LSHSS

A Framework for Managing

Controversial Practices
Judith Felson Duchan
State University of New York at Buffalo
Stephen Calculator
Rae Sonnenmeier
University of New Hampshire, Durham
Sylvia Diehl
University of South Florida, Tampa
Gary D. Cumley
University of Wisconsin, Stevens Point

peech-language pathologists working in are they violating their client's right to choose treatments?
schools are often faced with decisions Should they put the choice in the hands of the client?
regarding controversial clinical approaches. Should they even tell the client about the approach or the
Should they elect to use the approach? With whom? What controversy surrounding it?
are the ramifications for their clinical reputations if they In a recent clinical forum of this journal. Creaghead
use it? Why is the approach controversial and how might (1999) invited a group of authors to present contrastive
they go about defending their choice? If they do not use an perspectives on central auditory processing disorders,
approach requested by their client or the client's guardian, auditory integration therapy. FastForWord training, and
facilitated communication. Some authors in Creaghead's
ABSTRACT; Every day, speech-language pathologists forum suggested that professionals should develop clinical
working in schools make difficult, life-impacting deci- guidelines for how to approach controversial practices
sions regarding which assessment and intervention (Calculator, 1999; Duchan, 1999). It was felt that guide-
approaches to use with their clients. These decisions can lines could help speech-language pathologists make well-
become even more difficult when the approaches being
informed and principled decisions conceming the ap-
considered for use are controversial. The risks involved
in making choices about controversial practices are likely proaches chosen for intervention. The aim of this article is
to have increased significance simply because the to offer a framework for developing clinical practice
approach being considered is not widely accepted. The guidelines that can be used by school speech-language
increased professional risk may cause decisions to be pathologists.
made based on risk avoidance rather than on a careful The framework contains seven areas for clinicians and
consideration of the pros and cons of the approach itself.
researchers to consider in the course of making decisions
This article offers a clinical practice framework for
gathering information about controversial approaches and about a controversial practice. It is intended to be a
for implementing and monitoring their use. The frame- conceptual scaffold for developing guidelines for particular
work will be illustrated using facilitated communication controversial practices. It asks that service provision teams
as an example of a controversial practice. (a) identify the sources of the controversy for each practice,
(b) understand how the approach fits with more established
practices, (c) use specially designed informed consent
KEY WORDS: augmentative and alternative communica-
tion, clinical practice guidelines, controversial practices^ procedures, (d) develop client-specific procedures for using
facilitated communication the approach, (e) receive specialized training to implement
the approach, (f) document and evaluate outcomes of the

LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 32 • 133-141 • July 2001 © American Speech-Language-Hearing Association 133
0161-1461/01/3203-0133
approach, and (g) prepare for eventual challenges arising 2. FC may preclude the use of other treatments that are
from implementation of the controversial practice. effective and appropriate.
Each of these seven consideralions will be addressed 3. Messages produced with FC may lead to false
generally and in relation to a particular controversial allegations of abuse or mistreatment.
practice, facilitated communication (FC). FC is a tech-
The ASHA position statement also indicated that the
nique in which a facilitator provides multiple levels of
scientific validity and reliability of FC had not been
support to individuals with severe communication disabili-
demonstrated. The concern about the paucity of experimen-
ties (a communicator) to aid them as they communicate.
tal research supporting the validity and reliability of FC,
(See the Appendix for a detailed description of FC.) FC
for example, led ASHA to recommend that "information
qualifies as a controversial practice because of the degree
obtained through or based on Facilitated Communication
of discord concerning who FC should be used with,
should not form the sole basis for making any diagnostic or
whether a communicator's messages are influenced by the
treatment decisions" (ASHA, 1995).
facilitator, and the strong positive, as well as negative,
impact that FC has had on the lives of some individuals In summary, the sources of controversy when consider-
who have used the approach. ing a controversial practice can be discovered by examining
the theoretical rationale, outcome data, position or technical
reports, and consumer experiences. Once identified, the
sources can provide direction for practices. Comparison
A FRAMEWORK FOR MANAGING with similar, less controversial, practices might add to
CONTROVERSIAL PRACTICES information incorporated into consent practices. The sources
of controversy might also provide a framework for outcome
When approaching a controversial practice, clinicians documentation. An understanding of the risks is essential
and a team of professionals and consumers who are for school-based speech language pathologists to meet the
familiar with the issues should work together to develop challenges posed by the approach itself and by others who
clinical guidelines that are sensitive to the particular oppose the use of the approach.
practice. The guidelines might best be developed using a
structured framework such as the one described in the
Understand How the Approach Fits
following paragraphs.
With More Estahlished Practices
Identify the Sources of Controversy Historically, new approaches have been evaluated in the
context of current practices. Because new approaches have
Clinical guidelines should be responsive to the main typically evolved naturally from current approaches,
sources of controversy surrounding a clinical practice. practices that look unfamiliar are often the very ones that
Those persons considering the use of a controversial lead to controversy. It is useful, therefore, to develop a
practice should understand the various aspects of the clear understanding of the conceptual origins of new
controversy so that they can present a rationale for why approaches in the context of older, more established ones.
they have or have not chosen to implement the approach. For example, FC may best be considered to be part of,
Controversial issues should be considered when developing and not an alternative to, established practices in augmenta-
guidelines for implementing the practice as well as when tive and alternative communication (AAC). Regarding FC
researching its efficacy. as an AAC approach follows from ASHA's definition of
In order to discover the sources of controversy, speech- AAC because it is "an area of clinical practice that
language pathologists will need to analyze the theoretical attempts to compensate (either temporarily or permanently)
rationale for the approach so they can discover why it was for the impairment and disability patterns of individuals
developed and how it is being used. For those approaches with severe expressive communication disorders (i.e., the
that have outcome data, clinicians should analyze the severely speech-language and writing impaired)" (ASHA,
outcomes that have been used to argue for and against the 1989, p. 107). Viewing FC as part of AAC leads to
approach. Further, clinicians should identify both the risks associated practice recommendations that would not follow
and the benefits of the approach and scrutinize position if FC were treated as a new approach, divorced from
statements or technical reports issued by professional or standard practices.
consumer organizations bearing on its use. Finally, clini- The following are examples of practices that emerge
cians should communicate with consumers and/or their from considering FC practices as a type of AAC.
guardians who have had experience in implementing the
approach so as to ascertain its perceived effectiveness. • FC would be implemented best by clinicians who
have a strong background and clinical competencies in
The controversies associated with a particular approach AAC (ASHA, 1989).
are sometimes framed as "risks." For example, the Ameri-
can-Speech-Language-Hearing Association (ASHA, 1995) • Clients who are experiencing any degree of success
issued a position paper on FC, outlining three risks: with other AAC approaches should continue to have
access to and receive training in these methods,
1. Facilitators may be unduly influencing the content of particularly the methods with which they are develop-
the message. ing independent communication skills.

134 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 32 • 133-141 • July 2001
 • Additional AAC devices and strategies should be made regarding FC, in accord with legal practices
considered and introduced in conjunction with FC. associated with the development of individualized
• Communication partners should continue to accept and educational or family plans;
respect messages delivered by a broad variety of AAC • an assurance that the individual and family/guardian
Strategies and techniques as well as natural speech. can choose not to use FC or can terminate the use of
• Programs focused on speech enhancement can he FC at any time;
carried out along with FC practices. • an explanation that there is a possibility that facilita-
Because most clinical methods are judged on their tors might consciously or unconsciously influence the
theoretical and practical ties to existing approaches rather construction of a communicator's messages and that
than to outcome information or comparison studies, any facilitators need to monitor the supports they provide
reactions to a new clinical approach will depend heavily on in conjunction with FC in order to identify and, if
how easily it fits with ones in current use. Indeed, ap- possible, eliminate excessive influence;
proaches that fail to fit into established practices are often • an assurance that the communicator or family/guardian
the ones that become controversial. Identifying ties to will have access to the communicator's case records;
existing practices also can be useful as a guide for making and
decisions about how to implement a new approach. For
• an assurance that the communicator's sensitive
example, relating FC practices to AAC approaches can offer
messages will be kept confidential unless the commu-
clinicians grounded strategies for how to implement FC.
nicator or legal guardian gives permission to be
quoted. Validated reports having legal or safety
Use Specially Designed Informed ramifications will need to be conveyed to the proper
authorities.
Consent Procedures
Forms for obtaining written consent for controversial
When introducing research or a new clinical practice to practices should be developed by the team of professionals,
clients and their families or guardians, speech-language researchers, and consumers who are associated with the
pathologists typically provide information about the delivery of the services. The written consent forms should be
approach, including its pros and cons. Researchers who adapted to ensure that the person with communication
study humans are now required to establish a process of difficulty understands the consent process. Such forms might
informed consent in accord with local human subjects include the use of symbol-enhanced materials, and they may
review boards. be cast as yes/no questions. (See Kagan & Kimelman,
Providing detailed information and obtaining written [1995], and Parr [20001 for examples of such materials).
consent becomes even more crucial for controversial
practices. Clients who are able to understand should be
made aware that they have a right to choose their own Develop Client-Specific Procedures
means of communication and to participate in an interven- for Using the Approach
tion program (National Joint Committee for the Communi-
cative Needs of Persons With Severe Disabilities. 1992). Decisions regarding whether or how to use controversial
Before signing a written consent form, communicators or methods should be considered carefully from various points
legal guardians should understand their communication of view and with the needs of particular clients in mind.
rights, as well as the nature, benefits, and potential risks of Such decisions should be made by a team of individuals,
the approach in question. including the potential communicator, care providers, and
other members of the individual's school or rehabilitation
For example, in their position paper on FC, ASHA
team, such as the occupational therapist and physician. The
(1995) recommended that consent be obtained in writing
team should be made up of individuals wbo know the
before FC is initiated. Prior to obtaining written consent,
communicator well and who are expected to be involved
clinicians should explain various aspects of FC to clients or
witb the communicator over a sustained period of time. The
legal guardians. The method might be described as another
team should consider the risks and benefits of the contro-
form of AAC that can enhance communication abilities.
versial practice, how it will be implemented if used, and
Information provided to clients and/or their legal guardians
when and how it will be evaluated. The evaluation should
might include;
be based on careful documentation of the effectiveness and
• the nature of FC and controversies surrounding it; efficacy of the approach, with special attention to informa-
tion provided when initiating an approach, when monitoring
• the benefits and risks of FC;
the approach's impact once it has been started, and in light
• that FC is a technique whose efficacy has not been of the client's long-term goals.
validated by experimental research;
Initiating a controversial approach. Prior to initiating a
• descriptions of a full range of AAC approaches that controversial practice, clinicians should be clear about why
are also available, with a summary of potential risks they feel an approach may be appropriate for a particular
and benefits of different approaches; client. Candidacy decisions might be based on tbe research
• an assurance that the individual and family/guardian literature if tbere is evidence that clients with certain
will be fully informed and included in any decisions characteristics benefit from the approach. For approaches in

Duchan et al.: Framework for Managing Controversial Practices 135

which candidacy requirements are difficult to ascertain, the individuals witb autism would be imperative in pursuing
clinical team might institute the approach for a trial period long-term goals. It may be the case that individuals will
in order to collect data on its effectiveness. The desired want to communicate with physical support in some
effects of the approach should be related to a client's situations but not in others. It may be that the progress
established clinical goals. toward independence may occur over a protracted time
In the case of FC. a speech-language pathologist should period, as long as several years.
be on every FC team. The speech-language pathologist
should have broad and extensive AAC training and experi-
ence that includes work in tbe area of FC. Prior to initiat- Receive Specialized Training to Implement
ing tbe approach. FC teams should consider (a) the levels the Approach
of physical support to be provided, (b) tbe types of
strategies to be used by facilitators to support communica- Some controversial approaches may require that the
tion, (c) tbe types of contextual support to be provided clinicians have specialized training. Clinicians administering
(emotional support, materials, activities), (d) the type and any approach should receive the necessary training initially
level of technology to be u.sed in conjunction with the and keep abreast of any new training offered. When
physical support, and (e) tbe individuals who could be appropriate, programs should institute peer training in
potential facilitators. which unskilled practitioners serve as apprentices to those
who have bad experience and success with the approach.
Ongoing monitoring. In the course of administering a The specialized training sought by tbe novice in tbe
controversial practice, clinicians should monitor what approach should emphasize the relationship between the
procedures were used and the client's progress. Monitoring uniqueness of the controversial practice, while at the same
of procedures should be geared to providing evidence about time grounding the approach in more establisbed methods.
bow the client's individual needs are being addressed and Experts in the use of the approach should outline the
whetber the program is being respectful of the client's clinical competencies that are unique to tbe approach as
communication rights. The procedures used by the facilita- well as other clinical competencies needed for the execu-
tors to ensure appropriate levels of support and to monitor tion of the approach.
tbe message construction process also should be described.
Monitoring of progress should detail how tbe client is For example, school-based speech-language pathologists
responding to the program, including descriptions of his or using FC should have specialized training in providing
her communication skills in different settings with different physical and emotional support and promoting the com-
people. The methods used should be substantive and municator's progress toward physical independence. FC
replicable and should serve as an ongoing monitoring training should be embedded in AAC practices, including a
system to ensure that the program is being administered working understanding of tbe various symbols, strategies,
well in the course of its delivery. and techniques used in AAC (ASHA, 1989). Prospective
facilitators should have a working knowledge of the
For instance, ongoing monitoring during FC can serve researcb literature, as well as professional and consumer
several important purposes. It can be used to (a) evaluate positions and guidelines regarding FC practices.
tbe facilitator's technique in providing physical, communi-
cative, and emotional support; (b) track changes in the
communicator's FC skills over time; (c) improve the Document and Evaluate Outcomes
reliability and quality of tbe facilitator's techniques; and (d) of the Approach
collect evidence on how the communicator is constructing
messages, thereby providing some evidence that messages Documentation is needed to provide information
are being generated by tbe communicator and not the conceming an individual's communication progress and to
facilitator (McSheehan & Sonnenmeier, 1995). research the overall effectiveness of a clinical approach.
Long-term goals. A long-term vision is essential when Procedures used to document tbe individual's progress and
planning for individuals with communication disorders. The overall effectiveness of a controversial approach will vary
team, including clients and their family members, should be depending on the approach and what is being examined.
able to see bow the controversial practice fits with the The context in which the documentation is carried out
long-term communicative goals of the client. should be given careful consideration with an effort to
One long-term goal for the FC communicator, for document performance in naturally occurring and bigbly
example, may be to have the communicator convey motivating situations. For example, the effectiveness and
information independently, without physical support. efficiency of FC should be tracked in contexts in wbich the
Strategies that facilitators use to foster physical indepen- communicator is taking an active role. (See Weiss. Wagner,
dence should be evaluated regularly by tbe facilitator or & Bauman [1996] for details on such an approach.) Some
team members and should be in keeping with tbe client's examples of documentation for monitoring individual
goals. Input from the occupational and physical therapist progress and designing qualitative and experimental studies
regarding hand functioning and motor patterns should be are outlined in the following paragraphs.
solicited, especially in view of recent discoveries of motor Documenting individual progress. The team should
problems in individuals witb severe communication institute a variety of systematic procedures to examine a
disorders (Ghaziuddin & Butler. 1998; Leary & Hill, 1996). method's effectiveness for an individual. Data should be
Detailed evaluatioti of motor disabilities in nonspeaking collected regularly and, when possible, in natural situations

136 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 32 • 133-141 • July 2001
in which communicators take an active role. Documentation evidence tbat communicators are able to commutiicate using
carried out In naturally occurring contexts offers a way to tbe method.
evaluate a program's success and avoids having to subject Research documentation. Research documentation of the
clients to an excessive amount of formal testing. efficacy of intervention approaches has involved botb
Judgments conceming a method's effectiveness for an qualitative and experimental studies. One primary goal of
individual should not be based on a single assessment much of tbe researcb in FC bas been to document whether
session but instead on longitudinal and cross-situational tbe facilitator is influencing the responses of the communi-
comparisons of performance levels. Evaluators of progress cator. Qualitative and experimental research have differed on
should be aware tbat performance can fluctuate from day to what is taken as evidence of facilitator influence. Qualitative
day and even moment to moment. This fluctuation can lead researchers have based their judgments regarding tbe
to misjudgments concerning an individual's progress, wbich existence of facilitator influence on wbetber communicators
can result in misguided continuation or termination of a can create facilitated messages tbat contain information ibat
treatment approach. Thus, it becomes crucial to evaluate an is unknown to tbe facilitator, whether tbe messages they
approach over time and under different conditions. create have idiosyncratic content or style, and to what degree
communicators progress toward physical independence. Their
Experimental methods of documentation can approximate
approach has been to collect their data in naturally occurring
naturalistic conditions by using familiar settings, examiners,
contexts with familiar partners.
and elicitation tasks. For example, an elicitation task for
evaluating the effect of FC can be carried out using a Experimental researchers, on the other hand, have
classroom quiz on scbool subject matter. Validation across designed studies in which the facilitator and communica-
facilitators can be done by having tbe classroom quiz given tor bave been asked to create messages under controlled
by two familiar but different facilitators on different conditions (Calculator, 1999; Cardinal. Hanson. &
occasions, or by using a facilitator who does not know tbe Wakeham, 1996; Wbeeler, Jacobson, Paglieri, &
answers to the questions. (See Calculator [1999] for a Schwartz, 1993). Researchers have examined message
summary of modifications available to investigators of FC content and accuracy, as well as facilitator influence,
to approximate naturalistic conditions.) under varying treatment conditions. For example,
Re.sults from controlled procedures can be compared communicators have been asked to name pictures they
with those obtained using less controlled conditions. For see in conditions of sbared knowledge (the facilitator
example, witb FC. one migbt compare two conditions—one sees the same picture as the communicator), unshared
when both the communicator and facilitator have access to knowledge (the facilitator does not see the pictures
key information, and a second when the facilitator either shown to the communicator), and conflicting knowledge
lacks the necessary information to predict tbe message or is (the facilitator sees pictures tbat are different from tbe
provided with information tbat is contradictory to what the ones tbat the communicator sees). Researcbers using tbe
communicator knows. experimental paradigm have based their judgments of
Changes in how the communicator perfomfis a specific success on whether a communicator produces accurate
skill over time under different conditions is a standard way messages across these treatment conditions,
of assessing the success of clinical practices. In relation to The results from qualitative and experimental research
FC. one can document, over time, the communicator's approaches to FC differ considerably. Researchers usitig
needs for physical, emotional, and communication support. qualitative methods fmd communicators to vary in the
Documenting such changes offers one way of examining degree to which they are able to communicate unknown
how a communicator's messages are affected by different information and in tbeir ability to progress toward pbysical
applications of FC. Such infomiation concerning a com- independence. Researchers using experimental methods
municator's success with different facilitators and different have found, witb few exceptions, that communicators are
amounts of physical and emotional support is a useful way unable to produce correct answers in tbe unshared knowl-
to monitor the effects of, or need for. physical support and edge conditions. (See Cardinal et al. [1996] and Weiss et
a person's communicative independence. al. [1996] for notable exceptions and Cardinal & Biklen
Documentation data should be reviewed systematically by [1997] for a consideration of factors affecting performance
the team, communicator, and family to determine ihe overall under controlled conditions.) Experimental researchers also
efficacy of an approach for the individual communicator. bave found tbat, in the conflicting knowledge condition, tbe
Review of the functional outcomes, including communicative named item was often what the facilitator bad seen and not
effectiveness and efficiency, consumer satisfaction, and social what the communicator had seen, indicating the strong
outcomes, should be completed and reported. potential for facilitator influence (Green, 1994; Marcus &
Shevin, 1997).
If the documentation process fails to reveal success with
a controversial approach, the approach should be altered, Researchers and clinicians studying controversial ap-
minimized, or terminated. For FC, alteration should occur proaches need to examine the dramatic differences in results
wben there is documented evidence that facilitators are from different research approaches carefully and explore
inadvertently influencing the content of messages produced possible reasons for such discrepancies. (See Cardinal &
or if the individual can communicate effectively without Biklen [19971 for an example of this type of exploration.)
FC. FC should be minimized and other AAC approaches School clinicians sbould be acquainted with results of
used when actionable messages are communicated only different types of research and be able to justify their
tbrough FC. FC also sbould be terminated when tbere is no clinical decisions to use a particular evaluation metbod.

Duchan et al.: Framework for Managing Controversial Practices 137

Prepare for Eventual Challenges A second significant concern related to FC is tbe client's
Disagreemenis among professionals and between rigbt to privacy. Personal messages created using FC bave
professionals and their clients are everyday occurrences in been bigbly susceptible to public scrutiny, Clinicians must
clinical practice. However, problems arising from these respect a client's right to privacy, whenever possible. In
commonly experienced differences are exacerbated for those cases where facilitators would like to tell others
controversial practices because tension from tbe controversy about particular communications, they should ask permis-
can undermine tbe trust and respect tbat is needed to sion of the communicator, parent, or legal guardian.
resolve legitimate differences. Information about a communicator's clinical progress
In order to handle potentially difficult situations arising should be treated as confidential. Information shared among
from controversial practices effectively, clinicians need to members of the individual's educational or bealtb care team
prepare tbemselves beforehand. They should find out about should be relevant to their service provision concerns and
due process mechanisms for tbeir clients and the reporting considered confidential In the same way that clinical
procedures used in their employment context for resolving records are treated for all clinical information.
conflict and handling sensitive information. Included in tbe
mechanisms should be ways that clients and families can
express their frustrations about controversial practices and
have a role in clinical decision-making. Finally, mecha- CONCLUSION
nisms should be put in place to allow team members,
The framework can provide a structure for school
family members, and clients to work together to design
clinicians, their teams, and other agencies as they develop
ways to support communication needs during major life
guidelines for carrying out controversial practices. In this
transitions, such as moving from home to school settings,
article, the framework served as a structure for developing
changing schools, entering community programs, moving
protective guidelines for the use of FC. (See Table I in tbe
from school to work settings, and retiring from work.
Appendix for a summary of the FC guidelines derived from
When developing practice guidelines for particular the framework.)
controversial practices, clinicians should find out what sorts Many of the details of the FC guidelines would be
of issues might occur that are peculiar for that practice and appropriate as standard practices, not just those related to
build in protections and courses of action in the guidelines. FC. For example, issues of excessive clinician influence,
For example, for FC, issues bave arisen when sensitive the rights of clients or guardians to choose or terminate an
messages bave been transmitted through FC (Botash et al.. educational or clinical approach, and the advantages of
1994; Hostler, Allaire, & Christoph, 1993; Jones, 1994; using multiple communication modalities, also are consis-
Richer. 1994). Such statements, called actionable state- tent with goals of mainstream practices in AAC.
ments, may have to do with an individual's medical needs, As with all clinical practices, the framework and the
living situation, or social relationships. guidelines developed from it should be continually re-
Actionable statements that have legal and safety viewed in light of newly emerging theories, clinical
implications, such as reports of physical or sexual abuse or practices, and research results. School-based speech-
neglect, if corroborated, must be conveyed to the proper language pathologists and their team members should keep
authorities. These statements are particularly problematic abreast of new developments in order to provide their
when conveyed through FC because of tbe possibility that clients with state-of-the-art services. In so doing, speech-
the facilitator may be knowingly or inadvertently influenc- language pathologists are more likely to make well-
ing the content of the message. Actionable statements made informed decisions about electing or implementing new or
by facilitated communicators bave been substantiated in controversial clinical practices.
some instances and not in others {Botash et al., 1994)
Because of the potential of facilitator influence, action-
able statements produced through FC should be corrobo-
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Shane (Ed.). Facilitated communication: The clinical and social
GhaziuddJn, M., & Butler, E. (1998). Clumsiness in autism and phenomenon (pp. 259-298). San Diego. CA: Singular.
Asperger Syndrome: A further report. Journal of Intellectual
Sheehan, C , & Matuozzi, R. (1996). Investigation of the validity
Disability Research, 42, 43-48.
of facilitated communication through the disclosure of unknown
Glennen, S. L., & Decoste, D. C. (1997). Handbook of augmenta- information. Mental Retardation. 34, 94-107.
tive and alternative communication. San Diego. CA: Singular.
Weiss, M., Wagner, S., & Bauman, M. (1996). A validated case
Green, G. (1994). The quality of the evidence. In H. Shane (Ed.), study of facilitated communication. Mental Retardation, 34,
Facilitated communication: The clinical and social phenomenon 220-230.
(pp. 157-225). San Diego. CA: Singular.
Wheeler. D., Jacohson, J., Paglieri, R., & Schwartz, A. (1993).
Higginbotham, D., Sonnenmeier, R., & Ducban, J. (1993). The An experimental assessment of facilitated communication.
impact of technology on facilitated communication. Technology Mental Retardation, 31(1), 49-60.
and Disability, 2, 68-78.
Hostler, S., Allaire, J., & Christoph, R. (1993). Childhood sexual Received September 21. 2000
abuse reported by facilitated communication. Pediatrics, 91, Accepted January 6, 200!
1190-1191. DOI:10.1044/0161-146] (2001/011)
Jones, D. (1994). Autism, facilitated communication, and allega-
tions of child abuse and neglect. Child Abuse and Neglect, 18. Contact author: Judith Felson Duchan, 130 Jewetl Parkway,
491^93. Buffalo, NY 14214. Email: [email protected]

Duchan et al.: Framework for Managing Controversial Practices 139

APPENDIX. FACILITATED COMMUNICATION: THE METHOD AND ASSOCIATED GUIDELINES

Facilitated communication (FC) is a technique in which benefit from FC as well as other areas of augmentative and
physical, communication, and emotional supports are alternative communication (AAC) have been difficult to
provided by a facilitator to an individual with a communi- establish because of questions related to the viability of
cation disability (communicator). With this assistance, the standardized assessment procedures and because of prob-
communicator points to symbols, such as letters, pictures, lems in assessing linguistic and cognitive competencies of
and/or objects (ASHA, 1994. p. 2; Bikien, 1990). individuals with severe communication disabilities. (See the
Physical support in the form of resistance or light touch following references for a discussion of AAC candidacy
is provided at the communicator's shoulder, arm, wrist, or Issues: Beukelman & Mirenda [1998]; Calculator &
hand and is faded over time as the person improves in the Jorgensen [1994]; Calculator & Singer [1992]; Glennen &
ability to point independently. Communication support is Decoste [1997]; Higginbotham, Sonnenmeier. & Duchan
provided to clarify and confirm message content. For [1993]; Lloyd, Fuller, & Arvidson [1997]; Mirenda [1993];
instance, facilitators might offer verbal feedback and Schubert, [1992].)
support when communicators experience difficulty with FC has given rise to controversy because it is often
message formulation (e.g., "Keep on going" "I don't know difficult to ascertain who has produced the message—the
what you mean." "Can you tell me again?"). Emotional facilitator or the communicator. This issue has given rise to
support is provided to encourage self-confidence and self- a set of carefully constructed documentation procedures for
expression. Facilitators, for instance, are expected to identifying and controlling excessive facilitator influence
maintain a positive, supportive attitude and remain calm (Cardinal. Hanson, & Wakeham, 1996; Marcus & Shevin,
and respectful throughout the process of message formula- 1997; Shane, 1994; Sheehan & Matuozzi, 1996; Wheeler,
tion. (See Bikien (1990] and Crossley [1994] for details on Jacobson, Paglieri, & Schwartz, 1993).
the initial version of the approach and Duchan [1999] for a The seven-step framework offers school clinicians an
review of more recent practices.) organizational structure for designing clinical practice
FC has been used with individuals who are unable to guidelines. The guidelines in Table 1 offer an illustrative
communicate through the use of other alternative communi- example of how school practitioners might proceed as they
cation systems. Criteria for identifying those who might and their teams make decisions about FC, specifically.

140 LANGUAGE. SPEECH, AND HEARING SERVICES tN SCHOOLS • Vol. 32 • 133-141 • July 2001
Table 1. Guidelines for facilitated communication based on the framework for managing controversial practices,

Framework Guidelines for facilimted communication

1. Identify the sources of the controversy. Controversy has resulted because of the:
• potential for facilitator influence.
• de-emphasis of other AAC approaches.
• potential for the expression of actionable statements.

2. Understand how the approach fits with more r FC fits with AAC methods leading to the following practices:
established practices. • Speech-language pathologists using FC need training in AAC.
• Current AAC methods should be continued.
• Additional AAC devices and strategies should be introduced in
conjunction with FC.
• Communication partners should respect all messages whether
through FC, other AAC approaches, or speech.
• Speech enhancement approaches should be used alongside FC.

3. Use specially designed informed consent procedures. Information should be provided to the client and family/guardian
about:
• the nature of FC and controversies surrounding it.
• potential benefits and risks of FC.
• lack of experimental validation of FC.
• potential benefits and risks of other AAC approaches.
• assurance of their continuing involvement in making decisions
about FC.
• their right to choose or discontinue FC.
• potential for facilitator influence.
• their right of access to their case records.
• assurance of confidentiality re messages communicated using FC.

4. Develop client-specific procedures for using the approach. Practices associated with FC should include:
• a team approach.
• client-centered assessment, monitoring, and evaluation
approaches.
• progression toward physical independence.

5. Receive specialized training to implement the approach. Facilitators should have:

• skill in the provision of physical and emotional support.
• skill in the use of AAC.
• knowledge of research and clinical literature pertaining to FC.

6. Document and evaluate outcomes of the approach. Evaluation of FC should include:

• comparisons of client performance in different contexts, with
different facilitators, using different types of data analyses.
• documentation of client changes over time.
• use of data to inform decisions about whether to continue or
discontinue FC.

7. Prepare for eventual challenges. FC teams should;

• design corroboration procedures for responding to actionable
statements by FC users.
• create procedures for assuring clients their right to privacy.

Note. FC = facilitated communication. AAC = augmentative and alternative communication.

Duchan et al.: Framework for Managing Controversial Practices 141