Analysis of “Evaluation of A Mechanical Hand-Support for Facilitated Communication” Using Criteria from Crossley’s book on FCT
In 1998, the Journal of Autism and Developmental Disorders published a study conducted by Stephen M. Edelson, Bernard Rimland, Carol Lee Berger, and Donald Billings called Evaluation of a Mechanical Hand-Support for Facilitated Communication. The study was designed, primarily, to evaluate a custom-made hand-support device that the researchers hoped would aid in transition from (manual, human-touch) FC to independent typing. (p. 154) The study also gave researchers “an additional opportunity to evaluate the efficacy of FC as typically practiced.” (p. 154)
Hand-support device used by Edelson, Rimland, Berger, and Billings in their 1998 study (as published in the Journal of Autism and Developmental Disorders)
Today’s blog post is an analysis of this study using questions (in bold, below) gleaned from FC founder Rosemary Crossley’s book Facilitated Communication Training. For further discussion of these criteria, see my previous blog post. The first four questions reflect concerns Crossley had regarding blinded or controlled testing (sometimes called “message passing tests) in which the facilitator is prevented from knowing test protocols, thus giving those subjected to FC an opportunity to answer independently (e.g., without facilitator input). The last two are questions I’ve added based on concerns I’ve seen expressed by proponents in pro-FC literature.
Proponents often describe critics of FC/S2C/RPM in a negative light, accusing them of ableism or of “presuming incompetence” in their non-speaking clients. But what if one of the researchers in a study showing “no evidence for the efficacy of FC” was Bernard Rimland (who was the father of an autistic child and often referred to in the literature as “the father of autism”) or Carol Berger (an advocate for FC who wrote and lectured on the topic)? I find it difficult in this case (or, indeed, in most other cases) to take proponent accusations seriously.
Perhaps it’s because the Evaluation of a Mechanical Hand-Support for Facilitated Communication inadvertently supported reliably controlled tests that disproved FC and raised issues of facilitator control over letter selection (See controlled studies) that this study is often not included on pro-FC resource lists..
Please note: There is a summary of the article Evaluation of a Mechanical Hand-Support for Facilitated Communication, on our website (here), though if you have not read the complete article for yourself, I strongly suggest you do.
Was the partner (facilitator) trained and experienced with the facilitated communication method? Yes.
At the time of the study, Donald Billings was a special education teacher certified and trained to work with orthopedically impaired students. He “developed and improved” the support system used in the study. Billings was also trained as a facilitator and, in turn, trained the facilitator used in the study. (p. 154) He worked daily in the classroom using FC with the students.
Carol Berger, the facilitator, had over 8 years of experience with FC and “had written and lectured extensively on FC.” (p. 155)
Did the aid user (individual being facilitated) previously communicate fluently with that partner (facilitator)? Yes.
The facilitator, Carol Berger, also taught the participants how to use the hand-support device and assisted with pre- and post-training assessments of communication competence. (p. 155)
Was the aid user (individual being facilitated) satisfied there was a genuine reason for the validation being sought and give consent to the procedure? Tricky question to answer.
Crossley (and other proponents of FC/S2C/RPM) believe that FC-generated messages represent the thoughts and desires of the individuals being subjected to its use. However, since the very reason for controlled testing is/was authorship (e.g., ruling in or ruling out facilitator influence or control over letter selection) and no reliably controlled testing supports claims that FC-generated messages are independent and free from facilitator control, informed consent cannot be obtained using FC/S2C/RPM or any other facilitator-dependent techniques. (See Systematic Reviews)
The authors of the study did not mention how (or if) consent was obtained directly from the students or what techniques or methods were used to discuss the activity (e.g., FC, verbal confirmation, sign language, or evidence-based AAC).
Instead, the authors, abiding by ethical standards for children under the age of 18, distributed to and collected from the participants’ parents or guardians informed consent forms. The consent form was not included with the article, but the authors reported that the form contained information about the potential risks and benefits of participating in the study. (p. 155)
Since the following information was included in the article, the parents/guardians were, presumably, told the augmentative hand-support system was intended to (a) eliminate possible “contamination” of the disabled person’s message by facilitator influence; (b) allow the person to type while supported but without the facilitator’s hand doing the support; and (c) if possible, assist in transitioning the disabled person from manually facilitated support, through mechanically augmented support, to independent typing,. (p. 154)
The students, ultimately, participated in the study, but it is difficult to tell from the report the extent to which they understood its purpose.
Did the aid user have experience with the validation task required and demonstrate the skills required by the testing procedure? Yes.
The students who participated in the study had “a great deal of experience with FC” (ranging from 6 months to 13 years), were considered at least “moderately proficient at FC” (e.g., 60% or more correct responses in the FC condition in the pretraining phase), and had worked with the trainer for at least 6 months (range: 6 months to 7 years). (p. 155) In addition, each student received “approximately 1 to 1 ½ hours each week of one-on-one training with the hand support.” Tasks used in the training phase were like the ones used in the pre-training phase. The training period lasted 8 weeks. (p. 156)
Each student participated in a pretraining phase that included three conditions: (a) FC; (b) independent typing (no manual or mechanical support); and (c) mechanical device only – no facilitator support. (p. 155) The assessment tasks included: (1) pointing to pictures (line drawings); (2) pointing to letters; (3) pointing to digits, 0 to 9, and (4) copying words naming concrete objects (e.g. APPLE, CAT, PEN). (p. 156)
The students also participated in a post-training phase, which consisted of the same tasks, but with different pictures, words, etc.
Were researchers responsive to proponent concerns that testing be conducted in as natural a setting as possible? This was not addressed specifically, but it appears so.
The participants were “trained and evaluated on the device in the same classroom they had been using during their regular school attendance.” (p. 155).
Were participants given opportunities to take breaks and/or end the session when tired, agitated, or simply done for the day? Unknown.
The researchers did not comment on student behaviors during the trials, but once the original study was complete, the researchers obtained approval to continue using the device for another school semester (4 months) to “maximize the chance for positive findings.” (p. 157) It appears every attempt was made to optimize testing conditions and student participation in the study.
Results:
The authors of this study recorded the results of three conditions:
Facilitated Communication (assistance by a facilitator with stimuli in full view): all participants performed well above chance when pointing to pictures, letters, and numbers.
Independent Pointing/Typing: The majority of students were unable to point to pictures, letters, and numbers or type words without assistance.
Typing with the mechanical hand-support system: None of the six students could point to letters or copy words reliably using the hand-support system. Three students were moderately successful when pointing to pictures, and one of students could also point to numbers, but the students were also equally successful at pointing independently. (p. 156)
Despite extending the original study by 4 months, the researchers found “no evidence for the efficacy of FC, with or without the use of the hand device.” (p. 157) The authors wrote:
“Although this study was not an attempt to evaluate FC per se, the results are consistent with every controlled study on FC in that no evidence was found of consistent, useful, or spontaneous communication using this method. It is also noteworthy that five subjects who had 2 to 13 years of FC experience averaged only 30% correct responses in the conventional FC condition when asked to copy simple words, (e.g., CAT, KEY), which were printed on cards in full view.” (p. 157)
In re-reading this study, I find it quite telling that not only was there no evidence found for the efficacy of FC—despite a 4 month extension of the activity—but students subjected to FC use for 2 to 13 years were only expected to achieve a 60% accuracy level in the FC condition of the pretraining phase to qualify for the study. 60% seems like a low bar for people who’d been subjected to FC use for years. Shouldn’t these individuals have a stockpile of “mastered” words after years-long practice? This is the only study I can think of that alludes to a lack of skill building (e.g., letter/word recognition, ability to copy letters from a printed card in full view) despite years of facilitator-dependent practice. Perhaps, along with reliably controlled studies designed to rule in or rule out facilitator control during letter selection, we need additional studies addressing skill acquisition in individuals who’ve been subjected to FC/S2C/RPM year after year after year.
Note: I’d be interested to hear what happened to the facilitators’ belief in FC after the study was conducted. Did Carol Berger and Donald Billings continue facilitating their students? Did the school keep FC or did they discontinue its use? I believe Bernard Rimland eventually denounced FC publicly and voiced concerns about facilitator influence and control over letter selection.