In the mid 1970's, Australian educator Rosemary Crossley rediscovered a method of communication that American teacher and parent Rosalind Oppenheimer had used as early as the late 1950s and had written about in her 1974 book Teaching Methods for Autistic Children. The technique, which Crossley named facilitated communication (FC), involved providing physical and emotional support to a person with a developmental disability (such as autism, cerebral palsy and Down syndrome) and limited or no speech. This support enabled the person to point reliably, and thus to communicate by pointing at pictures, at whole words or at letters to form words. Crossley first used FC with Anne McDonald, a girl with cerebral palsy living in an institution for children with multiple disabilities, all of whom were presumed severely retarded.
The method is intended to help individuals overcome problems of voluntary physical movement including finger isolation (for example, the ability to extend the index finger while keeping the other fingers folded under the palm), tremor, hand-eye coordination and initiation of action (the ability to begin, continue and stop a movement).
Controversy over the method has to do with whether facilitated messages are authored by the person with the communication impairment or by the facilitator.
Anne McDonald proved her communicative competence to the satisfaction of the Victorian Supreme Court by typing the words "string" and "quit" after the words "string" and "quince" were given to her by the presiding officer while her facilitator, Crossley, was out of the room. A court-appointed psychologist also had Anne take a Peabody Picture Vocabulary Test, in which she selected from a set of four pictures the one that illustrated the meaning of the word said by the examiner. She was able to accomplish this task independently, that is, without physical support. Her score on the test was within the range expected for a person her age. McDonald has since completed a Bachelor's degree and is currently enrolled in a Master of Arts degree program.
However, the first formal, published FC validation study (a study to determine whether FC is valid communication) produced results that left many observers in a quandary. In this study, done by the Victorian state [Australia] government, three FC users were asked to describe gifts their facilitators had not seen; three others were asked to reply to questions different than those given the facilitators. Although the study showed that the method worked for some people, it also revealed evidence of facilitator influence on communication.
Criticism of FC has been harsh, fueled by the results of numerous controlled studies in which people using FC have failed to validate their communication. In the first, conducted in 1992, 12 individuals classified as autistic were shown colored pictures of familiar objects and asked to name them. None of the individuals gave correct responses when shown items different than those shown to the facilitators. However, in two instances, individuals did name appropriate categories for the items they were asked to identify -- responding "vehicle" instead of "van," and "food" instead of "bread."
Numerous subsequent studies seemed only to confirm these results. In one study after another, individuals were shown pictures that their facilitators could not see or were asked questions that their facilitators could not hear, and they did not respond correctly.
It did not surprise me that people did so poorly on the early tests. Being observed or tested may cause individuals to perform more poorly than usual. Moreover, none of the early studies gave participants the chance to practice test-taking. In each case the tests were done in one or two sessions.
Several recent studies, however, have revealed authorship by people using FC, although at the same time noting the presence of facilitator influence. Dr. Carol Vazquez conducted a study in which one individual was able to describe a video his facilitator had not seen and another was able to identify objects that her facilitator could not see. Vazquez concluded, "...erratic in their performance, each subject was able to report information unknown to the facilitator in one of four controlled sessions."
Elliot Simon and his colleagues asked FC users to report on activities in which they had engaged--such as getting snacks from a vending machine and visiting the library. The researchers found that "for some students there is evidence of authorship for information unknown by the facilitator." But the researchers also determined that facilitators could influence individuals' communication. In light of these findings, these researchers strongly advised pursuing the goal of independent typing, a goal I had also advised in my book Communication Unbound.
In a 1993 study, Ogletree and his colleagues evaluate a four-and-a-half year old's communication abilities. Without FC, the child was judged to have the communication ability of a six-month-old. With FC, he produced words--often misspelled or spelled the way they sounded--and described activities about which his facilitator was kept unaware--for example, blowing bubbles, playing with water and swinging. In conclusion, these authors called for "an open but objective posture regarding the method's use with persons with autism."
A year-long government study in Queensland, Australia, published in 1993, found that 87 percent of the 24 clients evaluated were able to validate their communication through responses to questions about their activities--for example, asking a person to report on a gift received while the facilitator was not present or to report on piano playing about which the facilitator was unaware. About half of these individuals were also successful in answering multiple-choice tests in which the facilitator did not know the answers (such as the names of family members).
The largest study of FC to date has been carried out in the California public schools by Donald Cardinal and his colleagues. Their unpublished study (currently under review by a professional journal) included more than 3,800 trials, more than all of the above-mentioned studies combined. Students classified as "severely disabled" were asked to spell randomly- selected words that they were shown while the facilitator was out of the room. They were asked to spell five words per session, in three sessions per week. By the end of the six- week study, 74 percent of the students were able to correctly spell one or more of the words shown to them by the tester while the facilitator was out of the room; half were able to spell at least two of the five words. On average, students reached their peak performance on this task after nine sessions. The researchers concluded that their test validated communication when many others had failed because the length of the study allowed students to practice the test activity--though not the actual words--and because the activity occurred under natural conditions, as part of the regular school day. For each word typed, the researchers estimated that there was no more than a one-in-one-hundred chance that the facilitator could guess the word correctly.
At Syracuse University, we have two controlled research studies underway in which FC users are proving their communicative competence. Both studies show that people are often able to succeed with validation tests if they have opportunities to practice the type of test activity and if the task accommodates particular difficulties such as word retrieval.
Nearly everyone has difficulty with word retrieval--for example, when we cannot think of the name of someone we see during the day, even though we may typically be able to recall the correct name some time later. Many people who use FC seem to have extreme word retrieval difficulty, even for naming obvious objects. In testing, one strategy to avoid word retrieval problems is to provide multiple-choice answers; this allows the correct answer to be available for selection.
In our current studies, individuals have taken several sessions--in some cases, as many as eight sessions--before succeeding with validation tasks. Nearly all of these tasks include multiple-choice options or other tasks that do not involve word retrieval--for example, unscrambling letters to form a word or completing math problems.
In light of these studies, reasonable people must admit that some individuals who were previously believed incapable of literate communication have demonstrated that under the right conditions, they are able to convey their own thoughts via FC.
The goal of FC is independent typing. Many people using FC may be able to reach that goal. Rosemary Crossley and her colleague, speech pathologist Jane Remington-Gurney, report that more than 30 individuals with whom they had worked in Australia are now typing independently. In North America, there have also been reports of substantial progress in typing ability, including independent typing.
At the 1994 annual conference of TASH (The Association for Persons with Severe Handicaps), I presented videotapes of two individuals typing without any physical support; each had first learned to communicate with facilitation. Both were previously believed to be severely retarded, but have since demonstrated excellent literacy skills.
Again, reasonable people must admit that individuals who learn to communicate with facilitation and then achieve independent typing have demonstrated the ability to communicate their own ideas.
There have been concerns about allegations of abuse made through FC. The only scientific investigation of this issue was conducted by pediatrician Ann Botash and her clinical team at a Syracuse, New York Hospital. When any child makes an allegation of abuse, a hospital team examines the case to see if there is any other "indication"--other than the allegation--to suggest that abuse might have occurred. Other "indications" of abuse might include physical evidence, a confession by the person accused or confirmed abuse of other children in the family. Botash's team examined all abuse allegations made through FC that were evaluated at the hospital over a three-year period, a total of 13 cases. The study found that other "indications" of abuse were found in 47 percent of these cases, the same percentage as in cases where allegations were not made through FC.
In addition, two recent court cases have upheld the right of an individual to use FC in court proceedings. In one case, a coworker of the accused said that the defendant had admitted his guilt during a private conversation outside of court.
In any instance of alleged abuse made through FC, there must be extreme care to assure that the FC user is the author of the allegation. I have consistently recommended a simple procedure--bring in a second facilitator who is unaware of the first allegation to see if the person can repeat his or her statement.
Given these findings, I strongly endorse the position taken by TASH: that no parent or person with a disability should be denied the right to use the method of communication of his or her choice, that no person should be denied access to basic rights--including the right to appear in court--on the basis of his or her communication method, and that validation of communication ability should always be discussed with the person who uses FC and should include multiple strategies attempted over long periods of time.
The latest research evidence on FC and the achievements of individuals using FC require us to ensure its future availability. It is not a miracle and it certainly will not work for everyone, but those who might benefit from it deserve the right to learn to use it, to type out their words, to be heard, to prove their communicative competence and to be recognized for their accomplishments.
[Editor's note: This article was published without references in Exceptional Parent; they are provided here for the use of our readers.]