Facilitated Communication Training: Chapter One - Assessment

Facilitated Communication Training, by Rosemary Crossley

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1.  ASSESSMENT FOR FACILITATED COMMUNICATION TRAINING

Facilitated communication training is a strategy for teaching people with severe communication impairments to use communication aids with their hands.  facilitated communication training is just one of many strategies for helping people with severe communication impairments, and this chapter aims to place it in the context of the overall field of augmentative and alternative communication and to outline the path that might lead to someone becoming involved in a facilitated communication training program.

Severe communication impairment
Individuals are described as having severe communication impairments when their speech and handwriting are insufficient to meet their communication needs.  The term is usually used in relation to people with no speech or very little intelligible speech, but it may also be applied appropriately to people whose speech, while clear and fluent, is still not meaningful or representative of their real thoughts.

Most people whose speech is severely impaired also have difficulty with handwriting.

Augmentative and alternative communication

Augmentative and alternative communication is the formal title for non-speech communication.  Augmentative communication includes any communication strategy needed to make an individual's speech more functional; Jan's family understand her speech, but when she's away from home she augments her speech by using a communication book containing proper names.  Alternative communication includes any communication strategy used when a person has no comprehensible speech at all.  In fact, the strategies used to augment speech are the same as those used instead of speech.  The difference between augmentative and alternative communication is merely the difference between partial and total dependency on non-speech communication.  For simplicity, the term augmentative communication is used throughout this book.

Who needs to use augmentative communication?

Anyone whose speech is not clear enough, fluent enough, or reliable enough to allow them to get across everything they need to say.

What communication strategies can be used instead of speech?

Speech may be replaced or augmented by :
    1. Gesture and body language.
    2. Manual sign
    3. Handwriting
    4. Communication aids

Gesture and body language are used to some extent by almost all people.  While some formalised gestures,such as nodding the head for 'yes' and shaking for 'no' are powerful, there are intrinsic limits on the sophistication of communication obtainable by gesture and body language alone.  In particular, while a person can respond to questions or circumstances through gesture and body language, initiating and carrying on a conversation is virtually impossible.
Manual sign is as powerful as speech for face-to-face communication, providing all parties to the interaction share extensive sign vocabularies - can use and understand thousands of signs, that is, in the same way as adult speakers use and understand thousands of words.  Few people who are not deaf have been exposed to sufficient manual sign to acquire large vocabularies.  Consequently manual signing only attains its full power when used in the deaf community.
Handwriting is as powerful as the literacy skills of writer and reader.  It loses the inflexion given by speech, sign and gesture, but it is probably the most common way of compensating for the kinds of speech incapacity caused by acute illness in older children or adults. 
Communication aids are devices developed or adapted for use by people with severe communication impairments.  Because they have very varied skills,needs and problems there is a large range of communication aids.  Some people with severe communication impairments can use their hands; others cannot, and have to use alternatives such as mouth sticks, headsticks, switches or eye-pointing.  Some can read and spell; others cannot, and need communication aids on which language elements are represented by pictures or symbols.  Some individuals use wheelchairs which can accommodate large communication devices; others walk and need small, light aids.  Some have the funds to purchase high tech equipment; others do not.  A communication aid may be as simple as a piece of cardboard with  NO and YES written on it or as complex as a laptop computer controlled with one switch which allows the user to speak on the phone or type an essay.
What is the best non-speech communication strategy?
The best non-speech communication strategy (or combination of strategies) is the one which allows the person with severe communication impairments to communicate as freely as possible in as many situations as possible to the maximum number of people. 
In deciding what strategies are feasible the first thing to consider is what physical abilities the person has.  Hand skills are the obvious place to start. 
Body language, gesture, and sign language have the advantage that no equipment is needed - they are called unaided strategies.  Handwriting needs minimal equipment.  If communication is to be fluent and comprehensible, however, these strategies do need good hand skills .  Manual sign and handwriting place considerable demands on motor planning and memory as well as on fine finger and hand movements.  Unfortunately, many individuals with severe communication impairments have problems in using their hands effectively, and for these people manual signing and handwriting are not realistic options.
A range of communication aid options is available for people with severe communication impairments who do not use their hands at all.  Ironically, those individuals with severe communication impairments who use wheelchairs have more communication aid access options than those who walk.  Large communication aids and displays which can be mounted on wheelchair trays, access strategies using headpointers, eye-pointing boards, or switch-controlled scanners - all these are feasible for wheelchair users, but impractical for individuals who walk. 
People with severe communication impairments who walk but cannot sign or write need small, easily portable communication aids and need to be able to use them with their hands.  The aid displays a set of choices, and the user makes selections from these choices, reducing the demands on fine motor skills, motor planning and memory.
The range of items to choose from may include pictures, special symbols such as Blissymbols, written words or phrases, or the letters of the alphabet.  The communication aid itself may be an electronic device, with spoken or written output, or it may be a piece of cardboard or a folder which the partner reads the message from as the user constructs it.  Whatever the nature of the communication aid or the display used, people who are walking are going to have to use their hands to select the items they want.
At initial assessment, unfortunately, many of these people do not have the pointing and selection skills necessary to use communication aids effectively.  As they have no other practical communication options - they cannot sign or write, they cannot carry eyepointing displays, or enlarged keyboards or scanning setups, and they cannot wear headpointers - the only remaining option is to try and teach them the hand skills necessary to use portable communication aids.  One teaching strategy that may be used with these individuals is facilitated communication training.
Facilitated communication training
In facilitated communication training a communication partner (facilitator) helps the communication aid user overcome neuro-motor problems and develop functional movement patterns.  The immediate aim in facilitated communication training is to allow the aid user to make choices and to communicate in a way that has been impossible previously.  Practice using a communication aid such as a picture board, speech synthesizer, or keyboard in a functional manner is encouraged, to increase the user's physical skills and self-confidence and reduce dependency.  As the student's skills and confidence increase the amount of facilitation is reduced.  The ultimate goal is for students to be able to use the communication aid(s) of their choice independently. 

Communication aid use involving facilitation

For facilitated communication training to be considered as an option for an individual they will:

  • have severe communication impairments
  • not currently have a fluent alternative communication strategy
  • not show the potential to acquire manual signing or handwriting skills easily1

or

  • be living in an environment where manual sign or writing are not going to be viable communication options
  • have difficulty with the clear, unambiguous selection of nominated items from functional communication displays
  • not be able to use other direct or indirect access options (usually for practical reasons, such as the unsuitability of these options for individuals who walk and have to carry their communication system with them).

Once it has been decided that an individual is a candidate for facilitated communication training it is then necessary to:

  • ascertain the nature of the problem(s) which currently preclude successful communication aid access
  • select appropriate remedial strategies, including facilitation strategies if needed
  • ascertain what representational systems (concrete objects, pictures, pictographs, written words, letters) are currently meaningful to the potential user
  • enable the individual with severe communication impairments to use the most empowering of the representational systems and selection strategies currently available to him/her by obtaining/making appropriate communication aids and teaching those in the individual's environment how the aids are used.

The individual with severe communication impairments can now practice using a communication aid with facilitation.  This is just the start of the training program.  Further teaching and assessment in areas such as literacy, hand function, and pragmatic interactive skills, will be required. 

If the person with severe communication impairments showed the ability to spell at the initial assessment further assessment and refinement of literacy skills is desirable.  If the person did not show usable spelling skills then involvement in a literacy program is desirable.  Spelling is the most empowering communication strategy for people with severe communication impairments who cannot sign fluently, and every effort should be made to develop literacy skills regardless of the presenting diagnosis of the individual with severe communication impairments.  Infants and individuals for whom literacy acquisition is problematical will need to be taught to use as large a vocabulary of pictures and symbols as possible. 

Given that the individual is using facilitation because of problems with hand use, regular hand function assessments, which may result in the prescription of exercise routines or splints, are important.

Whatever the representational strategy used, all aid users will need to be taught acceptable attention-getting strategies and other pragmatic skills, such as how to position themselves in relation to people they are talking to, so that they can best receive the message.

Multiple facilitators will have to be trained, as it is important that the user is able to communicate with as many people as possible to avoid dependency on any one facilitator.  The amount of facilitation provided requires regular review with the aim of reducing it as quickly as possible.  Additional exercises may be necessary to improve hand and arm function. 

Up to this point I have made no mention of specific labels or of psychological or intellectual assessment.  This is because the capacities of people with severe communication impairments cannot be judged until their communication impairments have been addressed.  No-one should be excluded from communication training because of previous negative intellectual assessments, and no ceiling should be placed on the options offered to individuals because of the labels they wear.  Intellectual assessment of people with severe expressive problems is difficult and unreliable.  Communication training is a pre-requisite for accurate assessment.

On to Chapter Two

Anne McDonald Centre. 538 Dandenong Road, Caulfield 3162 Victoria, Australia Ph: 03 9509 6324, Fax: 03 9509 6321
 
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