One of the most urgent goals in treating children on the autism spectrum is to help them develop communication skills. When children don’t have typically developing language skills, they may not have an effective way to convey their wants and needs. As a result, they are at risk of developing tantrums, aggression or self-injurious behaviors as a replacement. These behaviors are not only potentially harmful, they often aren’t understood.
That’s where functional communication training (FCT) comes in. FCT involves teaching an individual a reliable way of conveying information with language, signs, and/or images to achieve a desired end. It’s called “functional” because it doesn’t just teach kids to label an item (ie associating the word RED to a picture of an apple) but focuses on using words or signs to get something needed or desired — a food, a toy, an activity, a trip to the bathroom, a break from something.
FCT involves the use of positive reinforcement to teach children about language and communication, to increase their ability to interact effectively with others to get their needs met.
How functional communication training works
Stephanie Lee, PsyD, a clinical psychologist at the Child Mind Institute, explains how a clinician implementing FCT works. She begins, Dr. Lee says, by identifying something the child is highly motivated to achieve — say, a favorite food, toy or activity. That will serve as the natural reward for using a sign or picture that represents that thing.
“So if a child really, really likes his Ninja Turtles or Thomas the Tank engine, or a child’s favorite, favorite thing to eat is Cheetos,” she says, “we would take that item and then teach the child either a sign or a picture that represents that item.”
Initially, the child is set up for what Dr. Lee calls “errorless learning,” in which the therapist guides the child to use the sign or picture and obtain the reward. This supported communication is repeated, each time resulting in the earned reward, until the child is able to succeed with less and less prompting from the therapist.
“As we fade that prompting, the child becomes more and more independent in their communication,” says Dr. Lee.
Once kids are reliably using the word, sign or picture for that item when the item is present, the next step is for them to “generalize,” or use it outside the specific situation in which it’s been taught. For example, if a child is watching TV and wanting some chips, she might use the sign as a way to get those chips, Dr. Lee notes. That kind of spontaneous or sporadic use of the skill also needs to be reinforced across time. After a particular word or sign is being used consistently, new ones can be added to gradually build the child’s repertoire.
“Once the child has learned this system of communication — that the sign or the picture that they’re using needs to be received by someone else, in order for them to get their item — then slowly but surely we can teach a new sign or introduce a new picture,”explains Dr. Lee.
Goals in FCT
How quickly children progress with FCT often depends on their functioning, or cognitive level. For children with more complex needs or more significant language impairment, many, many trials might be needed for them to gain a few signs or pictures. “They may end up with a small repertoire of functional communication,” Dr. Lee notes, “but it’s the repertoire that they need most — the foods that they like, using the bathroom, that type of thing. Children with less complex needs and whose level of functioning is higher might actually end up gaining just as much language — if not more — than their typically developing peers.”
Some kids will be able to speak in full sentences, using an assistive tech device. Others will acquire only single words. “With the latter we would be looking to determine the most appropriate goals for them,” notes Dr. Lee. The benefit would be weighed against the effort it would take to achieve it. It is important to remember that treatment is tailored to the specific needs and abilities of each child.
Functional communication training is often taught one-on-one with a clinician who is either a speech and language pathologist or a behavioral psychologist trained in applied behavior analysis (ABA). Parents have an important role in reinforcing the training, practicing what the child has learned, and using it in a variety of situations. When FCT is done at school, teachers would need to help kids practice the signs they’ve learned.
FCT and problem behaviors
Functional communication training was originally developed, in the 1980s, as a way to reduce the troubling behaviors associated with autism, including self-injury and aggression. The idea was that these behaviors result from an inability to communicate needs effectively.
To use FCT to mitigate problem behavior, Dr. Lee explains, the starting point is to look at the function of those behaviors — what clinicians call a “functional assessment.” That requires close observation of the child. If a child is banging his head on the wall, or slapping himself, or hitting another child, what is the function of this behavior? “To get to the bottom of these behaviors we look at the antecedents and the consequences. What sets the stage for the behavior? When does it happen? When doesn’t it happen? Who does it happen with? What tends to happen afterwards?”
If the catalyst for the problem behaviors seems to be something the child is unable to communicate, then teaching the child a more reliable way to communicate his needs can extinguish that behavior.
Dr. Lee stresses that FCT only works to reduce problem behavior if you can correctly assess the function of the behavior for that individual. “The type of behavior or typography — that’s the technical term — really varies based on the individual,” she explains. “And it can vary for one individual at different points. For instance, someone might start with self-injurious behavior and then become aggressive, if he finds that aggression is more efficient.”
Replacing self-injury with language
Self-injurious behavior — like all behavior — serves a function, usually one of these:
- To get attention
- To access a desired item or activity
- To escape an undesired task
- To serve a sensory need
When head hitting or face slapping results in a child getting attention, getting something she wants, getting out of something she doesn’t want to do, or escaping an uncomfortable situation, the behavior is accidentally being reinforced. FCT can help break these unhealthy behavioral patterns.
Once children learn to ask for a break with a word, a sign or a picture, and get results quickly and efficiently, they are likely to choose the appropriate behavior rather than the self-injurious behavior.
Functional communication training can and has been applied to every age, from preschool to adulthood, but experts like to see it start as early as possible. “What we know about language development is that the earlier the intervention, the better,” notes Dr. Lee. “So the quicker we can get on these things and the quicker we can build the child’s communication repertoire the better off he is going to be.”
But Dr. Lee adds that she’s seen FCT work very effectively with adults who didn’t have this type of training earlier, and some gain skills quickly. “I’ve also seen adults who took a very long time to develop a very small repertoire of words,” she adds, “but that small repertoire was very, very important to them, and to the people around them in terms of better understanding what they’re needing and wanting.”