Facilitated Communication

Position Statement

Ad Hoc Committee on Facilitated Communication (FC) and the Rapid Prompting Method (RPM)

About This Document: This position statement is an official policy of the American Speech-Language-Hearing Association (ASHA). The position was developed by the ASHA Ad Hoc Committee on Facilitated Communication (FC) and the Rapid Prompting Method (RPM): Meher Banajee, chair; Bronwyn Hemsley; Russell Lang; Ralf W. Schlosser; Howard C. Shane; and Diane Paul, ex officio. Sandra Gillam, Vice President for Speech-Language Pathology Practice (2015–2017), served as the ASHA Board of Directors (BOD) liaison from August 1, 2017, to December 31, 2017. Marie Ireland, Vice President for Speech-Language Pathology Practice (2018–2020), served as the BOD liaison from January 1, 2018, to August 31, 2018. This position statement, an update of ASHA's 1995 position statement on FC, was open for peer review by all interested parties, and respondents included speech-language pathologists, audiologists, special educators, other related professionals, professional associations, families, individuals with disabilities, and advocacy groups.

Table of Contents

• Position Statement: Facilitated Communication
• Rationale
  • Description of Facilitated Communication
  • Background
  • Systematic Reviews of FC
• Recommendations
• References

Position Statement: Facilitated Communication

It is the position of the American Speech-Language-Hearing Association (ASHA) that Facilitated Communication (FC) is a discredited technique that should not be used. There is no scientific evidence of the validity of FC, and there is extensive scientific evidence—produced over several decades and across several countries—that messages are authored by the "facilitator" rather than the person with a disability. Furthermore, there is extensive evidence of harms related to the use of FC. Information obtained through the use of FC should not be considered as the communication of the person with a disability. 

Rationale

Description of Facilitated Communication

Facilitated Communication (FC)—also referred to as "Assisted Typing," "Facilitated Communication Training," and "Supported Typing"—is a technique that involves a person with a disability pointing to letters, pictures, or objects on a keyboard or on a communication board, typically with physical support from a "facilitator." This physical support usually occurs on the hand, wrist, elbow, or shoulder (Biklen, Winston Morton, Gold, Berrigan, & Swaminathan, 1992) or on other parts of the body. 

Background

ASHA first developed a position statement about FC in 1995 due to a lack of scientific validity and reliability (ASHA, 1995). This updated FC position statement takes a stronger stance against the use of FC than did ASHA’s 1995 statement. In the years since that position statement, there has been no credible scientific evidence of benefit and only growing evidence of the lack of efficacy and of the harms of FC. The use of FC risks harm to individuals with communication disabilities in that it may hinder or delay access to appropriate services and effective forms of intervention, including augmentative and alternative communication (AAC; see, e.g., Allen, Schlosser, Brock, & Shane, 2017; Brady et al., 2016; Iacono, Trembath, & Erickson, 2016; Logan, Iacono, & Trembath, 2017; Romski & Sevcik, 2016; Snell et al., 2010; Walker & Snell, 2013); Applied Behavior Analysis (ABA; Ivy & Schreck, 2016; Virues-Ortega, 2010; Vismara & Rogers, 2010); Functional Communication Training (Heath, Ganz, Parker, Burke, & Ninci,, 2015; Kurtz, Boelter, Jarmolowicz, Chin, & Hagopian); and other empirically supported interventions (ASHA, n.d.-a). The harms of FC also include false allegations of sexual abuse (Probst, 2005) and other forms of maltreatment (Boynton, 2012; Chan & Nankervis, 2014; Wombles, 2014).  

ASHA recognizes the human right of communication, as expressed in the United Nations Convention on the Rights of Persons With Disabilities (UNCRPD; United Nations, 2006), the Universal Declaration of Human Rights (UDHR; United Nations, 1948), the International Communication Project (2014), and the Communication Bill of Rights by the National Joint Committee for the Communication Needs of Persons With Severe Disabilities (NJC; Brady et al., 2016). FC is a technique that involves the person with a disability being dependent upon a "facilitator" to produce a message. The use of FC or other "facilitator"-dependent techniques (e.g., Rapid Prompting Method [RPM]; see ASHA's Position Statement on RPM [ASHA, 2018]) is not consistent with the communication rights of autonomy and freedom of expression (Chan & Nankervis, 2014) because the messages do not reflect the voice of the person with a disability but, rather, reflect the communication of the "facilitator." It must not be assumed that messages delivered via FC or any other "facilitator"-dependent technique (e.g., RPM) reflect the communication of the person with a disability. This position statement on FC does not pertain to independent typing without "facilitator" influence.

Systematic Reviews of FC

Recent systematic literature reviews of FC (Hemsley et al., 2018; Schlosser et al., 2014), based on research appropriately designed to determine the effectiveness of FC, demonstrate a lack of scientific studies to support the effectiveness of the technique and a preponderance of scientific evidence demonstrating "facilitator" influence and authorship of messages delivered by FC. In the almost 3 decades since FC was introduced, there has been no empirical evidence that messages composed using FC can be attributed to the person with a disability. Indeed, the conclusions of earlier systematic reviews (Felce, 1994; Jacobson, Mulick, & Schwartz, 1995; Mostert, 2001; Mostert, 2010; Probst, 2005; Schlosser et al., 2014; Wehrenfennig & Surian, 2008) are supported, and there have been no new authorship studies in the peer-reviewed literature since 2014 (Hemsley et al., 2018; Saloviita, Leppänen, & Ojalammi, 2014). That is, there is no scientific evidence that (a) FC provides access to communication or that (b) individuals achieve independence in communication through the use of FC. Rather, there is sufficient scientific evidence—obtained through numerous controlled and objective evaluations of the technique, including peer-reviewed studies—demonstrating that messages produced using FC are authored by the "facilitator" and not by the person with a disability.

Proponents of FC state that the technique reveals previously undetected literacy and communication skills in people with autism and other disabilities. However, these statements are made only on the basis of anecdotal reports, testimonials, and descriptive studies. Clearly, FC is a pseudoscience (i.e., a practice incorrectly framed as being based on scientific findings; Finn, Bothe, & Bramlett, 2005; Lof, 2011) and is "junk science" (i.e., faulty information or research used to advance specific interests; Agin, 2006). As such, the use of FC carries several negative and harmful consequences in that FC

1. is not an effective form of communication and does not provide access to communication;
2. denies the user's access to their human right of communication;
3. costs time and money that cannot be retrieved, and, hence, reduces opportunities for access to timely, effective, and appropriate treatment for independent communication;
4. gives false hope to families of individuals with little or no speech; and
5. has been associated with significant preventable harms arising through false allegations of sexual abuse (Probst, 2005) and other forms of maltreatment (Boynton, 2012; Chan & Nankervis, 2014; Wombles, 2014).

Recommendations

Speech-language pathologists (SLPs) are autonomous professionals who are responsible for critically evaluating all treatment techniques in order to hold paramount the welfare of persons served in accordance with the ASHA Code of Ethics (ASHA, 2016). SLPs should be mindful of their own legal and ethical responsibilities and risks; they are obliged to "provide services or dispense products only when benefit can reasonably be expected" and not do harm (ASHA, 2016). 

The substantial and serious risks of FC outweigh any anecdotal reports of its benefit. The scientific evidence against FC, evidence of harms of FC, and potential for future harms to people who use FC and their families cannot be ignored in clinical decision making. SLPs who use FC—despite being informed of and knowing these harms and risks—could face additional risks in terms of their own liability in the event of harms arising to people with disabilities or their families related to the use of FC. 

SLPs have a responsibility to inform and warn clients, family members, caregivers, teachers, administrators, and other professionals who are using or are considering using FC that

1. decades of scientific research on FC have established with confidence that FC is not a valid form of communication;
2. messages produced using FC do not reflect the communication of the person with a disability;
3. FC does not provide access to communication;
4. the use of FC is associated with several harms to individuals with disabilities as well as their family members or teachers; and
5. ASHA's position on FC is that it should not be used. 

SLPs also have an ethical responsibility to inform clients, family members, caregivers, teachers, administrators, and other professionals of empirically supported treatments for communication for individuals with communication limitations and to advocate for these treatments. Several systematic literature reviews have demonstrated the value of communication interventions for individuals with severe communication disabilities (Allen et al., 2017; Brady et al., 2016; Iacono et al., 2016; Logan et al., 2017; Romski & Sevcik, 2016; Snell et al., 2010; Walker & Snell, 2013). See the Augmentative and Alternative Communication evidence map (ASHA, n.d.-a) for summaries of available research on this topic, and see the Practice Portal on Augmentative and Alternative Communication (ASHA, n.d.-b) for information on a variety of empirically supported intervention approaches and technologies providing access to AAC. 

ASHA strongly supports continued research and clinical efforts to develop scientifically valid methods for developing and enhancing the authentic and independent communication and literacy skills of people with disabilities.  

ASHA's position on FC is consistent with as many as 19 other national and international professional and advocacy organization statements (Behavior Analysis Association of Michigan, n.d.).  

Additional ASHA resources are available to assist with implementation of this position statement:

• Evidence-Based Practice (ASHA, n. d.-c)
• Heard About a New Product or Treatment? Ask These Questions Before Deciding What to Do (ASHA, n. d.-d)
• What To Ask When Evaluating Any Procedure, Product, or Program (ASHA, n.d.-e)

For information about RPM, another "facilitator"-dependent technique, please refer to the ASHA Position Statement on RPM (ASHA, 2018). 

References

Agin, G. (2006). Junk science: How politicians, corporations, and other hucksters betray us. New York, NY: St. Martin's Press.

Allen, A. A., Schlosser, R. W., Brock, K. L., & Shane, H. C. (2017). The effectiveness of aided augmented input techniques for persons with developmental disabilities: A systematic review. Augmentative and Alternative Communication, 33, 149–159.

American Speech-Language-Hearing Association. (n.d.-a). Augmentative and alternative communication [Evidence Maps]. Retrieved from https://apps.asha.org/EvidenceMaps/Maps/LandingPage/990772a6-9cd8-4203-a76c-6ccd91eac874

American Speech-Language-Hearing Association. (n.d.-b). Augmentative and alternative communication [Practice Portal]. Retrieved from  www.asha.org/Practice-Portal/Professional-Issues/Augmentative-and-Alternative-Communication/

American Speech-Language-Hearing Association. (n.d.-c). Evidence-based practice. Retrieved from www.asha.org/Research/EBP/Evidence-Based-Practice/

American Speech-Language-Hearing Association. (n.d.-d). Heard about a new product or treatment? Ask these questions before deciding what to do. Retrieved from www.asha.org/public/speech/consumerqa/

American Speech-Language-Hearing Association. (n.d.-e). What to ask when evaluating any procedure, product, or program. Retrieved from www.asha.org/slp/evaluate/

American Speech-Language-Hearing Association. (1995). Facilitated communication [Position Statement]. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2016). Code of ethics [Ethics]. Retrieved from www.asha.org/Code-of-Ethics/

American Speech-Language-Hearing Association. (2018). Rapid prompting method [Position Statement]. Retrieved from www.asha.org/policy/

Behavior Analysis Association of Michigan. (n.d.). Resolutions and statements by scientific, professional, medical, governmental, and support organizations against the use of facilitated communication. Retrieved from www.baam.emich.edu/baam-fc-resolutions-compilation.html

Biklen, D., Winston Morton, M., Gold, D., Berrigan, C., & Swaminathan, S. (1992). Facilitated communication: Implications for individuals with autism. Topics in Language Disorders, 12(4), 1–28.

Boynton, J. (2012). Facilitated communication—What harm it can do: Confessions of a former facilitator. Evidence-Based Communication Assessment and Intervention, 6, 3–13.

Brady, N. C., Bruce, S., Goldman, A., Erickson, K., Mineo, B., Ogletree, B. T., . . . Wilkinson, K. (2016). Communication services and supports for individuals with severe disabilities: Guidance for assessment and intervention. American Journal on Intellectual and Developmental Disabilities, 121, 121–138. Retrieved from http://aaiddjournals.org/doi/abs/10.1352/1944-7558-121.2.121

Chan, J., & Nankervis, K. (2014). Stolen voices: Facilitated communication is an abuse of human rights. Evidence-Based Communication Assessment and Intervention, 8, 151–156.

Felce, D. (1994). Facilitated communication: Results from a number of recently published evaluations. British Journal of Learning Disabilities, 22, 122–126.

Finn, P., Bothe, A. K., & Bramlett, R. E. (2005). Science and pseudoscience in communication disorders: Criteria and applications.American Journal of Speech-Language Pathology, 14, 172–186.

Heath, A., Ganz, J., Parker, R., Burke, M., & Ninci, J. (2015). A meta-analytic review of functional communication training across mode of communication, age, and disability. Review Journal of Autism and Developmental Disorders, 2, 155–166.  

Hemsley, B., et al. (2018). Updating the Schlosser et al. (2014) systematic review of authorship in facilitated communication revealed no new authorship studies since 2014: Informing the new ASHA position statement on FC. Manuscript submitted for publication.

Iacono, T., Trembath, D., & Erickson, S. (2016). The role of augmentative and alternative communication for children with autism: Current status and future trends. Neuropsychiatric Disease and Treatment, 12, 2349–2361.

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Ivy, J. W., & Schreck, K. A. (2016). The efficacy of ABA for individuals with autism across the lifespan. Current Developmental Disorders Reports, 3, 57–66. 

Jacobson, J. W., Mulick, J. A., & Schwartz, A. A. (1995). A history of facilitated communication: Science, Pseudoscience, and Antiscience Science Working Group on Facilitated Communication. The American Psychologist, 50(9): 750–765.

Kurtz, P. F., Boelter, E. W., Jarmolowicz, D. P., Chin, M. D., & Hagopian, L. P. (2011). An analysis of functional communication training as an empirically supported treatment for problem behavior displayed by individuals with intellectual disabilities. Research in Developmental Disabilities, 32,2935–2942. 

Lof, G. (2011). Science-based practice and the speech language pathologist. International Journal of Speech-Language Pathology, 13, 189–196.

Logan, K., Iacono, T., & Trembath, D. (2017). A systematic review of research into aided AAC to increase social-communication functions in children with autism spectrum disorder. Augmentative and Alternative Communication, 33, 51–64.

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Mostert, M. P. (2010). Facilitated communication and its legitimacy—Twenty-first century developments.Exceptionality, 18, 31–41.

Probst, P. (2005). "Communication unbound – or unfound?" An integrative review on the effectiveness of facilitated communication (FC) in non-verbal persons with autism and mental retardation. Zeitschrift für Klinische Psychologie, Psychiatrie und Psychotherapie, 53(2), 93–128.

Romski, M., & Sevcik, R. (Eds.). (2016). Communication interventions for individuals with severe disabilities: Exploring research challenges and opportunities. Baltimore, MD: Brookes.

Saloviita, T., Leppänen, M., & Ojalammi, U. (2014). Authorship in facilitated communication. Augmentative and Alternative Communication, 30, 213–215.

Schlosser, R., Balandin, S., Hemsley, B., Iacono, T., Probst, P., & von Tetzchner, S. (2014). Facilitated communication and authorship: A systematic review. Augmentative and Alternative Communication, 30, 359–368.

Snell, M. E., Brady, N., McLean, L., Ogletree, B. T., Siegel, E., Sylvester, L., . . . Sevcik, R. (2010). Twenty years of communication intervention research with individuals who have severe intellectual and developmental disabilities. American Journal on Intellectual and Developmental Disabilities, 115, 364–380.

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United Nations. (2006). Convention on the Rights of Persons With Disabilities. Retrieved from https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html

Virues-Ortega, J. (2010). Applied behavior analytic intervention for autism in early childhood: Meta-analysis, meta-regression and dose-response meta-analysis of multiple outcomes. Clinical Psychology Review, 30, 387–399.

Vismara, L. A., & Rogers, S. J. (2010). Behavioral treatments in autism spectrum disorder: What do we know? Annual Review of Clinical Psychology, 6, 447–468.

Walker, V. L., & Snell, M. E. (2013). Effects of augmentative and alternative communication on challenging behavior: A meta-analysis. Augmentative and Alternative Communication, 2,117–131.

Wehrenfennig, A., & Surian, L. (2008). Autismo e comunicazione facilitata: Una rassegna degli studi sperimentali. Psicologia Clinica Dello Sviluppo, 12,437–464.

Wombles, K. (2014). Some fads never die—they only hide behind other names: Facilitated communication is not and never will be augmentative and alternative communication. Evidence-Based Communication Assessment and Intervention, 8, 181–186.