Facilitated Communication in Children with Autism

Facilitated Communication in Children with Autis

M M

BRIDGETTE KOVLER `23

Language is vital to the educational learning process and in forming meaningful connections through the conveyance of emotions, thoughts, and opinions. However, many non-verbal children with autism struggle to communicate with their loved ones and caregivers due to barriers in language expression. Parents are not able to celebrate the joyous feeling of bonding with their child through conventional means, and thus, turn to various methods to meet the needs of their child. In the 1990s, these methods included facilitated communication, the rapid prompting method, and a picture exchange communication system. Although these techniques were seen as effective in their time, later research suggested that they were merely pseudoscientific and flawed with regards to false authorship of messages and inconsistency in message conveyance. These older methods focused on children’s present communication needs and heavily relied on the aid of a facilitator, but communication interventions and therapies must be developed that take a more holistic approach in considering a child’s early language development, adaptability of use, and autonomy in order to be more effective. Evidence of efficacy in incorporating a more holistic approach is seen in methods such as the brief observation of social communication change, generalized pediatric communication therapy, and discrete trial training.

Flaws of Facilitated Communication and Rapid Prompting Method

Facilitated communication and rapid prompting method were utilized by parents of non-verbal autistic children in the effort to address their children’s needs, thoughts, and emotions. Facilitated communication involves storyboards, which do not require typical modes of communication, such as verbal language, facial expressions, and body language. However, this technique also poses potential flaws, such as false ownership and accusatory messages; it is difficult to identify if the facilitator is speaking for the child, as a facilitator supplements physical function by holding a child’s hand while the child presses keys on a keyboard to type messages or points to images or letters on storyboards. On various occasions, facilitators accused parents and caregivers of child abuse through the use of facilitated communication because they had the authoritative advantage to do so. Rapid prompting method, on the other hand, requires the child to point to letters in order to spell words. In this case, the facilitator holds the letter board instead of the child’s hand. Tactile prompts are more prominent in the rapid prompting method, such as ripping papers or giving the child a writing utensil to point with (1). The rapid prompting

“...facilitated method relies heavily on prompt dependency, which weakens the validity of the communication... therapy technique by suggesting that the information being conveyed is not specifiposes potential cally aligned with the exact thoughts of the individual with disabilities. Both methflaws, such as false ods are flawed with regards to enhancing communication among non-verbal autistic ownership and children and therefore, new methods that take on a new, more integrative approach accusatory messages; are required. it is difficult to Brief Observation of Social Communication Change identify if the Core autistic symptoms progressive ly change over time, as indicated by alter facilitator is speaking ation in verbal language communication. A study conducted by Janina Kitzerow, a for the child...” researcher in the Department of Child and Adolescent Psychiatry at the Frankfurt University Hospital, and her associates utilized a communication strategy called brief observation of social communication change (BOSCC) to assess early intervention techniques. This study selected 21 individuals with autism who were 46 to 69 months old and received one year of the Frankfurt early intervention program prior to the commencement of trials. This intervention program involved training parents and kindergarten teachers to enhance communication with young children. BOSCC consists of 16 behavioral items, which include social communication abilities and restrictive or repetitive behaviors. Clinicians scored the behavior items on a 0-5 scale. Video recordings of the children in social situations were taken before and after the one year of treatment. Two clinicians rated the children’s demonstrations of the be-

Figure 1 In facilitated communication, a facilitator holds the child’s hand to physically assist them in pressing keys on a keyboard to type messages, or pointing to images or letters on storyboards.

havioral items in the videos on a 0-5 scale. A 0 on the scale implied no abnormality and a 5 indicated significant abnormalities that could impair functioning. Thus, the researchers hoped for scores to decrease following intervention. The results demonstrated that the intervention decreased BOSCC scores overall and for most individual behavioral items, supporting the notion that early interventions, particularly those involving training of parents and teachers, are effective in countering communication-related autism symptoms in children within the age range of 46 to 69 months (2).

Generalized Pediatric Communication Therapy

In 2016, Andrew Pickles, a professor at the Institute of Psychiatry at Kings College, and his associates investigated whether a type of parent-mediated social communication therapy called Preschool Autism Communication Trial (PACT) had long-term impacts on communicated-related symptoms in autistic children. The PACT program involved twelve 2-hour therapy sessions over a span of 6 months, followed by 6 months of monthly support sessions. During this time, parents also did 20-30 minutes of daily exercises with the children. Symptoms were assessed based on questionnaires and scoring systems immediately after the treatment and then 5-6 years after treatment at approximately the age of 10. The PACT group was compared to a control group, which received a non-PACT traditional treatment (3). Questionnaires and surveys such as the social communication questionnaire, brief observation of social communication change, and vineland adaptive behavior scales were used. However, the primary outcomes and scoring systems used were autism symptom severity, which was assessed using the autism diagnostic observation schedule (ADOS) comparative severity score and the parent-child dyadic communication measure for autism. The effect size (ES) of PACT immediately following the intervention was found to be 0.64 and during follow-up was found to be 0.70, evidenced by an overall reduction of autism symptom severity (3). These results demonstrate that generalized pediatric communication therapy such as PACT, which involves practicing communication strategies both during therapy sessions and at home, is highly effective in helping autistic children apply learned communication skills across varying contexts; they are able to practice PACT communication skills at home, school, and in public areas, while facilitated and rapid prompting method were limited in their reach as they were restricted by the presence of the facilitator. This treatment’s continuing efficacy at later follow-ups also demonstrates its potency as a non-verbal autism intervention. Not only is this therapy effective in providing flexibility in skill applicability, but it provides skillful practice and integrative educational engagement with parents, caregivers, and teachers as well.

Discrete Trial Training

To enhance communication among non-verbal individuals, caregivers must focus on breaking down skills into small tasks that are more manageable. In 2018, Dr. Mohammed Akram Hamdan, faculty member at the Department of Special Education at the University of Tabuk, conducted a study containing 20 items measuring attention, imitation, understanding facial expressions, and maintaining eye contact in non-verbal children with autism. The study consisted of 26 children between the ages of 6 and 11 years, who were randomly placed in experimental and control groups. The experimental group was subject to discrete trial training intervention, while the control group was not. Both groups took a pre-test at the beginning of the study and a post-test after the intervention so that their scores could be used as a measure of effective learning. Discrete trial training relies on learning theory, which considers the methods by which students effectively comprehend and retain information while learning, and applies these methods to maximize childhood knowledge growth opportunities in the future (4). The quantitative results of the study demonstrated a mean of 2.6 on the pre-test and 3.34 on the post-test for the experimental group, showing significant improvement and retention of learned information and thereby indicating effective learning as a result of discrete trial training. The control group, however, had a pre-test mean of 2.34 and a post-test mean of 2.44, which was a less profound difference (4). This suggests that discrete trial training’s approach of repetition and positive reinforcement in breaking down topics into smaller concepts independently is an effective learning strategy. Specifically, non-verbal children were found to participate in imitation and symbolic play more as a result of the training, enhancing communication skills. This approach allows children to generalize the skills they have attained and apply them in a variety of settings, similar to the aims of generalized pediatric communication therapy. Other advantages of this technique include shorter lessons and increased involvement of teachers along with caregivers in knowledge acquisition, such that the need for facilitators is less. In this way, discrete trial training represents an effective communication method for non-verbal autistic children that grants them autonomy and independence, as the aid of facilitators and trained professionals is not necessary.

Conclusion and Future Directions

Past communication methods including facilitated communication and the rapid prompting method were flawed in their approaches to obtaining true authorship of messages by non-verbal autistic children. However, new methods have been more effective in eliciting language using a more integrative approach. The brief observation of social communication change (BOSCC) method considers the critical period of language development in children by delivering early intervention, allowing non-verbal autistic children to acquire enduring language skills. The skills acquired from generalized pediatric communication therapy can be applied to diverse settings, thus enhancing external validity by removing environmental constraints on communication. Lastly, discrete trial training lessened the need for a facilitator, thus granting a child more autonomy in conveying their thoughts and emotions. This also eliminates the concerns of false authorship and illegitimate message conveyal that accompany facilitated communication. All of these interventions look beyond the immediate environment and needs of the child (as facilitated communication and rapid prompting method did) and focus on building skills for life that can be implemented independently in a wide variety of settings. The success of these techniques suggests that a more holistic and integrative approach is needed in order to design the most effective interventions for non-verbal autistic children; additionally, the more integrative elements an intervention involves, the more effective it will be at reducing communication-linked autism symptoms. As these methods represent a step towards crafting a holistic approach to communication in non-verbal autistic children, they should therefore be used as a guideline for future research. Future development of interventions should consider present-day circumstances such as the COVID-19 pandemic and communication tactics, such as adapting to telehealth models to continue to deliver necessary therapies in a convenient, online setting, which may further increase the flexibility of such techniques as the child would be able to access the therapy session from any setting that they are in. Additionally, augmentative and alternative communication methods could be utilized, which involve the use of electronic tablets that let the child independently communicate in any setting without the need for a facilitator. Telehealth, augmentative, and alternative methods all seek to increase accessibility and adaptability of communication interventions, which are holistic in the sense that they consider changing times, circumstances, and allow for a wider reach. Other contextual factors such as engagement of family members and educators should be considered as well so that the child’s communication skills can be reinforced in these various settings, as in generalized pediatric communication therapy and discrete trial training. By building on BOSCC, generalized pediatric communication therapy, and discrete trial training with factors like telehealth options that would increase reach and accessibility, a more holistic approach to communication interventions is bound to arise, which goes above and beyond the narrow-focused methods of facilitated communication and rapid prompting method. While all of these methods, new and old, had the general well-meaning intentions of giving autistic children a voice, the efficacy of the interventions ultimately determines to what extent these children’s voices are heard. These methods will give autistic children the ability to effectively communicate with teachers, friends, caregivers, parents, and loved ones, forming valuable bonds and connections. Their opinions and feelings can be validated and acknowledged, granting these children their rightful place in society.

References

1.Rapid prompting method (RPM). American Speech-Language-Hearing Association, (1970). 2. J. Kitzerow, et al., Using the brief observation of social communication change (BOSCC) to measure autism-specific development. Autism Research 9, 940-950 (2016). doi: 10.1002/aur.1588. 3. A. Pickles, et al., Parent-mediated social communication therapy for young children with autism (PACT): long-term follow-up of a randomised controlled trial. The Lancet 388, 2501-2509 (2016). doi: 0.1016/S2215-0366(14)00091-1. 4. M. Hamdan, Developing a proposed training program based on discrete trial training (DTT) to improve the non-verbal communication skills in children with autism spectrum disorder (ASD). International Journal of Special Education 33, 1-13 (2018). 5. L. Zwaigenbaum, et al., Rethinking autism spectrum disorder assessment for children during COVID-19 and beyond. Autism Research 1, 1-9 (2021). doi: 10.1002/aur.2615. 6.I. Navarro, et al., Using AAC to unlock communicative potential in late-talking toddlers. Journal of Communication Disorders 87, 106025-106025 (2020). doi: 10.1016/j.jcomdis.2020.106025. 7. F. Craig, et al., Social communication in children with autism spectrum disorder (asd): correlation between dsm-5 and autism classification system of functioning—social communication (acsf:sc). Autism research 10, 1249-1258 (2017). doi: /10.1002/aur.1772.