Review of Ethics dialogue: Spelling to communicate as a treatment recommendation

Quigley, S. P., Haag, M., Bly, L., Bird, F., & Gardner, R. (2025). Ethics dialogue: Spelling to communicate as a treatment recommendation. Behavior Analysis in Practice, 18, 884-887.

Kate McKenna, MEd, MSEd, MS, BCBA
Association for Science in Autism Treatment

Introduction

Photographed by Theo Decker (pexels.com)

Spelling to Communicate (S2C) is an educational method designed for non-speaking, minimally speaking, or unreliably speaking individuals (aged 5+) to communicate by pointing to letters on a board. It aims to teach the motor skills needed to spell, unlocking intentional communication for those with autism or other motor-sensory disabilities. According to proponents, S2C focuses on bridging the gap between receptive language (understanding) and expressive communication by teaching the motor skills required to point to letters on a letter board. Proponents argue that it is a way for non-speakers to voice their thoughts and gain autonomy.

This method is not without detractors who have raised concerns. Some organizations, such as the American Speech-Language-Hearing Association (ASHA), have compared S2C to Facilitated Communication (FC) and warned that the technique may rely on the prompter rather than the user. Critics argue that the method risks the user’s autonomy, as the communication partner holding the board may influence the message. There are, as of yet, no rigorous scientific studies that demonstrate the effectiveness of S2C. Multiple reviews of the research literature have yet to find evidence that S2C and FC elicit genuine responses from those using them (Roberts et al., 2025; Celiberti et al., 2024).

Quigley et al. (2025) present an ethics dialogue case study examining how a multidisciplinary clinical team responded to a recommendation to use S2C for an adult with developmental disabilities. The article is structured as an applied ethical analysis, illustrating how behavior analysts should navigate non-evidence-based treatment recommendations within real-world service settings.

Description of the Ethical Dilemma

The central dilemma arises when a social worker on the treatment team recommends S2C, a communication method closely related to facilitated communication (FC), which is a widely discredited intervention lacking empirical support, for use with an adult client with developmental disabilities. The case requires clinicians to balance their ethical obligations to provide evidence-based treatment, respect for client and family preferences, and the maintenance of professional integrity and interdisciplinary collaboration. The ethical issue centers on whether the clinical team should accept and implement the recommendation, reject it based on the lack of evidence, or attempt to navigate a more nuanced response that includes education and collaboration. The authors identify BACB Ethics Code Standard 2.01 (providing effective treatment) as the most relevant guiding principle.

Evaluation of Spelling to Communicate

A critical component of the article is the evaluation of S2C as an intervention. The authors conclude that S2C is not evidence-based. The authors emphasize that no high-quality experimental research demonstrates that S2C independently produces valid communication from the individual. Instead, the risk exists that communication attributed to the client may originate from the facilitator.

Ethical Decision-Making Process

The article outlines a systematic, team-based decision-making process to respond to the suggested inclusion of a non-evidence-based treatment. The first step was to identify and describe the concern in detail and then proceed through a process to alert supervisors and seek advice. Next, the team gathered information by reviewing existing research literature and examining position statements from professional organizations. This step ensured that the decision was grounded in scientific evidence and professional consensus. The team then evaluated the recommendation in light of their organization’s code of ethics, which emphasized practicing within the scope of competence, providing effective treatment, and acting with professional integrity. The analysis concluded that implementing S2C would violate ethical obligations because it lacks empirical support and would not result in genuine communication with the client. Since maintaining rapport and professional communication with caregivers is critical, the team engaged in a collaborative and respectful discussion with the family about the lack of evidence-based support for S2C.

Ethical Conclusions and Recommendations

S2C should not be implemented by BCBAs as they are ethically obligated to avoid non-evidence-based interventions (Behavior Analyst Certification Board, 2020). Supporting such interventions would violate professional standards related to competence and effective treatment. While client and family preferences are important, they do not obligate clinicians to provide ineffective or unsupported treatments. Ethical codes require that services be both effective and evidence based. In similar situations, clinicians should attempt to provide stakeholders with a clear, family-friendly, and culturally relevant explanation of the research base, or lack thereof, for an intervention. This will be most effective if conducted in a way that preserves therapeutic rapport. This approach balances ethical responsibility with respect for client autonomy. Even when rejecting a recommendation, clinicians should communicate to maintain open communication with families and other professionals to avoid damaging trust or interdisciplinary relationships.

Broader Ethical Themes

A central ethical principle emphasized in both the case and subsequent commentaries is that clients have a right to effective, scientifically supported treatment. The article highlights the ongoing challenge of fad or unsupported treatments in developmental disability services. S2C is presented as part of a broader category of interventions that may gain popularity despite lacking empirical validation. S2C is associated with the belief that individuals with autism possess fully intact but inaccessible cognitive and linguistic abilities, a “hidden competency” narrative that can mislead families, create false hope, and distract families from pursuing scientific intervention based on evidence. No matter what the recommendation, behavior analysts must operate within their scope of competence and avoid implementing interventions for which they lack training or those that lack empirical support.

Implications for Practice

The authors offer several implications for applied behavior analysis. Clinicians must critically evaluate treatment recommendations, regardless of their source. The BACB Code of Ethics provides clear guidance when evidence conflicts with stakeholder preferences (Behavior Analyst Certification Board, 2020). Communication skills are essential for navigating disagreements with families and professionals. Additionally, human service organizations should ensure that staff are trained to identify non-evidence-based interventions and effectively respond using structured ethical reasoning (Brodhead, 2015).

Summary

A major strength of the article is its clear application of ethical principles to real-world clinical practice. The authors effectively demonstrate how behavior analysts can operationalize ethical standards, particularly those related to evidence-based treatment, scope of competence, and client welfare, when navigating complex interdisciplinary situations. The step-by-step description of the team’s decision-making process (e.g., identifying concerns, reviewing literature, consulting experts, and engaging stakeholders) provides a practical framework that is highly relevant for practitioners and trainees. Additionally, the article emphasizes the importance of professional communication, showing how clinicians can reject non-evidence-based recommendations while maintaining rapport and collaboration with families and other professionals. The structured format makes the article highly useful for training and professional development.

The authors’ critique of S2C is grounded in existing literature, particularly its similarity to facilitated communication, which has been widely discredited due to concerns about facilitator influence and lack of independent authorship. This analysis is persuasive and aligns with the broader scientific consensus. The article also appropriately highlights the ethical risk of promoting interventions based on the assumption of “hidden competence,” which may inadvertently mislead stakeholders and divert resources from effective treatments.

This article would be well placed as the first in a series focusing on the importance of stakeholder and professional collaboration when implementing treatment strategies. The discussion could be expanded to include more detailed strategies for navigating resistance from families or team members who strongly advocate for non-evidence-based interventions. The article also focuses primarily on the behavior analyst’s perspective, with less attention to how other disciplines conceptualize communication interventions. Future articles could be coauthored by a team of related service providers to expand the applicability in highly interdisciplinary settings.

Quigley et al. (2025) make a valuable contribution to the literature by illustrating how ethical standards can guide clinical decision-making in situations involving controversial or unsupported treatments. The article reinforces the principle that client rights include access to effective, evidence-based intervention and that professional responsibility may require clinicians to decline certain recommendations, even when they are supported by other stakeholders. Overall, this article serves as an important resource for behavior analysts seeking to navigate ethical dilemmas with both scientific rigor and professional sensitivity.

References

Behavior Analyst Certification Board (2020). Ethics code for behavior analysts. https://bacb.com/wp-content/ethics-code-for-behavior-analysts

Brodhead, M. T. (2015). Maintaining professional relationships in an interdisciplinary setting: Strategies for navigating nonbehavioral treatment recommendations for individuals with autism. Behavior Analysis Practice, 8, 70–78. DOI 10.1007/s40617-015-0042-7

Celiberti, D., Willis, J., & Daly, K. (2024). A treatment summary of Facilitated Communication. Science in Autism Treatment, 21(7).

Quigley, S. P., Haag, M., Bly, L., Bird, F., & Gardner, R. (2025). Ethics dialogue: Spelling to communicate as a treatment recommendation. Behavior Analysis in Practice, 18, 884-887.

Roberts, B., Hardesty, E., & Zane, T. (2025). Spelling to Communicate: Is there science behind that? Science in Autism Treatment, 22(4).

Reference for this article

McKenna, K. (2026). Review of Ethics dialogue: Spelling to Communicate as a treatment recommendation. Science in Autism Treatment, 23(7).

Other Related ASAT Reviews:

Related ASAT Articles

Related ASAT Treatment Summaries

Media Corner Letters:

#BehaviorAnalysts #Communication #Multidisciplinary #SLPs

A review of Ethics Dialogue: Spelling to Communicate as a Treatment Recommendation