5 questions, and Con- dition D contained all 10 questions randomly ordered.

In Condition A the questions were asked verbally of the subject by the facilitator, and the subject answered using the usual facilitated communication procedures. In Condition B the prerecorded questions were asked of the subject and facilitator via earphones, and then the subject responded. A comparison of Condition A with Condition B gave an indication of the extent to which the hearing of questions via ear- phones reduced the capacity of the subject to answer the questions. In Condition D the subject heard a question but the facilitator heard only music, which was played to screen the facilitator from hearing the sub- ject's question.

The responses to the questions were classified as follows: (a) A correct response in that either the expected answer was given, or a response that was in the same semantic category was given. An example of the latter would be if the question asked for the color of an object, and a color was given as an answer but it was the wrong color. (b) An unscorable response in that the subject gave a correct verbal response audible to the facilitator. (c) An incorrect response in that the response contained one or more ex- pected responses but they were responses to other questions. (d) No re- sponse in that either there was no response given or the response was uninterpretable.

The following procedures were used to ensure reliability of scoring. For responses that produced a written product, for example, the tape from a Canon Communicator, the responses were independently examined by three members of the assessment team. For a response to be considered

534 Moore et aL

correct, two of the three members had to score it as correct. For responses that did not produce a written product, for example, those responses pro- duced by the subject pointing at an alphabet board, the responses were independently recorded by two members of the assessment team and also by the facilitator. These records were then independently examined by three members of the assessment team to determine if they were correct. Again at least two needed to consider an answer correct for it to be scored as correct.

The critical condition as far as the validation is concerned is Condi- tion D. Subjects needed to be able to answer these questions correctly to demonstrate that they could independently communicate with the facili- tated communication technique. Because the facilitators knew all 10 an- swers and could potentially "guess" correct answers, some correction for guessing needed to be included. Based on a consideration of the binomial distribution of an event of probability p = 0.1, it was considered that at least 4 correct trials out of 10 were needed to set a probability of p < .05 of making a Type I error in determining the capacity of the subject to communicate using the facilitated communication technique.

The form of the facilitated communication differed among members of the group, and this caused the detailed nature of the assessments to differ for each case. It was necessary therefore to report the details of each case separately. Characteristics of the subjects are summarized in Table I.

Although there were eight disabled people (referred to as $1 through $8), there were only four facilitators (referred to as F1 through F4). The four facilitators had been trained by personnel from the D E A L Commu- nication Centre in Melbourne. The training involved both visits by the fa- cilitators to the D E A L Centre, and visits by D E A L personnel to the educational center.

Method of Facilitation

The method of facilitation for S1 involved the facilitator (FI) giving him physical assistance to push the keys on a lap-top computer positioned on the tray of his wheelchair. The physical assistance was effected by the facilitator standing on the subject's right side and holding the top of his right hand with her right hand.

The method of facilitation for $2 involved the facilitator (F2) giving him physical assistance to push the keys on a Canon Communicator with his right index finger. The physical assistance was effected by the facilitator

Eight Case Studies of Facilitated Communication

Table I. Subject Characteristics

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Extent of Use of spoken FC in

Subject Age Gender Diagnosis language months

1 22 M Cerebral palsy and unspecified None 20 level of intellectual disability

2 34 M Severe intellectual disability None 22

3 29 M Moderate to severe intellectual Short sentences 17 disability

4 41 M Moderate intellectual disability Single words 20

5 24 M Cerebral palsy and profound in- None 33 tellectual disability

6 24 M Moderate intellectual disability Short sentences 33

7 33 F No formal diagnosis Short sentences 24

8 25 F Severe to profound intellectual None 33 disability

standing on the subject's right side and using her right hand to grasp the upper side of the subject's right hand.

The method of facilitation for $3 involved the facilitator (F3) giving him physical assistance to point to letters on an alphabet board. The physi- cal assistance was effected by the facilitator grasping the upper side of the subject's hand and wrist. The subject pointed with the middle finger of his left hand.

The method of facilitation for $4 involved the facilitator (F3) giv- ing him physical assistance to push the keys on a Canon Communicator. The physical assistance was effected by the facilitator standing on the subject's right side using her right hand to grasp the subject's right hand. This entailed the facilitator's index finger supporting the subject's index finger.

The method of facilitation for $5 involved the facilitator (F4) provid- ing assistance to the subject to use a head pointer to point to letters on an alphabet board. The assistance was effected by the facilitator standing on the right hand side of the subject and using her right hand to hold the board at a height directly in front of the subject's eyes, and intermittently placing her left hand on the subject's head. When Question 1 in Condition

536 Moore et al.

A was presented, no response was produced in two sessions of 30 minutes. During this time the subject continually rested his head against the facili- tator's waist, attempted to remove the head pointer, and pushed the al- phabet board away from his body with his right hand. The assessment team decided not to continue with the assessment.

The method of facilitation for $6 involved the facilitator (F4) giving him physical assistance t o push the keys on a Canon Communicator. The physical assistance was effected by the facilitator standing on the subject's right side using her right hand to grasp the subject's right hand.

The method of facilitation for $7 involved the facilitator (F4) giving her physical assistance to point with the index finger of her right hand to letters on an alphabet board. The physical assistance was effected by the fa- cilitator grasping the forearm or wrist of the subject's right hand.

The method of facilitation for $8 involved the facilitator (F4) provid- ing assistance to the subject to use a head pointer to point to letters on an alphabet board. The assistance was effected by the facilitator standing on the right hand side of the subject and using her right hand to hold the board at a height directly in front of the subject's eyes, and intermittently placing her left hand on the subject's head. This subject was very slow in responding. Condition A questions were administered over 2 days in ses- sions of 1 hour 45 minutes and 1 hour 10 minutes, respectively. Given that no correct responses were given to these questions, the assessment team decided not to continue with the assessment.

RESULTS

The results for all assessments are summarized in Table II. Subjects 1, 2, 3, 4, 6, and 7 participated willingly in the assessments, and there was no evidence to suggest that these subjects or their facilitators were not co- operating fully with the procedures. The inability of the facilitators to get any meaningful responses from $5 and $8 could have been due to those subjects' unwillingness to cooperate, or alternatively could have been due to their inability to produce any response.

Inspection of the above data shows that not one of the subjects dem- onstrated an ability to communicate using the facilitated communication technique. For all subjects except $5 and $8, correct answers were provided for Condition A. In Condition B there was a small reduction in the number of correct responses, but there were still sufficient correct responses to demonstrate that the introduction of the earphones did not prevent correct responding. In Condition D the failure of any subject to achieve the critical level of four correct responses precludes the drawing of the conclusion that

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any one of them can communicate using the technique. Furthermore, the high rate o f incorrect responses produced by subjects $1 to $4 demonstrates that facilitators F1 to F3 were all significantly influencing the communica- tion of the subjects they were facilitating.

DISCUSSION

The general failure of all subjects in this study to demonstrate an ability to communicate using the facilitated communication technique, when considered with similar results from other studies (Intellectual Dis- ability Review Panel, 1989; Hudson et al., 1993), suggests that the technique and its uses must come under close scrutiny. The need for this is made even stronger by the fact that the use of the facilitated communication technique is often associated with the disabled person making allegations that serious misdemeanors have been committed by other people (Hudson, 1992; Rimland, 1992).

Of particular importance is the need for the theoretical basis of fa- cilitated communication to be examined. A first step in such a theoretical evaluation would be to clarify precisely what the goal or goals of facilitated communication training are. Is the primary objective to teach a person with a severe communication impairment to point? If so why is it that people such as some of the subjects in the aforementioned case studies have been on the program for 33 months but are still in need of considerable physical assistance in order to be able to point. There are well-established proce- dures for teaching fine motor skills that would achieve the objective of teaching someone to point in a much shorter time-span.

Alternatively, is the primary objective to provide the person with access to an established language and literacy system? If so, there are many technological devices that achieve this without the requirement of physical assistance by another person. The question of who is generating the communication would not be an issue if such a technological device was used.

Finally, if the primary or auxiliary goal is to provide emotional sup- port for the person, surely this can be provided by some means other than by providing physical assistance to point. If physical contact is necessary for the provision of emotional support a good argument can be made for holding the hand not used for pointing, or placing an arm on the person's shoulder.

In addition to a clarification of the goals of facilitated communica- tion training, a detailed analysis of the structure of the theory underpin- ning the training technique needs to be undertaken. As indicated by

Eight Case Studies ot" Facilitated Communication 539

Hudson (1992), of particular interest would be (a) the extent to which elements critical to the method, for example "word finding problems," or "index finger isolation and extension problems" (Crossley, 1992), can be clearly defined and reliably measured; (b) the extent to which the claims regarding these critical elements are consistent with scientific knowledge; and (c) the extent to which the various elements of the facilitated com- munication method are able to be integrated theoretically in an internally consistent manner.

A detailed theoretical critique, combined with further empirical evalu- ations, are urgently required if the controversy surrounding the use of fa- cilitated communication is to be resolved.

An interesting aspect of these case studies is the fact that the facili- tators were not convinced that the results showed that the subjects could not successfully communicate using facilitated communication. They con- sidered that the methodology used was inappropriate because the subjects might have had nominal aphasia and this would handicap them in giving the required single-word or short-answer responses. The facilitators were invited to suggest an alternative methodology. This methodology was then used but the same results were obtained (Moore, Donovan, & Hudson, 1993).

REFERENCES

Biklen, D. (1990). Communication unbound: Autism and praxis. Harvard Educational Review, 60. 219-314.

Crossley, R. (1992). Communication training involving facilitated communication. In DEAL Communicat ion Centre, Facilitated Communication Training. Melbourne: DEAL Communication Centre.

Cummins, B., & Prior, M. (1992). Autism and assisted communication: A reply to Biklen. Harvard Educational Review, 62, 228-241.

DEAL Communication Centre. (1991). Some considerations when attempting to validate a facilitated communication user's communication. Melbourne: Author.

Hudson, A. (1992). Assessing the validity of facilitated communication. Australian Educational and Developmental Psychologist, 9(2), 24-29.

Hudson, A., Melita, B., & Arnold, N. (1993). Brief report: A case study assessing the validity of facilitated communication. Journal of Autisn~ and Developmental Disorders, 23, 165-173.

Intellectual Disability Review Panel. (1989). Report to the Director General on the reliability and validity of assisted communkation. Melbourne: Author.

Jacobson, J. W,, & Mulick, J. A. (1992). Speak for yourself, o r . . . I can't quite put my finger on it! Psychology hm Mental Retardation and Developmental Disabilities, 17(3), 3-7.

Moore , S., Donovan , B., & Hudson, A. (1993). Brief report: Facilitator-Suggested conversational evaluation of facilitated communication. Journal of Autism and Developmental Disorders, 23, 541-552.

Rimland, B. (1992). Facilitated communication: Now the bad news. Autism Research Review hzten~ational, 6(1), 3.