Functional Communication Training in Children With Autism Spectrum Disorder

Abstract

VIGNETTE, PART 1: Alex is an endearing 3-year-old child with autism spectrum disorder (ASD) who attends Smith Preschool. While in circle time, he does not follow the teacher’s direction to sit on his mat. Lately, about 5 min after circle time begins, Alex tells his aide that he does not feel well and needs to go to the nurse. After the second time this happened, Alex’s teachers begin to realize that he probably is not really sick.

ASD is diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) as a disorder in social communication and restrictive repetitive interests. At present, the prevalence of ASD is 1 in 68 individuals, with an incidence in the United States of 1 in 54 boys and 1 in 252 girls (Centers for Disease Control and Prevention, 2014). Communication disorders in individuals with ASD may range from completely non-verbal to fully verbal. However, the content of communication is markedly impaired, with difficulties approaching others for social purposes, and maintaining and terminating conversations appropriately, and with challenges in higher level vocabulary and language. Behavioral symptoms vary greatly as well. Individuals on the spectrum may demonstrate noncompliance with change in routine, aggression, self-injurious behavior, and/or obsessive perseverations (e.g., unusual preoccupation with underpinnings of 1920’s Ford Model-T cars).

The purpose of this article is to explicitly address the correlation between communication and behavior, and to describe how to provide intervention addressing these two overlapping domains, using an intervention called functional communication training (FCT; E. G. Carr & Durand, 1985) in individuals with ASD. A step-by-step process will be outlined, with supporting literature and practical examples. Finally, interdisciplinary and cultural (i.e., familial and linguistic) considerations will be brought to light.

Recommended practices (RPs) have been developed as a guide to practitioners and family members who have, and/or are working with, young children who are at risk of developmental delays and/or disabilities (Division for Early Childhood, 2014). The intention of these RPs is to merge evidence from the field with clinical practice, while holding family involvement pinnacle in the process. These practices further support the child’s access to the natural environment (Childress, 2004), while addressing issues of diversity (e.g., cultural, linguistic).

Implementation of FCT is aligned with these RP guidelines; it includes input from all team members, including the parent, to assess the child and develop a manageable treatment plan that all practitioners can successfully employ. Young children (i.e., infants and toddlers) are developing social relationships, engaging in cognitive and communicative processes, and developing their learning styles (Zwaigenbaum et al., 2009). Accordingly, it is critical to include professionals from a variety of professions to address these domains (e.g., occupational therapists, psychologists, speech-language pathologists), as well as caregivers and educators.

FCT is founded in the field of applied behavior analysis (ABA; Cooper, Heron, & Heward, 2007; Tiger, Hanley, & Bruzek, 2008). By definition, the term applied, in ABA refers to a socially significant behavior. That is, providing instruction that will provide a positive social impact on a child’s life (i.e., teaching a child to request “apple” when she wants an apple).The term behavior, in ABA refers to any observable, measurable event (i.e., number of times a child attempts to request “apple”). When discussing a child’s behavior, frequently, the colloquial terms bad behavior or problem behavior are used. However, these terms should more appropriately be replaced by the term maladaptive behavior. Maladaptive behaviors are observable events, which have negative ramifications for an individual (Leslie & O’Reilly, 1999). For example, a child with ASD who engages in tantrum behavior will be denied access to a specific environment; therefore, tantrum behavior may be considered maladaptive. Maladaptive behaviors are generally observable events that are undesirable. Adaptive behaviors, conversely, are those observable events, which are desirable (e.g., verbally requesting a break in the absence of a tantrum). Finally, the term analysis in ABA refers to the continual inspection and monitoring of data and progress of a child during the learning process (e.g., tracking data to monitor mastery of requesting, “apple,” or periods of stagnant progress).

According to the principles of ABA, addressing maladaptive behavior requires development of a behavior plan (Cooper et al., 2007). Critical elements of a behavior plan include proactive (prevention) strategies, teaching new skills, and reactive strategies (i.e., responses when challenging behavior occurs; Cooper et al., 2007; Fettig, Schultz, & Ostrosky, 2013). Implementation of FCT would fall under the central component of the plan, which is teaching new skills. These new skills will provide the same function, while facilitating effective communication and minimizing incidents of maladaptive behavior. Reading through this article, one may make the connection between ABA and FCT, with the bridge between the two being a focus on effective communication, and interdisciplinary collaboration. Inclusion of all team members (e.g., speech-language pathologists, parents, special educators) is necessary to maximize outcomes.

“FCT as an intervention procedure in which practitioners address the underlying cause of a behavior (i.e., the function), and replace this behavior with some form of an appropriate communication skill, which meets the needs of that particular function.”

As early as 1985, Carr and Durand describe FCT as an intervention procedure in which practitioners address the underlying cause of a behavior (i.e., the function), and replace this behavior with some form of an appropriate communication skill, which meets the needs of that particular function. For example, if a child is engaging in tantrum behavior for purposes of escaping from a non-preferred activity (e.g., reading), he may be taught to verbally say the single word, “BREAK.” When the child uses this word, his teachers, therapists, and parents will take him for a walk during reading time. In doing so, they are providing him the opportunity to escape, using more appropriate communicative means, and thereby avoiding a tantrum (Tiger et al., 2008). The rationale supporting the implementation of FCT is that challenging (maladaptive) behaviors are frequently maintained by the same socially mediated functions (i.e., access to tangible items) that also motivate early emerging communication skills (i.e., asking for “break”; Mirenda & Iacono, 2009; Sigafoos, Arthur-Kelly, & Butterfield, 2006). See Table 1 for an example of the five functions of maladaptive behaviors.

Table 1

An Example of Five Potential Functions (Cooper et al., 2007) of One Observed Maladaptive Behavior

Behavior observed: A child is asking to go get a drink in the kitchen more frequently than usual.
Description	Example
Medical	Child is developing a cold and has a sore throat, though cannot express herself.
Escape	Child is struggling with being in home-based early intervention, as it is new and challenging for her.
Attention	Child loves to greet her grandmother, who is frequently cooking in the kitchen while she is in home-based early intervention.
Tangible	Child is developing an increased desire for access to the snack foods available in the kitchen (e.g., fruit snacks, goldfish).
Sensory	Child loves the echo her voice makes in the bathroom, which she passes on her way to the kitchen.

There is a large body of literature supporting the use of FCT as an effective intervention (J. E. Carr, Coriaty, & Dozier, 2000; Durand & Merges, 2001; Johnston, 2006; Koegel, Matos-Freden, Lang, & Koegel, 2012; Mancil, 2006; Matson, Dixon, & Matson, 2005; Tiger et al., 2008; Visimara & Rogers, 2010). To highlight, Mancil (2006) reported on findings of implementing FCT with one child in the natural environment. The natural environment is defined as a setting that is naturally occurring for a child’s age peers who do not have disabilities (Childress, 2004). Using a multiple baseline across-mands design, a dramatic decrease in maladaptive behavior was observed in this child in his home. A collateral effect of this intervention was that there was an increase in both number and lexical diversity of words. Tiger et al. (2008) provided a review of FCT practices as effective interventions. They included detailed discussion on the types of maladaptive behaviors addressed using FCT, procedures for identifying reinforcers for a better communicative response, physical locations to begin implementing FCT, fading procedures, and monitoring strategies throughout.

“(a) identifying function of a maladaptive behavior, (b) selecting an alternative means of communicating, and (c) providing systematic instruction to practice this alternative means of communication.”

More recently, Visimara and Rogers (2010) reiterated the point that there is a strong correlation between effective communication and prevalence of maladaptive behavior. They further discussed FCT in the context of skills-based intervention, supporting its efficacy to date. To that end, Koegel et al. (2012) provided a summary of research-based interventions, which may successfully be implemented in the Least Restrictive Environment (LRE). FCT was included as a function-based behavioral intervention in their discussion.

VIGNETTE, PART 2: Several members of Alex’s intervention team got together (i.e., psychologist, classroom teacher, special education teacher, parents, speech-language pathologist). A thorough functional behavioral assessment (FBA) was conducted, with contribution of all team members. Input from the classroom teacher indicated that Alex does not like being academically challenged. His parents further reported that new experiences are difficult for him. His speech-language pathologist indicated that his reduced expressive vocabulary can make these scenarios incredibly challenging, as he does not have the language to communicate his frustration. Collectively, the underlying cause of Alex’s request to go to the nurse’s office during circle time was determined to be ESCAPE. The content of the curriculum (i.e., days of the week) was becoming increasingly difficult, Alex was finding his time in the group to be a challenge, and he did not have an effective communicative outlet to express his frustration.

Three Steps in Successful Implementation of FCT

Mirenda and Iacono (2009) describe three critical steps in successful implementation of FCT. These are (a) identifying function of a maladaptive behavior, (b) selecting an alternative means of communicating, and (c) providing systematic instruction to practice this alternative means of communication. Each step is described and defined in detail below.

Step 1

The first step in successful execution of FCT involves identifying the underlying function of a behavior. This may be accomplished by way of a functional behavioral assessment (FBA) (Cooper et al., 2007; O’Neill et al., 1997). During an FBA, the team coordinator (most commonly a behavior analyst) will conduct a comprehensive assessment in an effort to paint the most complete picture of a child’s strengths and abilities. Inclusion of input from the parents and practitioners is instrumental in this assessment.

“Inclusion of input from the parents and practitioners is instrumental in this assessment.”

The outcomes of an FBA will ultimately identify the underlying cause (i.e., function) of an observed maladaptive behavior. Components of this assessment include indirect assessment (e.g., questionnaires, interviews, checklists provided to all team members). Examples of publicly available questionnaires and checklists include but are not limited to the following: Motivation Assessment Scale (MAS; Durand & Crimmins, 1992), Functional Assessment Screening Tool (FAST; Iwata, DeLeon, & Roscoe, 2013), and the Problem Behavior Questionnaire (PBQ; Lewis, Scott, & Sugai, 1994). In addition to indirect assessment, direct observations of the child, inclusive of data collection in a variety of naturally occurring settings (i.e., home, school, community) are further components of the assessment phase.

During the assessment process, practitioners (e.g., teachers, special educators, speech-language pathologists, behavior analysts) and family members (e.g., parents, siblings) work as integral members of an interdisciplinary team in an effort to best obtain the most thorough picture of the child. Questions regarding behavior across environments are answered when interdisciplinary data are consolidated. Collectively, the team will identify the child’s strengths, preferences, and interests (Division for Early Childhood, 2014). The data obtained from these methods of intake are then triangulated to determine the underlying cause function of a behavior in question (e.g., tantrumming). As demonstrated in Table 1, five functions of maladaptive behaviors are medical, escape, attention, tangible, and sensory.

Step 2

The second step in successful implementation of FCT is selecting an appropriate alternative means of communication. Ideally, the coordinator for this component of FCT should be a speech-language pathologist with skills and expertise in working with individuals with ASD, and having a thorough understanding of behavior. For example, if a child is throwing crayons across the room to gain attention of his caregiver during coloring activities, this behavior may be replaced with teaching him how to tap on his mother’s shoulder and say the word, “LOOK” upon completion of his picture. In effect, the word, “LOOK” would serve the same function as throwing the crayon, which is attention. This is one exemplar of how to replace a nonfunctional means of communication with one that is more functional and appropriate.

During this phase, cultural considerations must be taken into account. By definition, culture is essentially the values, beliefs, and perceptions used by members of a specific group (Battle, 2011; Hegde, 2010). Culture is characterized by family structure (e.g., nuclear, extended), ceremonial practice (e.g., religious, holiday), and rules for interpersonal communication (value placed on different behaviors). For example, not all cultures place the same emphasis on verbal communication (e.g., Latino community), while others hold a strong oral tradition (e.g., American Indian community). The membership of a particular culture for a child should be an integral part in intervention planning. This consideration will further facilitate effective appropriate communication, thereby strengthening community membership for the child.

“team members are providing systematic instruction of the desired communicative behavior under relevant conditions.”

Step 3

The third and final step in the process of FCT involves putting the theories proposed in Steps 1 and 2 regarding function of maladaptive behavior into practice. That is, team members are providing systematic instruction of the desired communicative behavior under relevant conditions. In effect, team members are providing opportunities for practice of a desired behavior, which can occur using a myriad of teaching strategies.

During Step 3 in the FCT process, RPs indicate that both practitioners and family members stand to promote the child’s communication as equal partners. This occurs not only by observing and interpreting interactions of the child but also by responding contingently, and providing natural consequences for the child’s communication (both verbal and non-verbal; Division for Early Childhood, 2014). This is an important consideration in Step 3 of FCT and warrants consideration so that all team members are consistent. Finally, four suggested intervention strategies for use during Step 3 of FCT may include (but are not limited to) the use of scripts, video modeling, social stories, and power cards. See Table 2 for a description of each strategy, with supporting evidence for its efficacy.

Table 2

Four Suggested Intervention Strategies for Use During Functional Communication Training (FCT)

Strategy	Description	Selected supporting literature
Scripts	Written or audio prompt.	Krantz and McClannahan (1993) and MacDuff, Ledo, McClannahan, and Krantz (2007)
Video modeling	Demonstrating desired behavior using video technology.	Bellini and Akullian (2007), Charlop-Christy and Daneshvar (2003), and Digennaro-Reed, Codding, Catania, and Maguire (2010)
Social stories	Short story describing a social scenario, with discussion of desired behavior.	Adams, Gouvousis, VanLue, and Waldron (2004); Crozier, and Tincani (2007); and Sansoti and Powell-Smith (2008)
Power cards	Visual prompts and written scripts modeling desired behavior incorporating individualized special interests of a child with autism spectrum disorder.	Gagnon (2001); Keeling, Smith Myles, Gagnon, and Simpson (2003); Machalicek, O’Reilly, Beretvas, Sigafoos, and Lancioni (2007); and Simpson (2005)

VIGNETTE, PART 3: Successful implementation of FCT for Alex included the following three steps. First, the function of the behavior was determined to be driven by escape. Second, the team identified teaching Alex the phrase, “can I take a break,” as an effective and more socially appropriate alternative than going to the nurse without cause. Third, Alex’s speech-language pathologist, parent, teacher, special educator, and psychologist explained to him that when circle time “gets hard,” he can use this phrase (a picture cue on an index card) to take a 3-min break with his aide. Face to face role-playing, which was videotaped and reviewed with him frequently (i.e., Video Modeling) by all team members, was used to demonstrate the relevant conditions, so that Alex could use this strategy.

To summarize, FCT is a three-step process that incorporates the knowledge, skills, and expertise of several team members (e.g., parents, teachers, behaviorists, speech-language pathologists), in an effort to identify the function of an observed maladaptive behavior, and replace it with a more appropriate form of communication. Depending on the abilities of the individual child, one must consider the form of communication; the child may use verbal speech, Augmentative Alternative Communication (AAC), or a combination of both. When working with individuals with ASD who are not effective or efficient communicators, AAC may be implemented to either (a) support existing communication patterns (i.e., function as an adjunct to verbal speech), therefore augmenting communication, or (b) in lieu of verbal speech completely (American Speech-Language-Hearing Association, 2007), thereby serving as an alternative means of communication. Many individuals with ASD use AAC. Some use low-tech (i.e., non-electronic) means such as the Picture Exchange Communication System (PECS; Frost & Bondy, 1994, 2002), and others use electronic options such as an iPad™ or the Dynavox™ (Mirenda & Iacono, 2009). When considering particular intervention strategies, the skills, abilities, and unique interests of the child should be considered to maximize outcomes. See Figure 1 for a summary of principles of FCT.

Figure 1

Flow chart and summary of three-step process in functional communication training

Cultural Considerations

With respect to culture (i.e., familial, religious, linguistic), each strategy outlined here may be easily adapted to meet the unique requirements of the individual. With family members actively involved in the interdisciplinary team, one may establish responses that are socially acceptable. Therefore, the entire team must account for cultural diversity. For example, while in the northeast part of the United States, initiating eye contact during a request is looked upon highly, this same act may be considered as a sign of disrespect in a different culture. Religious considerations should also be made when selecting specific targets in Step 2 and identifying an intervention strategy in Step 3. For example, it would not be appropriate to develop an intervention using the cartoon character Peppa Pig, should the family be averse to the consumption of/exposure to pork due to religious observances.

“each strategy outlined here may be easily adapted to meet the unique requirements of the individual. With family members actively involved in the interdisciplinary team, one may establish responses that are socially acceptable. Therefore, the entire team must account for cultural diversity.”

Finally, team members must make linguistic considerations during the decision-making process. Does the child come from a balanced bilingual home (i.e., speaking both Spanish and English equal amounts of the time)? If not, which language is dominant in the home? Inclusion of first and second language in a unified and systematic manner affords maximal opportunities for practice of the desired communication, ultimately reducing the maladaptive behavior in question.

Conclusion

When working with individuals with communication disorders (e.g., ASD), principles of evidence-based practice (EBP) should provide familial, clinical, and educational direction. Evaluating the quality of evidence, by way of review of the literature, is an element of EBP (American Speech-Language-Hearing Association, 2005). There is a wide body of peer-reviewed literature supporting the use of FCT (E. G. Carr & Durand, 1985; Digennaro-Reed, Codding, Catania, & Maguire, 2010; Tiger et al., 2008; Volkmar, Paul, Klin, & Cohen, 2005), making it an EBP for individuals with challenges in communication and behavior. FCT has been shown to be particularly effective in treating the communication deficits observed in individuals with ASD (Carr et al., 2000; Durand & Merges, 2001; Johnston, 2006; Mancil, 2006; Matson et al., 2005; Prizant & Wetherby, 2005). As observed in Alex’s Vignette, FCT is a systematic approach to reducing maladaptive behavior in young children with ASD, while replacing this behavior with more appropriate and effective communication.

FCT requires many considerations to be implemented most efficaciously. In addition to the aforementioned process, there needs to be consideration of (a) multiple professionals involved and (b) cultural factors. First, FCT lends itself well to interdisciplinary collaboration in the following ways. During Step 1, involvement of all team members is necessary to determine the function of an observed behavior for the learner. In Step 2, alternative means of communication are identified. Finally, Step 3 involves the commitment of all team members, particularly family members, as this is the actual implementation component of this process.

In summary, using the three principles outlined above (i.e., identifying the function of behavior, identifying an alternative communicative response, and implementing intervention under relevant conditions), in addition to creative teaching strategies (e.g., scripts, video modeling, social stories, power cards), and considering interdisciplinary and cultural factors, children such as Alex stand to be successful learners and ultimately effective communicators.

Footnotes

Author’s Note

You may reach Dana Battaglia by e-mail at dbattaglia@adelphi.edu.

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