Augmentative and Alternative Communication, 2014; 30(4): 359–368
© 2014 International Society for Augmentative and Alternative Communication
ISSN 0743-4618 print/ISSN 1477-3848 online
DOI: 10.3109/07434618.2014.971490
REVIEW
Facilitated Communication and Authorship: A Systematic Review*
RALF W. SCHLOSSER1, SUSAN BALANDIN2, BRONWYN HEMSLEY3, TERESA IACONO4,
PAUL PROBST5 & STEPHEN VON TETZCHNER6
1
Speech-Language Pathology and Audiology, Northeastern University, & Otolaryngology and Communication Enhancement,
Boston Children’s Hospital, Boston, MA, USA, 2School of Health and Social Development, Deakin University,Victoria, Australia,
3
Speech Pathology, The University of Newcastle, New South Wales, Australia, 4La Trobe Rural Health School, La Trobe University,
Australia 5Psychology, Universitaet Hamburg, Hamburg, Germany, 6 Psychology, University of Oslo, Oslo, Norway
Abstract
Facilitated Communication (FC) is a technique whereby individuals with disabilities and communication impairments allegedly
select letters by typing on a keyboard while receiving physical support, emotional encouragement, and other communication
supports from facilitators. The validity of FC stands or falls on the question of who is authoring the typed messages – the individual
with a disability or the facilitator. The International Society for Augmentative and Alternative Communication (ISAAC) formed
an Ad Hoc Committee on FC and charged this committee to synthesize the evidence base related to this question in order to
develop a position statement. The purpose of this paper is to report this synthesis of the extant peer-reviewed literature on the
question of authorship in FC. A multi-faceted search was conducted including electronic database searches, ancestry searches,
and contacting selected authors. The authors considered synopses of systematic reviews, and systematic reviews, which were
supplemented with individual studies not included in any prior reviews. Additionally, documents submitted by the membership
were screened for inclusion. The evidence was classified into articles that provided (a) quantitative experimental data related to
the authorship of messages, (b) quantitative descriptive data on the output generated through FC without testing of authorship,
(c) qualitative descriptive data on the output generated via FC without testing of authorship, and (d) anecdotal reports in which
writers shared their perspectives on FC. Only documents with quantitative experimental data were analyzed for authorship. Results
indicated unequivocal evidence for facilitator control: messages generated through FC are authored by the facilitators rather than
the individuals with disabilities. Hence, FC is a technique that has no validity.
Keywords: Autism; Developmental disabilities; Facilitated Communication
to make sure the person looks at the keyboard and checks
for typographical errors) (see Syracuse, n.d.). The main
area of dispute is whether people with disabilities are
being facilitated to express their own communicative
intentions, or whether the source of the output is that of
the facilitators (e.g., Mostert, 2012).
The purpose of this review was to examine and synthesize the research evidence on who is authoring the
messages generated through FC. In addition, in the
paper we outline the methods and procedures of the
review that informed the development of the Position
Statement, formally adopted by a majority vote of the
Council and Executive Board of the ISAAC on 20 July,
2014. Since the Council Meeting on the 20 July 2014,
minor changes have been made in the formatting of the
review to meet journal article requirements (e.g., APA6
Introduction
Facilitated Communication (FC) (also described as
“supported typing”) is a technique whereby individuals with disabilities and communication impairments
allegedly select letters by typing on a keyboard while
receiving physical support, emotional encouragement,
and other communication supports from facilitators
(Syracuse, n.d.). Although it is acknowledged that FC
also includes the pointing to pictures or objects, the
focus of this review is on typing. According to the
Institute on Communication and Community Inclusion (see Syracuse, n.d.), the physical support may
be provided at the index finger, hand, arm, elbow, or
shoulder. Besides the provision of physical supports,
the facilitator may provide emotional encouragement,
and other communication supports (e.g., monitoring
*This document is being made available as ISAAC governance material. As with all ISAAC material published in the AAC journal, it did not go through the
journal’s peer review process, and has been published as received by the editors of the journal.
Correspondence: Ralf W. Schlosser, Department of Speech-Language Pathology and Audiology, Northeastern University, 106 Forsyth, Boston, MA 02115,
USA. E-mail: R.Schlosser@neu.edu
359
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R.W. Schlosser et al.
formatting, introduction of sections and headings) and
these changes do not affect the content of the review.
Method
Formation of the AdHoc Committee on Facilitated
Communication
The ISAAC Executive Committee called to order an
AdHoc Committee on Facilitated Communication
(subsequently referred to as “the Committee”) and
charged it with the development of a position statement on facilitated communication (FC). The committee included the following individuals in alphabetical
order: Balandin, Susan (Deakin University, Australia),
Bober, Allmuth (Stiftung Scheuern – Einrichtung
der Behindertenhilfe, Germany), Hemsley, Bronwyn
(The University of Newcastle, Australia), Iacono,
Teresa (La Trobe University, Australia), Ochs, India
(AAC Consumer, USA), Probst, Paul (Universitaet
Hamburg, Germany), Schlosser, Ralf (Northeastern
University, USA) (Chair), and von Tetzchner, Stephen
(University of Oslo, Norway).
title, abstract, or text regardless of how a particular
database chose to index the entry (Schlosser, Wendt,
Angermeier, & Shetty, 2005). The databases searched
are operating in the English-speaking world. Some
of these databases do index studies and reviews published in languages other than English (an English
language constraint was not imposed). However,
there was no attempt to systematically search for
non-English documents, which would have required
the searching of databases that operate in nonEnglish speaking countries. Ancestry searches
involved the searching of bibliographies of obtained
studies, reviews, previous position statements, and
websites for additional studies that may have qualified for inclusion. Also, select authors were contacted
to identify additional studies and reviews. Finally,
the journal Evidence-Based Communication Assessment and Intervention, the Database of Abstracts of
Reviews of Effects (DARE), and the EBP Compendium of the American Speech-Language and Hearing
Association were searched for synopses of systematic
reviews.
Materials Submitted by the ISAAC Membership
Introduction to the Review Process
A democratic process was adopted by the committee
throughout the review process. Members of committee were able to reach consensus on most issues. On
matters for which the committee could not reach agreement, members voted by e-mail. All members of the
committee had input, but each individual member was
free to hold his/her own views on the position statement
and/or report. Individual views have not been discussed
or disclosed in accordance with the rights afforded each
member of ISAAC to hold a private view on matters
relating to FC. Thus, the accompanying position statement has been based on the evidence found in the
review of literature, and not on the personal opinions of
the individuals on the committee.
Search for Synopses, Systematic Reviews, Narrative
Reviews, and Studies
A multi-faceted search strategy was employed to identify potentially relevant published synopses, systematic
reviews, narrative reviews, and studies. This strategy
consisted of database searches, ancestry searches, and
contacting individual authors. The following databases
were searched: Cumulative Index of Nursing and
Allied Health Literatures (CINAHL); Educational
Resources Information Clearinghouse (ERIC); Medline (via Pubmed); Language and Linguistics Behavior
Abstracts (LLBA); and PsychINFO (via EBSCO).
Since Facilitated Communication is typically not a keyword indexed in the thesaurus of most databases, we
chose to use the following terms as free-text phrases:
“facilitated communication”, “supported typing”, and
“assisted typing”.This strategy resulted in the identification of material that included these phrases in the
The ISAAC office announced to its membership that
written materials related to the issue of FC could be
submitted but noted that videotapes would not be
included in the review. The additional materials submitted to ISAAC are listed in Appendix A to be found at
online http://informahealthcare.com/doi/abs/10.3109/0
7434618.2014.971490. All were considered for inclusion along with the documents obtained through the
search methods described above.
Developing the Criteria for Inclusion
The Committee developed an inclusion checklist (see
Appendix B to be found at online http://informahealthcare.com/doi/abs/10.3109/07434618.2014.971490).
The checklist provided the means to the classification
of documents (about FC or not; peer-reviewed or not)
and their level of inclusion (i.e., quantitative, qualitative,
experimental, descriptive, or anecdotal data). Materials
that were not about FC were excluded. In completing
the inclusion checklist, the committee also captured
whether each written document was peer-reviewed.
For materials that were peer-reviewed and deemed to
be about FC, a decision was made on the appropriate
analysis level of inclusion as outlined below.
Level One Written Documents. Studies and reviews that
provided quantitative experimental data that related to
the authorship of the messages were included for level
one analysis. Quantitative experimental studies (or
systematic reviews of such studies) involved an a priori
controlled manipulation of knowledge/stimuli presented
to the facilitator and FC used by the individual in an
attempt to empirically establish who was authoring the
messages produced in response to the stimuli.
Augmentative and Alternative Communication
Facilitated Communication
Level Two Written Documents. Studies and reviews that
included quantitative descriptive data on the output
generated through the process of FC without a priori
testing of authorship were deemed appropriate for level
two analysis. These were studies that included quantitative descriptions of the output (generated through the
FC process) without empirical manipulation related to
authorship.
Level Three Written Documents. Written documents that
included qualitative descriptive data on the output
generated through the process of FC without pretesting of authorship were deemed appropriate for level
three analysis. Qualitative data were considered those
generated through qualitative research methods, such as
participant observations and interviews.
Level Four Written Documents. Documents representing anecdotal reports written by individuals using FC,
individuals who previously used FC, facilitators, former
facilitators and others sharing their perspectives on FC
were deemed appropriate for level four analysis.
The Criteria of Peer Review for all Written Documents.
Given that the committee included researchers and
scholars from both qualitative and quantitative traditions in which peer-reviewed articles enjoy the highest
regard, the inclusion of articles, across all four levels of
analysis, was restricted to those that appeared in peerreviewed journals.
Process for Determining and Applying the Level
of Inclusion to WritDocuments
The first author and Chair of the Committee coded all
potential written documents found through the search
or submitted to the ISAAC office for inclusion. Exceptions were those articles that were written in languages
beyond the competence of the Chair (i.e., neither German
or English). In these cases two other members of the
committee with competence in the relevant language
read the articles. Approximately 60% of written documents were independently coded by a second member
of the Committee (Schlosser, Wendt, & Sigafoos, 2007).
Any disagreements between the two coders were resolved
through consensus (Schlosser et al., 2007).
Handling of Non-English Literature. Within the committee, all members were able to read English and some
were also able to read French (n ⫽ 3), German (n ⫽ 4),
and Italian (n ⫽ 2). Materials in languages other than
English, German, French or Italian were not included
in this review.
Classification of Level One Written Documents
Level one evidence has the potential to appropriately
inform conclusions regarding authorship, and hence,
the validity of FC. In order to determine the author
of messages, an experimental design was required.
© 2014 International Society for Augmentative and Alternative Communication
361
Further requirements were the inclusion of conditions
(e.g., blinded facilitator, non-blinded facilitator, facilitated, not facilitated) that were established a priori and
manipulated while assessing the impact of each condition on the output that was generated.
Studies Including Both Blinded and Non-blind Conditions.
In the peer-reviewed journal literature, the following nine
systematic reviews met the criteria for level one analysis:
Cummins and Prior (1992); Felce (1994); Jacobson,
Mulick, and Schwartz (1995); Kezuka (2002); Mostert
(2001, 2010); Probst (2005); Simpson and Myles (1995a);
and Wehrenfennig and Surian (2008). Per analysis of the
Probst (2005) systematic review, 23 studies (all dated in
the years 1993–1998) met the criteria for level one analysis
and included a blinded FC condition with a nonblinded
FC condition as a comparison (Bebko, Perry, & Bryson,
1996; Bligh & Kupperman, 1993; Braman, Brady,
Linehan, & Williams, 1995; Cabay, 1994; Calculator &
Hatch, 1995; Eberlin, McConnachie, Ibel, & Volpe, 1993;
Hirshoren & Gregory, 1995; Hudson & Arnold, 1993;
Kerrin, Murdock, Sharpton, & Jones, 1998; Kezuka, 1997;
Klewe, 1993; Konstantareas & Gravelle, 1998; Montee,
Miltenberger, & Wittrock, 1995; Moore, Donovan, &
Hudson, 1993a; Myles & Simpson, 1994; Myles, Simpson,
& Smith, 1996; Oswald, 1994; Shane & Kearns, 1994;
Simon et al., 1994; Simpson & Myles, 1995b; Smith, Haas,
& Belcher, 1994; Vasquez, 1994; and Vasquez, 1995). In
addition to studies included in Probst’s (2005) systematic
review, four studies (dated in the years 2001–2014) met
criteria for level one analysis and included both a blinded FC
condition and a non-blinded FC condition: Olney (2001);
Perini, Rollo, & Gazzotti (2010a); Saloviita, Leppänen, and
Ojalammi (2014); and Schiavo, Tressoldi, and Martinez
(2005). Thus, in total, 27 studies considered in this review
included both blinded and non-blinded conditions.
Studies Including a Blinded Condition Without a
Non-blinded Condition. In the peer-reviewed journal
literature, and per analysis of Probst (2005), a further
13 studies (all dated within the period 1992–1996) met
the criteria for level one analysis and included a blinded
FC condition without a non-blinded FC condition: Beck
and Pirovano (1996); Bomba, O’Donnell, Markowitz,
and Holmes, (1996); Calculator and Singer (1992);
Cardinal, Hanson, and Wakeham, (1996); Crews et al.
(1995); Heckler (1994); Regal, Rooney, and Wandas
(1994); Sheehan and Matuozzi (1996), Siegel (1995),
Smith and Belcher (1993); Szempruch and Jacobson
(1993); Weiss, Wagner, and Bauman (1996); and Wheeler,
Jacobson, Paglieri, and Schwartz (1993).
Other Studies Including Controlled FC Conditions. In the
peer-reviewed journal literature, and per analysis of
Probst (2005), six studies (all dated within the period
1993–1995) involved controlled FC conditions, and
rendered conclusions about the validity of accusations
of sexual abuse made through FC: Bligh and Kupperman
(1994); Calculator and Hatch (1995); Hudson, Melita,
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and Arnold (1993); Heckler (1994); Shane and Kearns
(1994); and Siegel (1995).
Classification of Level Two Written Documents
In the peer-reviewed literature, 11 studies (all dated
within the period 2001–2012) met the criteria
for level two analysis: Bara, Bocciarelli, and Colle
(2001); Bernardi and Tuzzi (2011a; 2011b); Bigozzi,
Zanobini, Tarchi, Cozzani, and Camba (2012); Bruno,
Schnakers, Vanhaudenhuyse, Moone, and Laureys
(2010); Emerson, Grayson, and Griffiths (2001);
Grayson, Emerson, Howard-Jones, and O’Neil
(2012); Tuzzi (n.d.); Tuzzi (2009); Tuzzi, Cemin, and
Castagna (2004); and Zanobini and Scobesi (2001).
Classification of Level Three Written Documents
In the peer-reviewed literature, seven studies (all dated
within the period 1991–2011) met the criteria for level
three analysis: Bennett (2011); Biklen and Schubert
(1991); Broderick and Kasa-Hendricksen (2001);
Niemi and Karna-Lin (2002); Olney (1995); Sipila and
Maatta (2011); and Zanobini and Scopesi (2001).
Classification of Level Four Written Documents
In the peer-reviewed literature, 24 written documents
(all dated within the period 1994–2012) met the criteria for level four analysis: Ackerson (1994); Biklen
and Burke (2006); Biklen and Schneiderman (1997);
Boynton (2012); Bryen and Wickman (2011); CaustonTheoharis, Ashby, and Cosier (2009); Clarkson (1994);
Emerson et al. (1998); Focht-New (1996); Johnson,
DMan (2011); Kasa-Hendrickson, Broderick, and Hanson
(2009); Koppenhaver, Pierce, and Yoder (1995); Marks
(1994); Mirenda (2008); Mostert (2012); Niemi, and
Karna-Lin (2003b); Palfreman (2012); Pentzell (2010);
Savarese (2010a); Savarese, Baggs et al. (2010a); Savarese,
Block et al. (2010b); Stock (2011); Todd (2012); and von
Tetzchner (2012).
Excluded Materials
In total, 334 documents were excluded entirely because
they did not focus on FC, mention of FC was made
only in a tangential manner, or the documents were
not published in a peer-reviewed journal. Excluded
materials are listed in Appendix C to be found at
online http://informahealthcare.com/doi/abs/10.3109/
07434618.2014.971490.
Results
Evidence on Authorship
In the following four main sections, results based on the
sources described above for level one, level two, level
three, and level four evidence are presented. In light
of the purpose for constituting the Committee, the
validity of FC as a method of communication was judged
according to the evidence regarding message authorship:
that is, evidence to indicate who authored messages –
the FC user or the facilitator. Following classification of
the materials, the next level of analysis focused on the
strength of evidence in relation to authorship.
Level One Evidence
In the analysis of level one evidence, the pyramid
of navigating evidence-based information sources
in health care fields in general (DiCenso, Bayley, &
Haynes, 2009; Haynes, 2006) and augmentative and
alternative communication in particular (Schlosser &
Sigafoos, 2009) were followed. Accordingly, consumers
of research evidence should seek out systematic reviews
before individual studies. Systematic reviews have been
shown to be preferred sources of evidence because they
provide systematic aggregated evidence to minimize
error that may arise from relying on any one individual
study. They often include additional methodological
steps to increase confidence in the conclusions (e.g.,
identify risks of bias in included studies, and take this
into account).
Synopses. Implementation of the pyramid further
requires that consumers seek out synopses (or appraisals) of systematic reviews before the systematic reviews.
This preference for appraisals has been based on the
premise that not all reviews are equal in terms of quality of methods to address trustworthiness (Schlosser,
Wendt, & Sigafoos, 2007). Hence, we followed this
approach. One synopsis by Schlosser and Wendt (2008)
was identified which provided an appraisal of a systematic review by Probst (2005). A search in other sources
for synopses of systematic reviews (i.e., Database of
Abstracts of Reviews of Effects; EBP Compendium)
failed to yield other synopses.
Systematic Reviews. Several reviews published in the
peer-reviewed journal literature were located that
included level one evidence. Among the systematic
reviews located, some were quite dated (Cummins &
Prior, 1992; Felce, 1994; Jacobson et al., 1995; Mostert;
2001; Simpson & Myles, 1995), with a further one being
in Japanese (Kezuka, 2002) and, therefore, excluded.
Among the more recent systematic reviews (Mostert,
2010; Probst, 2005; Wehrenfennig & Surian, 2008),
we relied primarily on Probst (2005) because it has
been appraised in a synopsis and was deemed as a highquality systematic review (Schlosser & Wendt, 2008).
The other two systematic reviews by Mostert (2010) and
Wehrenfennig and Surian (2008) were also examined
for additional and more recent studies. Conclusions
from these studies and reviews were also compared to
those of Probst (2005).
The systematic review by Probst (2005) was the
only one that has since been appraised in a synopsis
(Schlosser & Wendt, 2008). It is important to note that
Augmentative and Alternative Communication
Facilitated Communication
while Probst (2005) is a German language publication,
all of the primary studies included in Probst (2005)
were also included in three systematic reviews published
in English: Felce (1994), Jacobson et al. (1995), and
Mostert (2001). Specifically, we relied on the body
of studies that included a facilitator-blinded and a
facilitator-non-blinded condition as studies without a
non-blinded condition are not as rigorous and therefore
convincing methodologically. Based on his analysis and
synthesis of 23 studies, Probst (2005) concluded that
there was overwhelming evidence for facilitator control
in FC. In terms of the validity of accusations made
through FC communication regarding sexual abuse,
Probst concluded on the basis of an analysis of six studies that the majority of communicative messages were
influenced by facilitator control.
The review by Wehrenfennig and Surian (2008)
included no additional studies to those included in
Probst (2005). Their conclusions concurred with those
by Probst (2005). It is unclear whether the quantitative
results/interpretations provided in their Table 1 were
arrived at independently or simply taken from Probst
(2005). However, Wehrenfennig and Surian (2008,
p. 457, translated from P. Probst) noted that “Overall, the
conclusions from our review are consistent with the conclusions of the previous reviews (Jacobson et al., 1995;
Jordan et al., 1998; Mostert, 2001; Probst, 2005)”.
Mostert (2010) added four more recent studies relative to the review by Probst (2005), but none
were deemed to include any control procedures, which
were necessary for level one evidence. The conclusions
reached by Mostert (2001, 2010) are fully consistent
with Felce (1994), Jacobson et al. (1995), Probst (2005),
and Wehrenfennig and Surian (2008). The review by
Mostert (2012), although not following systematic
review guidelines closely, did include a review of previous reviews of FC and drew broader conclusions from
the more recently generated evidence of the pro-FC
movement; no additional studies were reviewed.
Individual Studies. As well as the systematic review studies, four individual studies met the inclusion criteria for
level one analysis in the current review (Olney, 2001;
Perini et al., 2010a; Saloviita et al., 2014; Schiavo et al.,
2005). The study by Olney (2001) was not included by
Probst (2005), Mostert (2010), or Wehrenfennig and
Surian (2008). It is likely that this omission was due to it
being published in Disability Studies Quarterly. This is a
journal in the field of disability studies linked to literary
analysis in the humanities that is indexed by the Modern
Languages Association database rather than databases
commonly searched in the field of communication sciences and disorders. The study by Perini et al. (2010a)
was too recent to be included in any of the reviews.
The study by Schiavo et al. (2005) was too recent to
be included in Probst (2005), and was excluded by
Mostert (2010) due to the English-language restriction
as a criterion for inclusion. The study was included
in Wehrenfennig and Surian (2008) in their narrative
© 2014 International Society for Augmentative and Alternative Communication
363
analysis, but not the tabular summary of studies. The
study by Saloviita et al. (2014) was too recent to be
included in any of the reviews. Therefore we engaged in
our own appraisal of these four studies and provide here
a summary of the study and the appraisal and conclusions of the Ad Hoc committee about each study.
Olney (2001). In this study, individuals with developmental disabilities and their regular facilitators were
asked to respond to multiple-choice questions, vocabulary-based computer game items in blind as well as
non-blind conditions.
Appraisal by the Committee. This experimental study
included nine participants, aged 16–42 years (M ⫽ 28.5,
SD ⫽ 7.3). The dependent variable was the accuracy of
verbal comprehension of written language: the number
of correct responses was examined under facilitatorblind and facilitator nonblind conditions (the independent variable). The participants were expected to match
words to definitions by selecting one of four alternatives
(A, B, C, D) presented in a multiple choice format: for
example, the word “loyal:” A “devoted”, B “easily controlled or handled”, C “thick, crowded” and D “lazy”.
The internal validity of this study was fundamentally
flawed, in particular by (a) lack of pretesting, (b) lack
of control for unspecific factors that may confound the
independent variable (blind-nonblind) with participant
training and assessment implementation variables, and
(c) selective consideration of outcomes in favor of the
FC-is-valid-claim.
Conclusions of the Committee. The outcomes do support
the assumption of facilitator influence and thus are consistent with other experimental studies. While some of
the participants were literate and were the authors of
the letter completing task, the outcomes for these participants were not better with FC than without. The lack
of evidence of validity is consistent with the systematic
reviews presented in the present report.
Perini et al. (2010a) (Italian). This study was an investigation of the performance of a 12-year-old child with
autism in two different settings using two different interventions: a special facility that the child attended in the
afternoon and used FC, and at the child’s school where
a behavioral approach to enhancing the child’s communication was used. Three different procedures were
used in testing the child’s picture naming: (a) non-blind
facilitator, (b) blind facilitator, and (c) support of the
investigator. The child’s answers were more appropriate when the facilitator was familiar with the questions.
The authors found no empirical evidence to support the
effectiveness of FC and recommended further research
of both FC and the behavioral approach.
Appraisal by the Committee. This single case study was
of a 12-year-old nonspeaking boy (M) diagnosed with
autism and moderate to severe intellectual disability,
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R.W. Schlosser et al.
who reportedly functioned in the normal cognitive and
socio-emotional range under FC conditions. The study
aims were to examine (a) the validity and effectiveness of FC in a controlled study within the setting of
an afternoon-care center, and (b) the effectiveness of a
behavioral treatment program (without using FC) for
the enhancement of low-level written language abilities
within an inclusive secondary school classroom. Greater
emphasis will be placed on the first aim.
For the first aim, M’s linguistic behavior, the dependent variable, was the number of correct responses: for
example, picture naming, was measured under three
conditions (Independent Variable): facilitator not blind,
facilitator blind and only experimenter’s control (i.e.,
unspecified physical and emotional assistance). The
results indicated clearly better achievements under the
facilitator not blind condition than under the other
two conditions. The authors illustrated this finding by
the following example: Under the facilitator not blind
condition M responded to “What animal is this?” correctly with “A simple elephant”; under the facilitator
blind condition he typed: “Ansinlo Fenicortte” [notabene: “asino” is the Italian word for “donkey”]; and
under the only experimenter control condition M typed
“Pujiypupu”. From these results, the authors concluded
that the study failed to provide empirical evidence of the
validity and effectiveness of FC.
The internal validity of this study was compromised
by the following: (a) incomplete facilitator control: due
to unexpected technical problems, the facilitator was
only visually, but not acoustically blinded, (b) incomplete
description of the dependent variable, which comprised
three different tasks formats, and (c) incomplete presentation of results. Despite the methodological deficits
described, the authors’ conclusions were in accordance
with those of numerous other controlled studies. Overall,
the first partial study did not provide any empirical evidence to support the validity and effectiveness of FC.
For the second aim, the pre-training assessment of M
indicated low-level literacy competencies for skills such
as letter recognition. The subsequent behavioral training
targeted comprehending and writing one-word expressions as for example, “fico” (fig) or “luna” (moon).
The results showed significant improvements following
training. The authors’ conclusions in terms of the effectiveness of the behavioral training for enhancing literacy
abilities were consistent with the interdisciplinary stateof-the-art knowledge.
Saloviita et al. (2014). This study was published too
recently to be included in any previous systematic or
other reviews. The aim of the study was to explore
authorship of messages for 11 students using FC in
two schools in Finland. All participants had intellectual
disability and the cohort included students with autism
and Down syndrome. All students used a paper keyboard, two sometimes used a computer keyboard and
two sometimes used a Lightwriter™ for communication. Tests included information passing tasks under
facilitator-blinded and non-blind conditions. Results
indicated strong facilitator influence on message construction and did not validate FC as communication
method for students or facilitators. Furthermore, two
students evidenced poorer performance on tasks when
facilitated than when communicating independently.
Conclusions of the Committee. No empirical evidence was
provided that supported the validity and effectiveness of
FC. The authors concluded that the use of FC is unjustified and unethical (“ingiustificato e immorale”, p. 115)
due to the lack of scientific evidence, and because FC
can distract from the use of effective interventions with
strong empirical evidence. These ethics-related conclusions were concordant with those presented both in
systematic reviews and in several position statements
published by academic and professional groups.
Appraisal by the Committee. In this experimental study with
11 Finnish participants, aged 7–15 years, information
passing (dependent variable: number of correct responses)
was examined under facilitator-blind and facilitator nonblind conditions (the independent variable). Seven children participated in pilot testing to ensure that the tasks
were functional and to familiarize the facilitators and some
participants with the protocols. Some small changes (e.g.,
reduction in length of some tasks) were made after the
pilot study. The participants completed six testing activities
Schiavo et al. (2005) (Italian). This study included five
individuals with autism aged 13–28 years. Participants
were read an illustrated historical story or shown a magazine picture and asked to comment in writing. In the
blind condition, the answers were written with support
from a facilitator who had been out of the room when
the experimenter presented the materials. In the nonblind condition, the facilitator was in the room when
materials were presented. Results indicated that the
answers were more appropriate in the non-blind condition, but also about half of the answers were acceptable
in the blind condition.
Appraisal by the Committee. It was not reported (a) how
the tasks were assigned to the participants, (b) whether
the facilitators knew the item pool, (c) whether one
or more facilitators were the same for more than one
participant, or (d) whether the facilitators knew each
other. It was unclear who determined the correctness
of a response; that is, there were no controls in place to
minimize the possibility of false point assignments (e.g.,
no inter-rater agreement of any kind).
Conclusions by the Committee. The results along with the
appraised shortcomings in this study do not support FC
as a valid method. The finding relative to the participant
who was facilitated by the shoulder shed serious doubts
about the assumptions made by others (Bernardi &
Tuzzi, 2011) that this level of support minimizes or
rules out facilitator control when recruiting participants
for descriptive studies of the output of FC users.
Augmentative and Alternative Communication
Facilitated Communication
(object naming, picture-naming, describing a picture,
reading, name writing, and independent pointing). The
researchers addressed arguments made by Biklen (1993)
against the validity of previous experiments, such as presence of dyspraxia in users of FC. Tasks included facilitator
and participants having the same cues or different cues,
and the facilitator having no cues and being blind to the
task. Test-retest (whether responses were correct or not)
and inter-rater agreement were high. Results indicated
that when the facilitator was aware of the correct response,
the participants’ facilitated responses were more than 80%
correct.When the facilitators were blind to the task or were
given a different cue to that given the participants, only
3 out of 182 test opportunities were correct. Two participants who could type independently were able to complete
some tasks correctly when independent, but were consistently wrong when facilitated by a facilitator blind to the
task. Limitations of the study included that one researcher
collected all the data, the facilitators were trusted to close
their eyes rather than be blindfolded or patched, and
occasionally the facilitator of a participant differed across
tasks. Such changing of facilitators for individuals was
common practice in the schools. Furthermore, observations indicated that facilitators did not follow guidelines of
the Facilitated Communication Institute (2010)/Institute
of Communication and Inclusion (ICI) (2012) guidelines
(e.g., ensuring that the person using FC looked at the keyboard, applying fading techniques).
Conclusions by the Committee. The outcomes in this study
did not support independent authorship of messages
using FC. The influence of the facilitator when the facilitator knew the correct response was strong. The finding
that there was no evidence for independent authorship
was consistent with previous studies. Of interest was that
one student was withdrawn from the study when it was
clear that the facilitator was the author of the messages,
as the school staff considered that this news would be
distressing for the family. When the final results were
presented, FC was immediately stopped in one school,
but continued in the other. Although many of the facilitators were trained and FC was a well supported practice
in both schools, often the facilitators did not follow the
ICI guidelines. It was not clear if this had any impact on
the results. Further research testing the ICI guidelines
would be needed to determine whether this indeed had
any influence on the results in this study.
Overall Appraisal of Additional Level One Studies. The four
additional studies identified at level one provided support for the conclusions reached in the systematic review
of Probst (2005) and subsequent systematic reviews
(Mostert, 2010; Wehrenfennig & Surian, 2008).
Level Two Evidence
Level two evidence provides quantitative descriptive
data enabling analysis of the output generated when
individuals are being facilitated using FC. By analyzing
© 2014 International Society for Augmentative and Alternative Communication
365
the characteristics of the message output, without first
blind testing to gauge any facilitator influence, many
authors of these studies have made inferences about
the abilities of individuals who use FC and indirectly
asserted the validity of FC. Based on the committee’s
expertise in research design, such evidence was found
inappropriate in informing the question of authorship, the focus of the committee’s work. Numerous
alternative explanations cannot be ruled out by using
such descriptive designs. In fact, these studies were
predicated on the assumption that the participants in
their studies were the authors of the messages generated, without having engaged in due diligence by
verifying that this was indeed the case. In light of the
overwhelming level one evidence for facilitator control,
this appears a tenuous assumption at best and an ethically unjustifiable one at worst. In-depth analyses of
these studies was not warranted because it was evident
that the authors of these studies failed to pre-establish
authorship by their participants. Any future level two
studies may have merit (not to inform authorship) if
participants are first screened to ensure that they are
the authors of the messages generated using blind or
double-blind procedures, before data are collected to
address questions other than authorship.
Level Three Evidence
This evidence provides descriptive qualitative data
regarding the output generated by individuals using FC.
The same conclusions apply as for level two evidence.
Level Four Evidence
As noted, level four evidence comprised reports that
included perspectives of individuals from various stakeholder groups (e.g., former FC users, parents/family
members of FC users, teachers, speech language therapists/pathologists) regarding FC. Many of these reports
included assertions of positive changes in the lives of people using FC and their families; others included claims of
negative impacts of FC on the lives of individuals using
FC and their families. Because these anecdotal reports
were essentially perspectives of individuals, they could
not be accepted as scientific evidence (a) supporting a
demonstration of authorship, or (b) refuting a demonstration of authorship. Therefore, for the purposes of this
position statement and review, a more in-depth analyses
of these perspectives was not warranted.
Conclusions
This paper provides an evidence-based review of the
extant literature on the question of authorship in
FC. Four levels of analysis were used in this review,
although only literature that met level one criteria was
deemed to provide scientific evidence of authorship
of communicative messages. Three systematic reviews
and four individual studies met level one criteria and
366
R.W. Schlosser et al.
this literature provided robust evidence that FC is not
a valid technique.
Author Note
The authors would like to thank and acknowledge the
members of the AdHoc Committee who served the International Society for Augmentative and Alternative Communication (ISAAC) and its membership for part or all of
the process and provided valuable input to the review and
development of the position statement (ISAAC, 2014). We
are also grateful to Janice Bedrosian, Howard Shane, and
Jeff Sigafoos who served as external readers to the review
and position statement prior to its release to the membership for consultation. In addition, the authors would like
to thank all of the members of ISAAC who submitted
additional materials, and ISAAC Chapter Presidents and
Representatives to the ISAAC Council who provided written feedback from members to the Executive Board prior
to its adoption at the ISAAC Council Meeting on 20 July
2014. The collaborative efforts of all of these individuals
served to enhance the rigor and consultation with which
this statement was developed and are greatly appreciated.
Finally, we would like to thank Hannah Sheets of Northeastern University who served as a Research Assistant.
Notes
1. Bronwyn Hemsley served on the Committee as
originally constituted. She excused herself after joining the ISAAC Executive Committee and becoming
President Elect. Susan Balandin, who had originally
been asked to serve as an outside reviewer, replaced
Bronwyn on the Committee as of March 11, 2013.
Bober, Allmuth resigned from the committee, effective March 9, 2014. In addition to the committee, a
group of outside peer reviewers was constituted to
serve as readers of draft statements and reports. The
following individuals served in this capacity: Balandin, Susan (Deakin University, Australia), Bedrosian,
Janice (Western Michigan University, USA), Shane,
Howard (Boston Children’s Hospital, USA), and
Sigafoos, Jeff (Victoria University of Wellington, New
Zealand).
2. This paper was published in a peer-reviewed journal, but because it is an editorial it was not considered to have been peer-reviewed and was therefore
excluded.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for
the content and writing of the paper.
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