Kathleen M. Holehan, MA, BCBA, LBA and Thomas Zane, PhD, BCBA-D
Department of Applied Behavioral Science, University of Kansas
Many who work in autism and other intellectual and developmental disabilities hope that once a fad treatment has been debunked and proven ineffective, the fad loses support and disappears from practice (Frazier, 2015). Although this may be the case with most fads, some persist despite being refuted by scientific evidence (Lilienfeld, Marshall, Todd, & Shane, 2014). Most recently, Facilitated Communication (FC; Crossley & Remington-Gurney, 1992), a method proven implausible, ineffective, and dangerous in the 1990s is gaining popularity and re-emerging in practice under new names (e.g., Supported Typing, Saved By Typing, Spelling To Communicate, Typing To Communicate, Rapid Prompting Method).
With the re-emergence of FC under new names, a major issue is raised. That is, FC was first introduced and debunked almost 30 years ago in the early 1990s. It is possible that new clients, clinicians, speech pathologists, and the general public are unaware of the dangers and ineffective results of FC as a treatment for individuals with autism and other intellectual or developmental disabilities. Because FC is not dead and is in fact gaining popularity, it is important to revisit previous literature debunking FC as well as to closely examine FC procedures re-emerging with new names in order to evaluate their efficacy and to disseminate whether or not they are efficacious.
FC was developed in Australia in the early 1970s by Rosemary Crossley, a teacher at St. Nicholas Hospital, and was brought to the United States in 1989 by Douglas Biklen, a sociologist and professor of special education at Syracuse University (Jacobson, Mulick, & Schwartz, 1995). Crossley developed FC as a means for individuals who are non-verbal and intellectually disabled (e.g., diagnosed with cerebral palsy, Down syndrome, autism, or other developmental disability) to communicate with assistance from another person, called a facilitator (Jacobson et al., 1995). Specifically, FC is a procedure in which a facilitator supports the hand of an individual as the individual uses his or her index finger to point to letters on a board or strike keys on a keyboard. The letters pointed to or the keys struck spell out the intended message (Biklen, 1990).
What is the historical link between ASD and Facilitated Communication?
Biklen introduced FC to the United States with the premise that non-verbal individuals diagnosed with autism and other developmental disabilities are of reasonably normal intelligence but cannot express themselves due to the neurological condition known as apraxia (Biklen, Morton, Gold, Berrigan, & Swaminathan, 1992). Biklen referred to apraxia as a disconnect between the motor and language systems of the brain that precludes direct communication. Biklen and Crossley believe it is this disconnect which prevents individuals from independently pointing to letters or striking keys therefore requiring assistance from a facilitator. The facilitator’s purpose is to stabilize the individual’s hand movements allowing letters to be selected and the intended message to be produced without influencing the selection of letters or keys (Biklen et al., 1992; Crossley & McDonald, 1980; Jacobson et al., 1995).
In 1990, Biklen published a study in the Harvard Educational Review (Biklen, 1990) where 21 individuals who were previously unable to communicate began communicating using FC. That is, with the assistance from a facilitator, the individuals were able to type full sentences, write poetry, and express the happiness that came from being able to communicate. With this publication, FC rapidly gained support. It seemed as almost overnight the procedure was being promoted and disseminated by large universities (e.g., Syracuse University, University of Maine, University of Wisconsin Madison), used in school and home settings, and featured in the media (e.g., New York Times Magazine, USA Today, The Washington Post).
Is there any research to support Facilitated Communication?
Despite the immediate support and fascination with FC, some were doubtful. Specifically, researchers began to question the validity of the procedure and the authorship of the messages produced (Jacobson et al., 1995). As researchers began to question the validity of FC, studies were developed to determine the authorship of the messages produced. Specifically, researchers used one of two controlled experimental paradigms to examine the validity of FC (Lilienfeld et al., 2014). The first paradigm was referred to as “message passing.” Message passing consisted of researchers displaying an object, giving an instruction, or asking a question either (a) with only the participant present (i.e., facilitator absent) or (b) with both the participant and facilitator present. The participant was then asked to respond appropriately, using FC, about the object seen, instruction given, or question asked. The hypothesis was that if the message was produced by the participant, it should not matter whether the facilitator saw the item, heard the instruction, or was aware of the question asked. The second paradigm was referred to as “double blind.” The double-blind paradigm consisted of the participant and the facilitator receiving the same or different information, instructions, or questions. Each individual (i.e., participant and facilitator) was blind to the other’s experiences. The hypothesis was that if the message was produced by the participant, the message should correspond to the participant’s experiences and not the facilitator’s (Jacobson et al., 1995; Saloviita, Leppänen, & Ojalammi, 2014).
Results of many controlled message passing and double-blind studies revealed that the facilitator was controlling the messages produced (e.g., Bligh & Kupperman, 1993; Cabay, 1994; Eberlin, McConnachie, Ibel, & Volpe, 1993; Hudson, Melita, & Arnold, 1993; Moore, Donovan, & Hudson, 1993; Moore, Donovan, Hudson, Dykstra, & Lawrence, 1993; Regal, Rooney, & Wandas, 1994; Shane & Kearns, 1994; Simon, Toll, & Whitehair, 1994; Vasquez, 1994; Wheeler, Jacobson, Paglieri, & Schwarz, 1993). Specifically, in the message passing studies, only when both the facilitator and participant saw the same object, received the same instruction, or heard the same question was the participant able to correctly respond. The participant responded incorrectly for items, instructions, and questions not seen or heard by the facilitator. In the double-blind studies, participants’ responses almost always corresponded to the facilitators’ experiences and not to their own. The evidence overwhelmingly supported the notion that FC only “works” when the facilitator is aware of the correct answer (Lilienfeld et al., 2014). The American Psychological Association (APA) summarized FC studies by stating, “The short version of this long story is that study after study showed that facilitated communication didn’t really work” (APA, 2003).
Despite the evidence, Biklen and his colleagues continued to support the validity of FC, arguing that the controlled tests were flawed (Lilienfeld et al., 2014). First, supporters maintained that the testing conditions used in controlled studies placed participants in confrontational and stressful situations, which affected their ability to correctly respond (Biklen & Cardinal, 1997; Crossley, 1994; Saloviita et al., 2014). Second, supporters proposed participants may be responding inaccurately due to difficulty communicating an exact word on command (i.e., word finding; Saloviita et al., 2014). Lastly, supporters argued that there have been some controlled studies where FC has been validated (e.g., Calculator & Singer, 1992; Cardinal, Hanson, & Wakeham, 1996; Vasquez, 1994). Jacobson et al. (1995) responded to these supporters and addressed each suggested flaw. First, Jacobson and colleagues expressed their concern with supporters stating the testing conditions were confrontational and stressful as the same participants were able to communicate in front of television cameras, at conferences and conventions, while taking examinations, and under interrogations for sexual abuse all of which are all presumably confrontational and stressful situations. Second, Jacobson and colleagues argued that although there was substantial literature indicating that individuals with autism have word finding problems with verbs, there is no literature indicating they have the same problem with nouns (Borthwick & Crossley, 1993). All controlled studies, with the exception of Simon et al. (1994), used nouns and not verbs as labels. Lastly, the limited positive reports that supporters cite to validate FC are simply not adequate enough to provide convincing support for it, in the face of overwhelming evidence to the contrary.
With the overwhelming evidence against the validity and use of FC, researchers and clinicians believed FC had been effectively repudiated. No one would continue using FC with all the evidence showing facilitators produced the messages, right? Wrong! Green et al. (2006) summarized survey data to determine the current use and acceptance (at that time) of FC. They found that 9.8% of children with autism were using FC. Additionally, the coverage of FC in the press, scholarly articles, internet and presence in academic settings was (and is) on the rise (Wick & Smith, 2009). Perhaps the most alarming survey data was reported by Schreck and Mazur (2008), who found that 6.4% of Board Certified Behavior Analysts (BCBAs) were using FC as a treatment and 5.1% believed FC was supported by research. Data suggested that those BCBAs who had been practicing for fewer than five years were more likely to report using FC than those who had been practicing for more than five years. These data are important as it suggests newer BCBAs may not be aware that FC was proven ineffective and discredited in the 1990s (Schreck & Mazur, 2008).
Over the past 30 years, the supporters of FC have given different names to FC. For example, Syracuse University has renamed FC as Typing To Communicate (“Typing To Communicate,” n.d.). Although a new name has been introduced and the University seems to have re-branded the procedure, the website clearly states that typing to communicate is FC. The website explains that typing to communicate or FC is a form of augmentative and alternative communication (AAC) that involves pointing to pictures or typing, with the aid of a facilitator, on a keyboard. The assistance provided by the facilitator is described to be individualized and can range from support on the hand to a touch on the shoulder. Even with the new name, the procedure seems exactly the same as the procedure for the debunked FC. Some of the other common re-names are Supported Typing, Saved By Typing (http://www.savedbytyping.com/) and Spelling To Communicate (https://www.aalive.org/spelling-to-communicate). Spelling To Communicate was developed at and is currently being used by the Growing Kids Therapy Center (“Spelling To Communicate,” 2018). Spelling To Communicate is described as a procedure to teach individuals with motor challenges to point to letters to spell as an alternative to vocal communication. With Spelling To Communicate, a facilitator does not touch the individual communicating, but instead holds a keyboard or letter board in front of the individual, such that the individual can independently point to the letters to spell out words. Spelling To Communicate seems different than original FC; however, there is the potential that the facilitator is controlling the messages by slightly moving the key or letter board without realizing it (Tetzchner, 2012). The Saved By Typing website has the least informative information as it omits a clear description of the procedure and instead offers videos of the procedure in action as testaments (“Saved By Typing,” n.d.). From the videos, one can see that the procedure of Saved By Typing is identical to that of FC procedures. That is, a facilitator sits behind an individual and supports their hand, wrist, shoulder, or back as they point to letters on a screen or keyboard. Again, despite a new name, the procedure looks exactly the same as the procedure for the debunked FC. Not surprisingly, there is no literature on these new procedures. That is, almost all new-named procedures have websites that describe the procedures and attempt to “sell” the treatment; however, none mention empirical studies which have validated the efficacy of the newly named procedure.
Researchers have hypothesized several reasons for the continued use of FC. First, Lilienfeld et al. (2014) recognized that FC is surviving because it has re-named itself. Although the names are new, the procedure is the same (i.e., a facilitator supports the individual such that they can point to letters or keys). Second, as FC’s coverage in the media and internet continues to rise, parents and clinicians may look to gain information from these sources rather than from peer-reviewed sources. The problem here is that internet and media sources may mislead parents and clinicians to believe FC is an effective type of AAC system (Ganz, Antonis, & Morin, 2018). Lastly, FC is appealing. The premise is that FC is evoking individuals’ abilities to communicate. The emotion that comes with this communication and seeing a child or client “communicate” for the first time no doubt is compelling. However, it seems as though these emotions are preventing parents and clinicians from accepting the results of scientific research and are fostering the continued use of FC (Lilienfeld et al., 2014).
There should be no further research on Facilitated Communication or this method under any different name. As numerous independent research groups have already exposed the flaws and biases of FC, research on any of these methods will likely show the same level of failure to produce positive results. Instead, consumers and treatment providers should use any number of empirically-derived, evidence-based practices to teach individuals to communicate to the best of their ability. Behavioral approaches are effective and are supported by strong empirical evidence; this should be our alternative and more compelling narrative to oppose FC. The National Autism Standards (National Autism Center, 2015) and the State of Maine (Tweed et al., 2009) are excellent sources of established (research supported) strategies to promote communication and language, such as incidental teaching, functional communication training, and Picture Exchange Communication System.
What is the bottom line?
Despite the evidence refuting FC both in the 1990s and 2000s, the procedure is still being used and is believed, by some, to be a valid treatment for individuals with autism and other intellectual or developmental disabilities. Regardless of its name, any procedure that requires ongoing support (i.e., support is never faded) from a facilitator should be opposed and rejected. FC should not be considered a valid means of communication. Furthermore, as behavior analysts, we are bound to provide evidence based and valid treatments. Facilitated Communication does not meet this criterion and therefore should not be used in practice.
Position statements by professional organizations:
American Academy of Child and Adolescent Psychiatry. (1993, October). Policy statement of facilitated communication. AACAP Newsletter, February 1994. Reviewed June 2008.
American Academy of Pediatrics. (1998). Auditory integration training and facilitated communication for autism. Pediatrics, 102, 431-433. This was reaffirmed in 2009.
American Association on Mental Retardation. (1994). AAMR Board approves policy on facilitated communication. AAMR News & Notes, 7(1). Now AAIDD.
American Association of Intellectual and Developmental Disabilities (2019) Facilitated Communication and Rapid Prompting Method: Position Statement of the AAIDD Board of Directors.
American Psychological Association. (1994). Resolution on facilitated communication by the American Psychological Association. Adopted in Council, August 14, 1994, Los Angeles, California.
Association for Behavior Analysis. (1995). Statement on facilitated communication. ABA Newsletter, 18, (2).
International Society for Augmentative and Alternative Communication (2014). ISAAC Position Statement on Facilitated Communication, Augmentative and Alternative Communication, 30:4, 357-358, DOI: 10.3109/07434618.2014.971492
Speech-Language & Audiology Canada ((2018). Use of Facilitated Communication and Rapid Prompting Method.
Victorian Advocacy League for Individuals with Disability. Position Statement on the Use of Facilitated Communication.
American Psychological Association (2003, November 20). Facilitated communication: Sifting the psychological wheat from the chaff. Retrieved from https://www.apa.org/research/action/facilitated.aspx
Biklen, D. (1990). Communication unbound: Autism and praxis. Harvard Educational Review, 60, 291-315. https://doi.org/10.17763/haer.60.3.013h5022862vu732
Biklen, D. E., & Cardinal, D. N. (1997). Contested words, contested science: Unraveling the facilitated communication controversy. New York, NY: Teachers College Press.
Biklen, D., Morton, M. W., Gold, D., Berrigan, C., & Swaminathan, S. (1992). Facilitated communication: Implications for individuals with autism. Topics in Language Disorders,12(4), 1-28. https://doi.org/10.1097/00011363-199208000-00003
Bligh, S., & Kupperman, P. (1993). Evaluation procedure for determining the source of the communication in facilitated communication accepted in a court case. Journal of Autism and Developmental Disorders, 23(3), 553-557. https://doi.org/10.1007/BF01046056
Borthwick, C. J., & Crossley, R. (1993). The validation of facilitated communication. Caulfield, VA (Australia): DEAL Centre.
Cabay, M. (1994). A controlled evaluation of facilitated communication with four autistic children. Journal of Autism and Developmental Disorders, 24(4), 517-527. https://doi.org/10.1007/BF02172132
Calculator, S. N., & Singer, K. M. (1992). Preliminary validation of facilitated communication. Topics in Language Disorders, 13(1), ix-xvi. https://doi.org/10.1097/00011363-199211000-00003
Cardinal, D. N., Hanson, D., & Wakeham, J. (1996). Investigation of authorship in facilitated communication. Mental Retardation, 34(4), 231-242.
Crossley, R. (1994). Facilitated communication training. New York, NY: Teachers College Press.
Crossley, N., & McDonald, A. (1980). Annie’s coming out. New York, NY: Penguin.
Crossley, R., & Remington-Gurney, J. (1992). Getting the words out: Facilitatedcommunication training. Topics in Language Disorders, 12(4), 29-45. https://doi.org/10.1097/00011363-199208000-00004
Eberlin, M., McConnachir, G., Ibel, S., & Volpe, L. (1993). Facilitated communication: A failure to replicate the phenomenon. Journal of Autism and Developmental Disorders, 23(3), 507-530. https://doi.org/10.1007/BF01046053
Frazier, K. (2015). Facilitated communication has returned from the dead. Skeptical Inquirer,39.3, 9.
Ganz, J. B., Katsiyannis, A., Morin, K. L. (2018). Facilitated communication: The resurgence of a disproven treatment for individuals with autism. Intervention in School and Clinic, 54(1), 52-56. https://doi.org/10.1177/1053451217692564
Green, V.A., Pituch, K.A., Itchon, J., Choi, A., O’Reilly, M. & Sigafoos, J. (2006). Internet survey of treatments used by parents of children with autism. Research in Developmental Disabilities, 27(1), 70-84.
Hudson, A., Melita, B., & Arnold, N. (1993). Brief report: A case study assessing the validity of facilitated communication. Journal of Autism and Developmental Disorders, 23(1), 165-173. https://doi.org/10.1007/BF01066425
Jacobson, J. W., Mulick, J. A., & Schwartz, A. A. (1995). A history of facilitated communication: Science, pseudoscience, and antiscience working group on facilitated communication. American Psychologist, 50(9), 750-765. https://doi.org/10.1037/0003-066X.50.9.750
Lilienfeld, S. O., Marshall, J., Todd, J. T., & Shane, H. C. (2014). The persistence of fad interventions in the face of negative scientific evidence: Facilitated communication for autism as a case example. Evidence-Based Communication Assessment and Intervention, 8, 62-101. https://doi.org/10.1080/17489539.2014.976332
Moore, S., Donovan, B., Hudson, A. (1993). Facilitator-suggested conversational evaluation of facilitated communication. Journal of Autism and Developmental Disorder, 23, 541-551
Moore, S., Donovan, B., Hudson, A., Dykstra, J., & Lawrence, J. (1993). Evaluation of eight case studies of facilitated communication. Journal of Autism and Developmental Disorders, 23, 531-539. https://doi.org/10.1007/BF01046054
National Autism Center. (2015). Findings and conclusions: National Standards Project, Phase 2 Randolph, MA: Author.
Regal, R. A., Rooney, J. R., & Wandas, T. (1994). Facilitated communication: An experimental evaluation. Journal of Autism and Developmental Disorders, 24, 345-355. https://doi.org//10.1007/BF02172232
Saloviita, T., Leppänen, M., & Ojalammi, U. (2014). Authorship in facilitated communication: An analysis of 11 cases. Augmentative and Alternative Communication, 30(3), 213-225. https://doi.org/10.3109/07434618.2014.927529
Saved by typing (n.d.). Retrieved from: https://savedbytyping.com
Schreck, K. A., & Mazur, A. (2008). Behavior analyst use of and beliefs in treatments for people with autism. Behavioral Interventions, 23, 201-212. https://doi.org/10.1002/bin.264
Shane, H. C., & Kearns, K. (1994). An examination of the role of the facilitator in “facilitated communication.” American Journal of Speech-Language Pathology, 3, 48-54.
Simon, E. W., Toll, D. M., & Whitehair, P. M. (1994). A naturalistic approach to the validation of facilitated communication. Journal of Autism and Developmental Disorders, 24(5), 647-657. https://doi.org/10.1007/BF02172144
Spelling to communicate (2018). Retrieved from: https://growingkidstherapy.com/aboutus/
von Tetzchner, S. (2012). Understanding facilitated communication: Lessons from a former facilitator – Comments on Boynton, 2012. Evidence-based Communication Assessment and Intervention, 6(1), 28-35.
Tweed L, Connolly N., Beaulieu A., Interventions for Autism Spectrum Disorders: State of the Evidence. Augusta, ME: Muskie School of Public Service and the Maine Department of Health and Humans Services;2009. A collaboration of the Maine Department of Health and Human Services & the Maine Department of Education.
Typing to communicate (n.d.). Retrieved from: http://ici.syr.edu/typing-to-communicate/
Vasquez, C. (1994). A multi-task controlled evaluation of facilitated communication. Journal of Autism and Developmental Disorders, 24(3), 369-379. https://doi.org/10.1007/BF02172234
Wheeler, D. L., Jacobson, J. W., Paglieri, R. A., & Schwarz, A. A. (1993). An experimental assessment of facilitated communication. Mental Retardation, 31, 49-60.
Wick, J., & Smith, T. (2009, Winter). Popular media citations for facilitated communication Autism and Related Developmental Disabilities Special Interest Group Newsletter, 25.
Citation for this article:
Holehan, K. M., & Zane, T. (2020). Facilitated Communication reincarnated: Is there science behind that?. Science in Autism Treatment, 17(5).