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The purpose of this meta-analysis was to summarize single-case intervention studies in which Functional Communication Training (FCT) involving augmentative and alternative communication (AAC) was implemented in school settings. Overall, the findings suggest that FCT involving AAC was effective in reducing challenging behaviour and promoting aided or unaided AAC use among participants with disability. FCT was more effective for the participants who engaged in less severe forms of challenging behaviour prior to intervention. Additionally, FCT was more effective when informed by a descriptive functional behaviour assessment and delivered within inclusive school settings. Implications for practice and directions for future research related to FCT for students who use AAC are addressed.
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Augmentative and Alternative Communication
ISSN: 0743-4618 (Print) 1477-3848 (Online) Journal homepage: http://www.tandfonline.com/loi/iaac20
A systematic review of Functional Communication
Training (FCT) interventions involving
augmentative and alternative communication in
school settings
Virginia L. Walker, Kristin J. Lyon, Sheldon L. Loman & Samuel Sennott
To cite this article: Virginia L. Walker, Kristin J. Lyon, Sheldon L. Loman & Samuel Sennott
(2018) A systematic review of Functional Communication Training (FCT) interventions involving
augmentative and alternative communication in school settings, Augmentative and Alternative
Communication, 34:2, 118-129, DOI: 10.1080/07434618.2018.1461240
To link to this article: https://doi.org/10.1080/07434618.2018.1461240
Published online: 22 May 2018.
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RESEARCH ARTICLE
A systematic review of Functional Communication Training (FCT) interventions
involving augmentative and alternative communication in school settings
Virginia L. Walker
a
, Kristin J. Lyon
b
, Sheldon L. Loman
c
and Samuel Sennott
c
a
Department of Special Education, Illinois State University, Normal, IL, USA;
b
University of Kansas, Lawrence, KS, USA;
c
Department of
Special Education, Portland State University, Portland, OR, USA
ABSTRACT
The purpose of this meta-analysis was to summarize single-case intervention studies in which
Functional Communication Training (FCT) involving augmentative and alternative communication
(AAC) was implemented in school settings. Overall, the findings suggest that FCT involving AAC was
effective in reducing challenging behaviour and promoting aided or unaided AAC use among partici-
pants with disability. FCT was more effective for the participants who engaged in less severe forms of
challenging behaviour prior to intervention. Additionally, FCT was more effective when informed by a
descriptive functional behaviour assessment and delivered within inclusive school settings. Implications
for practice and directions for future research related to FCT for students who use AAC are addressed.
ARTICLE HISTORY
Received 26 July 2017
Revised 2 March 2018
Accepted 30 March 2018
KEYWORDS
Augmentative and
alternative communication;
Functional Communication
Training; meta-analysis;
literature review;
communication-based inter-
vention; school settings
Challenging behaviour has the potential to interfere with stu-
dent learning, social relationships, and inclusion in school
settings (Harrower & Dunlap, 2001; von der Embse, Brown, &
Fortain, 2011). It is widely understood that communication
and behaviour are highly related, whereby challenging
behaviour often serves a communicative purpose (Mirenda,
1997). As such, it is critical that school-based practitioners
provide appropriate and effective supports to resolve chal-
lenging behaviour among students with complex communi-
cation needs. Specifically, communication-based supports
should be considered for students with these particular sup-
port needs, as communication skills can equip students with
a socially valid way to have their needs met (Beukelman &
Mirenda, 2013). A robust and comprehensive communication
system provides students with the ability to convey a rich
range of communicative functions, promoting academic and
social inclusion across their school day (Mirenda, 1997).
Students with complex communication needs are more
likely to engage in challenging behaviour due to difficulties
in communication (Reichle & Chen, 2016). It is not uncom-
mon for these students to use augmentative and alternative
communication (AAC) to address a range of communication
support needs, including those related to challenging behav-
iour (Snell et al., 2010). These AAC systems can be made up
of any combination of unaided systems (e.g., manual sign or
gesture, sign language) or aided systems (e.g., pages, cards,
or books of symbols, computer-based speech-generating
devices) (Beukelman & Mirenda, 2013). For individuals with
complex communication needs who use AAC and engage in
challenging behaviour, communication-based strategies such
as Functional Communication Training (FCT) (Carr & Durand,
1985) may result in the desirable outcomes of reducing chal-
lenging behaviour and improving communication skills
(Walker & Snell, 2013).
Functional Communication Training
Carr and Durand (1985) established FCT as a communication-
based approach to address challenging behaviour, whereby
the function of the behaviour is identified and a functionally
equivalent communicative response is taught as an alterna-
tive to the behaviour. Challenging behaviour may serve one
or more functions: (a) escape (to escape from or avoid an
undesirable activity, event, or attention); (b) tangible
reinforcement (to obtain access to a desirable object, activity,
or event); (c) attention (to gain attention from an adult or
peer); or (d) automatic reinforcement (e.g., sensory stimula-
tion) (to obtain a desirable outcome without the involvement
of others). To identify the function of a behaviour, a descrip-
tive and/or experimental functional behaviour assessment
(FBA) is conducted. Descriptive FBA typically incorporates the
following key features: (a) defining the behaviour; (b) inter-
viewing key informants (e.g., teachers, paraprofessionals,
parents); (c) administering questionnaires/rating scales to key
informants (e.g., Motivation Assessment Scale; Durand &
Crimmins, 1992); and/or (d) observing the behaviour directly
to understand the environmental conditions under which it
occurs (i.e., antecedents conditions that are present imme-
diately prior to behaviour; and consequences conditions
that are present immediately after the behaviour) (ONeill,
CONTACT Virginia L. Walker vlwalk2@ilstu.edu Department of Special Education, Illinois State University, Campus Box 5910, Normal, IL 61790, USA
Supplemental data for this article can be accessed here.
ß2018 International Society for Augmentative and Alternative Communication
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION
2018, VOL. 34, NO. 2, 118129
https://doi.org/10.1080/07434618.2018.1461240
Albin, Storey, Horner, & Sprague, 2015). Experimental FBA
involves testing the hypothesized behaviour function(s) by
manipulating environmental conditions (antecedents or con-
sequences) to determine the effect on challenging behaviour
(e.g., functional analysis) (Iwata, Dorsey, Slifer, Bauman, &
Richman, 1982). The ultimate goal of FBA is to inform the
development of effective intervention strategies (e.g., FCT)
that align with the identified behaviour function(s).
As an evidence-based practice, FCT involves determining
the message of a student's challenging behaviour and teach-
ing the student to communicate the same message more
appropriately(Durand & Moskowitz, 2015, p. 116). This pro-
cess involves (a) conducting an FBA to identify the function(s)
of challenging behaviour, (b) selecting a functionally equiva-
lent replacement behaviour, and (c) teaching that communica-
tive response. For example, if a childs challenging behaviour
(e.g., hitting peers during recess) is maintained by access to a
preferred item (e.g., desired toys), the student would be
taught a communicative response to request the desired toys
(e.g., Can I play with the race car?). Figure 1 illustrates a com-
peting behaviour pathway that can be used to develop inter-
vention strategies based on FBA outcomes. It provides a
summary of FBA outcomes and includes the following: (a) a
clear description of challenging behaviour, (b) triggering ante-
cedents or events that predict the behaviour, (c) maintaining
consequences, (d) setting events or factors that make the chal-
lenging behaviour more likely to occur, and (e) replacement
behaviour that matches the function of the challenging
behaviour (Sugai, Lewis-Palmer, & Hagan-Burke, 2000).
The primary mechanism of change for FCT is functional
equivalence between the challenging behaviour and the com-
municative response that is taught as a replacement behaviour
(Carr & Durand, 1985; Durand & Moskowitz, 2015; Mirenda,
1997). Teaching a functionally equivalent communicative
response may include prompting, providing reinforcement,
shaping, fading prompts, and withholding reinforcement con-
tingent on challenging behaviour (Tiger, Hanley, & Bruzek,
2008). Although FCT has been reported as a challenging inter-
vention to implement with fidelity (Brown, Anderson, & De
Pry, 2015), school-based practitioners have successfully imple-
mented FCT with adequate training and support (Andzik,
Cannella-Malone, & Sigafoos, 2016). Nonetheless, there is a
growing need to examine further communication-based inter-
ventions to address challenging behaviour that can be imple-
mented successfully in a range of school settings and by
practitioners who work with students who use AAC
(Beukelman & Mirenda, 2013; Morningstar et al., 2016).
Study rationale and research questions
The purpose of this meta-analysis was to systematically
review single-case intervention studies in which FCT that
involved aided and unaided AAC was implemented in school
settings to address challenging behaviour. Prior related litera-
ture reviews have evaluated FCT across communication
mode, age, and disability (Heath, Ganz, Parker, Burke, & Ninci,
2015; Tiger et al., 2008), FCT for individuals with intellectual
disability (Kurtz, Boelter, Jarmolowicz, Chin, & Hagopian,
2011), and practitioner-implemented FCT across any commu-
nication mode (Andzik et al., 2016). Tiger et al. (2008) con-
ducted a descriptive review of FCT studies to identify
variations in FCT procedures across studies and provide prac-
tical guidance based on the research evidence. Their findings
suggest that FCT is effective for individuals with developmen-
tal disabilities (e.g., autism spectrum disorder (ASD) and intel-
lectual disability) and across a wide range of participant and
intervention conditions. Guidelines based on this review
addressed strategies for (a) selecting consequences for
replacement behaviour and challenging behaviour, communi-
cation mode for replacement behaviour, and FCT teaching
procedures; and (b) identifying FCT settings and
interventionists.
Heath et al. (2015) conducted a meta-analysis to review
FCT studies involving individuals with disability across any
Antecedent Behaviour Consequence/Function
Events or stimuli
immediately
preceding
challenging
behaviour
Challenging behaviour (distracting,
disruptive, or destructive) results in
obtaining or avoiding
consequence Escape
Tangible
Attention
Automatic reinforcement
Struggling with
challenging
behaviour
Using Functional
Communication
Training
Socially acceptable and efficient
behaviour (e.g., using AAC system to
communicate) results in obtaining or
avoiding consequence
Implications
Social
challenges and
exclusion
FCT
FCT
FCT with AAC
1. Identifying the communicative function of behaviour
2. Selecting an appropriate communicative alternative
3. Teaching the communicative alternative
Inclusion
Figure 1. A competing behaviour pathway for developing intervention strategies based on FBA outcomes.
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 119
age or communication mode. Findings from this review sug-
gest that FCT is more effective in reducing challenging
behaviour for individuals with ASD compared to those with
intellectual disability. In addition, verbal modes of communi-
cation were more effective than AAC modes, with aided AAC
resulting in more substantial outcomes compared to unaided
AAC. Kurtz et al. (2011) conducted a descriptive literature
review of FCT studies, focusing specifically on individuals
with intellectual disability across any age and any communi-
cation mode. A majority of participants had an additional
diagnosis of ASD and received FCT delivered by therapists or
behaviour analysts within inpatient units. In most cases, the
interventions were based on the results of experimental FBA.
The authors concluded that FCT qualified as a well-estab-
lished practice for reducing challenging behaviour among
individuals with intellectual disability, although information
about communication mode was not reported.
Most recently, Andzik et al. (2016) conducted a descriptive
review to examine FCT for students with disability imple-
mented by practitioners in school settings. In most cases,
teachers implemented the intervention in non-inclusive
school settings (e.g., self-contained special education class-
rooms). Findings also revealed that practitioner training was
described in only half of the studies, and few studies
reported the accuracy with which practitioners implemented
FCT. Similar to the review conducted by Heath et al. (2015),
Andzik et al. (2016) did not report on communication mode
across participants. Collectively, these reviews provide valu-
able information on the current status of FCT across a range
of participants. However, only one focused on its use in
school settings for students with disability. Understanding
the current status of FCT in relation to practices used within
school settings for students with disability is important, as
such information has the potential to inform guidelines for
FCT implementation across various school settings, thus
improving the likelihood that a range of practitioners can
successfully deliver FCT.
More information is needed to understand the practicality
of FCT implementation across inclusive and non-inclusive
school settings, given that challenging behaviour can serve as
a barrier to inclusion for students with disability. Emerging evi-
dence suggests that interventions informed by FBA can be
effective in addressing challenging behaviour when imple-
mented by practitioners in inclusive school settings (e.g.,
Walker, Chung, & Bonnet, 2017); however, less is known about
implementation within inclusive settings for students who use
AAC, a population less likely to access inclusive school envi-
ronments (Kleinert et al., 2015). Another gap in the literature
involves the descriptive methodology used for synthesizing lit-
erature related to FCT in school settings. For example, Andzik
et al. (2016) provided a descriptive analysis of study character-
istics and quality, but did not analyse intervention effect or
study characteristics that moderate such an effect.
As such, there is a need for meta-analytic strategies to
explore further the current status of FCT in school settings
for students who use AAC across different inclusive and non-
inclusive environments. Appropriate for single-case research,
meta-analysis allows for quantification of intervention effect
and an analysis of whether specific study characteristics
moderate FCT outcomes among this unique student popula-
tion (Moeyaert, Zimmerman, & Ledford, 2018; Vannest &
Ninci, 2015). Therefore, with the goal of helping practitioners
implement socially important and evidence-based practices
in schools, this study was designed to answer the following
questions: What are the characteristics of study participants,
settings, and FCT applied within the studies? (b) What is the
overall quality of the studies? (c) What are the overall effects
of FCT interventions involving aided and unaided AAC on
challenging and replacement behaviour? (d) Do any of the
study characteristics moderate intervention outcomes?
Method
A meta-analysis was conducted to synthesize single-case
intervention studies (Moeyaert et al., 2018) involving FCT and
AAC for students with disability in school settings. The
upcoming sections outline procedures related to the litera-
ture searches, data extraction and coding, and intervention
effect calculation and analysis.
Search procedures
In January 2016, a search of the literature was conducted to
locate potentially relevant articles using three different strat-
egies. First, an online database search of PsycINFO, ERIC,
Medline, and ProQuest Dissertation and Theses databases
was conducted. Searches were limited to references pub-
lished in English. Search terms synonymous or related to the
search categories of augmentative and alternative
communicationand Functional Communication Training
were applied to all search fields. See the Supplementary
Materials for a full description of the search terms, databases,
and journals included in the search. Online database searches
captured both published and unpublished studies (i.e., disser-
tations, thesis papers) to reduce the risk of publication bias
(Cooper, Hedges, & Valentine, 2009). After eliminating dupli-
cates and irrelevant sources, a total of 223 relevant referen-
ces remained from the online database search.
Second, a search was conducted of 17 peer-reviewed jour-
nals that commonly publish research related to special edu-
cation, communication-based intervention, and behavioural
intervention by examining the title and abstract of each ref-
erence for the previously described search terms. This search
strategy yielded 71 potentially relevant references. Finally, an
ancestry search of reference lists according to previous
research (Heath et al., 2015; Kurtz et al., 2011; Snell, Chen, &
Hoover, 2006; Walker & Snell, 2013) and articles identified
through the other search methods was conducted, resulting
in 81 additional references for consideration. After eliminat-
ing additional duplicates and irrelevant sources, 234 referen-
ces remained to be considered for inclusion in the
current review.
Inclusion criteria
The remaining 234 references were examined by the first
and second authors to determine eligibility for inclusion in
120 V. L. WALKER ET AL.
the review. Both reviewers were assistant professors in spe-
cial education and had prior experience with meta-analysis.
Each reviewer was allocated 50% of the references, which
were judged against the following criteria. First, the inde-
pendent variable in the study must have included FCT involv-
ing any mode of AAC (i.e., the targeted replacement
behaviour was a functionally equivalent communicative
response in the form of unaided or aided AAC). Studies that
involved both speech and AAC were included only when
graphic displays of data permitted the extraction of data spe-
cific to AAC measures. Second, the FCT intervention must
have been delivered within any school environment in early
childhood through high school settings. School environments
included, but were not limited to, classrooms, gymnasiums,
cafeterias, playgrounds, and hallways. Studies conducted in
residential facilities, hospitals, and other community settings
were excluded. Finally, the effect of the FCT intervention on
challenging behaviour and/or aided or unaided AAC must
have been evaluated with an experimental single-case
design, a conventional methodology for research involving
low-incidence populations (Kratochwill et al., 2010). These
designs included multiple baseline designs, changing condi-
tions designs, and reversal or withdrawal designs. It should
be noted that studies without measures of challenging
behaviour qualified for inclusion in the review when meas-
ures of aided or unaided AAC use were reported. Given that
FCT is a communication-based intervention, studies that
reported only AAC outcome measures were included so that
communication outcomes resulting from FCT for students
who exhibit complex communication needs could be ana-
lysed. Studies were excluded if they did not (a) involve FCT
in a school setting (n¼155), (b) include FCT involving AAC
(n¼134), or (c) include an experimental single-case design
(n¼124). Following application of the inclusion and exclu-
sion criteria, the two reviewers identified a total of 17 studies
eligible for inclusion.
To assess inter-rater reliability, both the first and second
authors applied the inclusion criteria to 30% of the studies
rated by the other reviewer. Inter-rater reliability was calcu-
lated using the percentage agreement approach, whereby the
number of agreements is divided by the number of agree-
ments plus disagreements and multiplied by 100 to yield a
percentage (Ledford, Lane, & Gast, 2018). Overall, there was
99% agreement (range ¼97100%) in the decision to include
or exclude studies. When a disagreement occurred, the two
authors met to discuss coding discrepancies and reach con-
sensus on a decision to include or exclude a study.
Data extraction and coding
After applying the inclusion and exclusion criteria, the first
and second authors extracted the participant, intervention,
and quality-of-study characteristics from 47% and 53% of the
17 eligible studies, respectively. Descriptive coding items were
drawn from previous literature reviews (Snell et al., 2010; Tiger
et al., 2008; Walker & Snell, 2013). In addition, each reviewer
applied the What Works Clearinghouse (WWC) design stand-
ards (Kratochwill et al., 2010) to each study and qualifying
participant, following the application process described by
Maggin, Briesch, and Chafouleas (2013). It should be noted
that data were extracted at the participant level. Thus, the
reviewer completed one coding form for each qualifying stu-
dent participant in a given study. Each coding category and
corresponding coding items are described below, and a com-
plete coding form is available from the authors.
Participant characteristics
The coding form included five items relevant to student par-
ticipant characteristics. In addition to gender, student
grade level or age was coded as follows: early childhood (<5
years-old), Grades K5(511 years-old), Grades 68 (1214
years-old), or Grades 912 (1521 years-old). Information
about the reported diagnosis of each student participant
(intellectual disability, ASD, multiple disabilities, learning dis-
ability, emotional behavioural disorder, traumatic brain injury,
sensory impairment, physical disability, other health impair-
ment) was also extracted. Finally, two coding categories were
included to describe studentsexpressive communication
level and their AAC mode, if any, prior to training. Expressive
communication was categorized according to level as prelin-
guistic (no real words/symbols), emerging (single words/sym-
bols or rote-word/symbol combination), and multiword (non-
rote combinations of two or more words/symbols) (Snell
et al., 2010). Modes of AAC prior to training were categorized
as (a) aided: non-electronic devices (e.g., communication
books and boards), electronic (e.g., speech-generating devi-
ces); (b) unaided: gestures (e.g., sign language, hand-leading,
reaching, facial expressions); (c) multimodal; and (d) no AAC
prior to training.
Dependent measures
Two dependent measures were examined: challenging
behaviour (the reported behaviour that necessitated FCT
intervention) and aided or unaided AAC use (the functionally
equivalent communicative response in the form of unaided
or aided AAC). It should be noted that the communication
mode of replacement behaviours reported for student partici-
pants was either aided or unaided AAC or a combination of
the two modalities. From this point forward, replacement
behaviour is referred to as aided or unaided AAC use, with
the recognition that AAC is a communication modality that
functions beyond replacing challenging behaviour in promot-
ing functional communication and social skills across differ-
ent communication partners (Snell et al., 2010). The coding
form included two descriptive items relevant to these
dependent measures. First, the form, or mode, of the aided
or unaided AAC use during training was coded as aided,
unaided, or multimodal AAC use. When studies included
measures of challenging behaviour, information about the
following priority levels of the challenging behaviour was
extracted: destructive (physical aggression toward others,
property damage, self-injurious behaviour), disruptive (verbal
aggression, disruptive verbal behaviour, disruptive physical
behaviour), or distracting (non-participation, non-compliance,
stereotypy) (Walker & Snell, 2013).
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 121
Intervention characteristics
The coding form included 16 items pertaining to FCT inter-
vention characteristics organized under three categories: FBA,
FCT strategies, and FCT conditions. The type of FBA tool
used to identify the function of challenging behaviour was
identified as either descriptive or experimental. The identified
behaviour function(s) based on the FBA and addressed
through the FCT intervention was identified as either atten-
tion, escape, tangible, automatic reinforcement, or mul-
tiple functions.
Items addressing FCT strategies (Tiger et al., 2008) were
establishing operations (contrived, natural), prompting and
prompt-fading procedures (least-to-most prompting, time
delay, etc.), and consequences for challenging behaviour
(reinforcement, punishment, extinction). Finally, several char-
acteristics associated with FCT conditions were examined: (a)
the training setting (contextualized, decontextualized; inclu-
sive, non-inclusive), (b) type of trial (massed, distributed), and
(c) the quantity of FCT (trials per session, sessions per day or
week, duration of FCT condition over course of study).
Inclusive school settings were those in which same-aged
peers without disability were present (Andzik et al., 2016).
Information about the role of the FCT implementer (experi-
menter, therapist, special education teacher, general educa-
tion teacher, paraprofessional, other) and whether the
implementer received training prior to implementing FCT
was extracted. If the implementer did in fact receive training,
training quantity (trials per session, sessions per day or week,
duration of FCT condition over course of study), training con-
text (contextualized, decontextualized), and the type of train-
ing (didactic, experiential) were coded. A list of selected
coding items and corresponding definitions related to these
characteristics is provided in Table 1.
Quality indicators
Several study characteristics were examined to descriptively
assess study quality pertaining to external, internal, and
social validity. The WWC design standards included the fol-
lowing four indicators: (a) the independent variable was
Table 1. Selected coding items and definitions for intervention characteristics.
Coding item Definition
Establishing operations
Contrived Setting up conditions to intentionally increase the value of the maintaining reinforcer; trials conducted
under contrived conditions (e.g., FCT trials are delivered repeatedly throughout the school day, regard-
less of class period, during classes in which reading comprehension activities do not necessarily occur
for a student whose challenging behaviour is maintained by escape from reading comprehen-
sion activities)
Natural Waiting for the maintaining reinforcer to become valuable before conducting trial; trials conducted during
naturally occurring routines (e.g., FCT trials are embedded during 6th period reading class (an existing
class in which reading comprehension activities naturally occur) for a student whose challenging
behaviour is maintained by escape from reading comprehension activities)
Prompting and prompt-fading procedures
Least-to-most prompting Instructor uses a prompting hierarchy whereby the learner is first given the opportunity to independently
perform the target response before being provided with the least intrusive level of assistance; the level
of assistance is increased until the target response is performed correctly
Most-to-least prompting Instructor uses a prompting hierarchy in which the learner is first provided with the most intrusive level
of assistance; the prompting is faded over time as the learner responds to less intrusive prompts until
independence is reached
Time delay Instructor uses a controlling prompt that is provided after a delay interval and naturally fades as the
learner begins to perform the target response before the delivery of the prompt
Simultaneous prompting Instructor uses probe trials to determine when acquisition of a behaviour has occurred and that are con-
ducted before training trials involving immediate delivery of a controlling prompt
Graduated guidance Instructor provides the minimum amount of physical guidance necessary to ensure a correct response by
the learner on a moment-to-moment basis
Training setting
Contextualized Conducted in a natural environment; generally natural but trainer can set up preferred materials in the
natural environment
Decontextualized Removed from natural environment; contrived for study rather than under natural conditions; pull-out;
conditions are manipulated according to time or setting; individuals present that are strikingly different
than scheduled routines
Type of trial
Massed One trial follows the next trial; trials scheduled by session rather than by natural opportunities
Distributed Trials are separated by variable amounts of time and are included as part of a routine
Consequences for challenging behaviour
Reinforcement Increase in the likelihood of a behaviour as a function of the contingent delivery (or removal) of an
event/object/stimulus (e.g., FCT trials involve removal of the requirement to complete reading compre-
hension activities contingent on challenging behaviour for a student whose challenging behaviour is
maintained by escape from reading comprehension activities)
Punishment Decrease in the likelihood of a behaviour as a function of the contingent delivery (or removal) of an
event/object/stimulus (e.g., FCT trials involve delivery of additional reading comprehension activities
contingent on challenging behaviour for a student whose challenging behaviour is maintained by
escape from reading comprehension activities)
Extinction Withholding reinforcement for a challenging behaviour to reduce the behaviour (e.g., FCT trials involve
preventing student from escaping reading comprehension activities contingent on challenging behav-
iour for a student whose challenging behaviour is maintained by escape from reading comprehen-
sion activities)
122 V. L. WALKER ET AL.
systemically manipulated; (b) each dependent variable was
measured systematically over time by more than one asses-
sor on at least 20% of data points in each condition and met
minimal thresholds (i.e., 80% for percentage agreement indi-
ces, 0.60 for kappa measures); (c) the study included at least
three attempts to demonstrate an intervention effect at three
different points in time or with three different phase repeti-
tions; and (d) each phase had a minimum of three data
points. Based on these indicators, each participants graph
was examined to determine whether design standards were
met with or without reservations or were not met. The
authors determined whether measures of FCT implementa-
tion fidelity, generalization to multiple implementers, mul-
tiple settings, or the natural environment, maintenance, and
social validity were reported for each participant. It should
be noted that, rather than establishing quality as an inclusion
criterion, a descriptive summary of study quality was pro-
vided in the current study. This approach is common in
meta-analytic research that serves to descriptively summarize
a group of studies and can highlight the need for additional
high-quality research to strengthen a particular body of lit-
erature (e.g., Goh & Bambara, 2012; Walker et al., 2017).
To assess inter-rater reliability across descriptive coding
items, the same reviewers, the first and second authors,
coded a sub-set of articles (35%) originally coded by the
other reviewer, and compared item-by-item responses for
agreement. Overall, agreement was 97% (range ¼83100%)
across descriptive coding items.
Intervention effect calculations and moderator analyses
In the context of single-case research, visual analysis of
graphed data is the standard approach for determining the
effectiveness of an intervention and detecting a functional
relation between the independent and dependent variables;
this approach typically involves exploring both within condi-
tion variables (condition length, level, level change, trend)
and between condition variables (change in trend, change in
level, data overlap) (Kratochwill et al., 2010). However, quanti-
fying intervention effect becomes equally important when
the objective is to estimate an intervention effect across mul-
tiple studies and participants and to identify variables that
moderate such an effect, which is typically the goal of meta-
analytic research (Cooper et al., 2009; Vannest & Ninci, 2015).
Several non-overlap indices have been explored for the pur-
poses of quantifying intervention effect across single-case inter-
vention studies (Parker & Vannest, 2009; Vannest & Ninci,
2015). Many of these indices fail to account for outliers and
trends or variability in the data, such as the percentage of non-
overlapping data (Scruggs, Mastropieri, & Casto, 1987), the
improvement rate difference (Parker, Vannest, & Brown, 2009),
and the non-overlap of all pairs (Parker & Vannest, 2009). As
such, Tau-U (Parker, Vannest, Davis, & Sauber, 2011), an inter-
vention effect metric that takes into account baseline trend,
was used to estimate intervention effect for the purposes of
this review. Tau-U was calculated for each qualifying participant
and each dependent measure (challenging behaviour, aided or
unaided AAC use) because student participants were treated as
the unit of analysis. Initially, raw data values were extracted
from each student participant graph using UnGraph (Biosoft,
2004), a digitizing software that has acceptable reliability and
validity (Shadish et al., 2009). Subsequently, Tau-U calculations
were completed with a Tau-U online calculator (Vannest,
Parker, & Gonen, 2011).Duetotheuniquefeaturesofeach
type of single-case design, specific guidelines were applied to
each design, as described by Walker and Snell (2013)and
Walker et al. (2017). Tau-U scores can be interpreted as follows:
small change: <0.20; moderate change: 0.200.60; large
change: 0.600.80; and large-to-very large change: >0.80
(Vannest & Ninci, 2015). To assess inter-rater reliability for Tau-
U calculations, a sub-set of articles was coded a second time
(35%). Inter-rater reliability was 100%.
Moderator analyses across each qualifying participant and
intervention coding category were conducted to determine
whether differences existed among study characteristics in
intervention effect, as measured by Tau-U scores of challeng-
ing behaviour and aided or unaided AAC use. In addition, a
moderator analysis of the WWC design standards determined
whether design quality affected student outcomes. Only
those coding items reported across eight or more student
participants were included in these analyses (Walker & Snell,
2013; Walker et al., 2017); therefore, some coding items or, in
some instances, entire coding categories, were excluded from
analyses, due to having an insufficient number of cases.
Tables 2 and 3show the participant and intervention coding
categories and corresponding coding items that qualified for
inclusion in the moderator analyses. Tau-U scores across cod-
ing items were compared using the Kruskal-Wallis one-way
ANOVA on SPSS 22.0 for Mac, with follow-up pairwise com-
parisons conducted with the Mann-Whitney U-test.
Results
Findings for descriptive analyses
The analyses yielded a descriptive summary of participant,
intervention, and quality-of-study characteristics. These results
are described in detail in the sections that follow and are
reported as the percentage of cases (i.e., student participants)
representative of each coding item. A summary of select
descriptive characteristics at the study level is reported in
Table 4. Because some coding items were coded as cannot
determine, percentages do not always total 100%. It also was
possible to apply more than one code within a given coding
category; therefore, totals for some categories surpass 100%.
Participant characteristics
A majority of the participants were male (70%), with signifi-
cantly fewer females receiving FCT intervention (30%). The
reported grade levels were as follows: Grades K5 (43%), early
childhood (26%), Grades 912 (20%), and Grades 68 (11%).
The primary diagnosis was most often reported as intellectual
disability (65%) or ASD (28%). Less common diagnoses
included emotional behavioural disorder (17%), physical dis-
ability (10%), sensory impairment (9%), multiple disabilities
(4%), and other health impairment (4%). The expressive
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 123
communication level prior to FCT was typically not reported
or was not clearly described for over half of the participants
(61%); however, of the participants for whom expressive com-
munication level was reported, a majority communicated at
an emerging level (89%), with only 11% communicating at a
pre-linguistic level. Similarly, the modes of AAC used by par-
ticipants prior to training were not reported for over half of
the participants (52%). The participants tended to use unaided
modes (50%) or multiple modes (27%) of AAC prior to FCT;
four (18%) did not use AAC prior to intervention, and only
one (5%) used electronic aided AAC prior to FCT.
Dependent measures
Studies included measures of aided or unaided AAC use for
21 of the participants. However, the form of the replacement
behaviour was reported for all participants, regardless of
whether the study measured improvement in replacement
behaviour. Modes of AAC during FCT included the following:
aided (67%), multiple modes (17%), and unaided (15%).
Studies included measures of challenging behaviour for 43
participants. The priority levels of challenging behaviour tar-
geted for FCT were destructive behaviour (60%), disruptive
behaviour (50%), and distracting behaviour (24%). The most
common destructive behaviour types were physical aggres-
sion (50%) and self-injurious behaviour (46%); fewer partici-
pants engaged in property damage (29%). Disruptive
behaviour involved verbal behaviour (e.g., calling out, crying;
74%), physical behaviour (e.g., leaving work area, falling to
the floor; 65%), and verbal aggression (e.g., teasing, threaten-
ing students or adults; 4%). Finally, a majority of participants
who engaged in distracting behaviour did not participate or
comply within problematic activities (90%); only one (10%)
engaged in stereotypy.
Intervention characteristics
Prior to FCT, both experimental (59%) and descriptive (52%)
FBAs were conducted to identify the function(s) of participants
challenging behaviour. The identified function(s) based on FBA
and addressed through the FCT intervention varied, with a
majority reported as escape (43%) or multiple functions (28%);
fewer were identified as attention (17%) or tangible (11%).
The establishing operations for FCT were identified in fewer
than half of the participants (41%). Most FCT sessions were con-
ducted when the trainer waited for the maintaining reinforcer
to become valuable (i.e., natural; 28%) versus setting up condi-
tions to intentionally increase the value of the reinforcer (i.e.,
Table 3. Moderator analysis findings for aided or unaided AAC use.
Characteristic (n)
Tau-U
a
MSD v
2
Gender
Female (8) 0.92 0.13 0.53
Male (13) 0.86 0.19
Disability
ASD (8) 0.83 0.24 0.46
ID/DD (11) 0.81 0.24
Challenging behavior
Distracting (8) 0.97 0.06 6.44
Disruptive (10) 0.86 0.22
Destructive (10) 0.79 0.22
FBA tool
Descriptive (12) 0.96 0.07 5.18
Experimental (14) 0.77 0.29
Behavioural function
Multiple functions (9) 0.93 0.11 2.92
Escape (9) 0.80 0.21
Implementer
General educator (8) 0.96 0.07 2.78
Experimenter (10) 0.92 0.11
Special educator (11) 0.84 0.21
Implementer training: Context
Decontextualized (12) 0.97 0.06 <0.001
Contextualized (9) 0.97 0.07
Implementer training: Type
Didactic (16) 0.94 0.09 0.02
Experiential (13) 0.93 0.10
FCT setting
Inclusive (8) 0.96 0.19 4.77
Non-inclusive (12) 0.81 0.07
Tau-U small change: <0.20; moderate change: 0.200.60; large change:
0.600.80; very large change: >0.80.
v
2
values are derived from Kruskal-Wallis test.
a
Not all studies provided graphed data of replacement behaviour, thus MTau-
U scores do not reflect replacement behaviour across all participants within
a category.
p<0.05 (alpha level refers to comparison across moderator levels).
Table 2. Moderator analysis findings for challenging behavior.
Characteristic (n)
Tau-U
a
MSD v
2
School level
Grades K5 (17) 0.94 0.14 0.34
Grades 912 (9) 0.85 0.20
Early childhood (12) 0.84 0.23
Gender
Female (11) 0.98 0.20 4.84
Male (30) 0.84 0.20
Disability
ID/DD (27) 0.86 0.20 0.81
ASD (11) 0.85 0.22
EBD (8) 0.85 0.20
Challenging behavior
Distracting (11) 0.94 0.08 1.83
Destructive (25) 0.87 0.18
Disruptive (23) 0.84 0.19
AAC mode
Aided electronic (14) 0.94 0.09 3.13
Multiple modes (8) 0.88 0.15
Aided non-electronic (12) 0.79 0.24
Consequence to challenging behaviour
Extinction (31) 0.88 0.22 0.37
Punishment (8) 0.88 0.18
Implementer
General educator (8) 0.88 0.22 0.77
Experimenter (13) 0.86 0.21
Special educator (23) 0.85 0.21
Implementer training: Context
Decontextualized (28) 0.92 0.18 1.07
Contextualized (12) 0.92 0.14
Implementer training: Type
Didactic (32) 0.92 0.14 <0.001
Experiential (29) 0.91 0.14
FCT setting
Inclusive (9) 0.89 0.21 1.27
Non-inclusive (24) 0.84 0.20
Tau-U small change: <0.20; moderate change: 0.200.60; large change:
0.600.80; very large change: >0.80.
ID/DD: intellectual disability/developmental delay; ASD: autism spectrum dis-
order; EBD: emotional behavioural disorder.
v
2
values are derived from Kruskal-Wallis test.
a
Not all studies provided graphed data of challenging behaviour, thus MTau-
U scores do not reflect challenging behaviour across all participants within
a category.
p<0.05 (alpha level refers to comparison across moderator levels).
124 V. L. WALKER ET AL.
contrived; 13%). Less than a quarter of participants (24%)
received a stimulus prompt (e.g., picture of expected communi-
cative behaviour) during FCT sessions. The prompt and prompt-
fading procedures used during FCT sessions were described
clearly across fewer than half of the participants (48%) as fol-
lows: least-to-most prompting (28%), most-to-least prompting
(15%), time delay (9%), and graduated guidance (4%). FCT
implementers responded to challenging behaviour with extinc-
tion (71%), punishment (18%), or reinforcement (13%).
Implementation of FCT typically occurred in contextualized
settings (56%), whereas 11% of participants received interven-
tion in decontextualized settings. Most received FCT within
non-inclusive school settings (58%), with fewer receiving inter-
vention within inclusive settings with peers without disability
(18%). For 22% of the participants the setting could not be
determined, and for the majority of participants (80%) the
type of FCT trial (massed, distributed) could not be deter-
mined. However, 20% of participants received training in a
massed context. The quantity of FCT (trials per session, ses-
sions per day or week, duration of FCT condition over course
of study) was described clearly across 19 participants, with
FCT implemented 16 times per daily session over the course
of 28 weeks. Special education teachers (50%) or experi-
menters or therapists (39%) implemented FCT interventions
most often; general education teachers (17%), paraprofession-
als (15%), and other teachers for whom a specific role was
not specified (13%) implemented FCT less frequently. Of the
implementers receiving FCT training (72%), most received
training in contextualized settings (85%) and in both didactic
(97%) and experiential (88%) forms.
Quality indicators
Overall, a majority of cases met the WWC design standards
with reservations (42%) or without reservations (30%).
Slightly more than a quarter of the cases (28%) did not meet
the design standards. Implementation fidelity of FCT was
measured across 50% of participants. Generalization to mul-
tiple implementers (52%), multiple settings (29%), or other
conditions (29%) was measured across 46% of participants,
whereas maintenance was measured in only 17% of cases.
Finally, the social validity of the FCT intervention was
reported for less than half of the participants (30%).
Findings for overall effect and moderator analyses
Overall, FCT interventions involving AAC resulted in very
large changes (as measured by Tau-U scores) in reducing
challenging behavior (M¼0.88, SD ¼0.18, range ¼0.381.00)
and increasing aided or unaided AAC use (M¼0.88,
SD ¼0.17, range ¼0.301.00). Moderator analysis results are
reported in Tables 2 and 3. These findings suggest that a
majority of study characteristics did not moderate the effect
Table 4. Summary of study characteristics, including number of participants who met inclusion criteria (n), targeted challenging behaviour (CB), type of AAC
used, FBA tool, FCT prompting procedures, FCT implementer, and What Works Clearinghouse design standards (WWC).
Included study nCB AAC FBA tool Prompting FCT implementer WWC
a
Buckley and
Newchok (2005)
1 Destructive Aided Experimental CD Therapist 0
Casey and Merical (2006) 1 Destructive Aided Experimental,
descriptive
Other Paraprofessional 1
Davis, Fredrick, Alberto, and
Gama (2012)
4 Destructive, disrup-
tive, distracting
Aided Experimental CD Special educator 0, 1
Day, Rea, Schussler, Larsen,
and Johnson (1988)
1 Destructive Unaided Experimental TD Special educator,
paraprofessional
2
Donovan (2003) 3 Destructive, disrup-
tive, distracting
Aided, unaided Experimental,
descriptive
MLP Special educator 1
Durand (1993) 3 Destructive,
disruptive
Aided Descriptive SP, CD Classroom teacher 1
Durand (1999) 5 Destructive,
disruptive
Aided Experimental SP, GG, CD Special educator,
classroom
teacher
1
Dwyer, Rozewski, and
Simonsen (2012)
3 Disruptive,
distracting
Multimodal Descriptive SP, MLP Experimenter 2
Flynn and Lo (2016) 1 Disruptive Unaided Experimental SLP Special educator 2
Franco et al. (2009) 1 Disruptive Aided Experimental MLP Experimenter 0
Hetzroni and Roth (2003) 5 Destructive, disrup-
tive, distracting
Aided, multimodal Descriptive SLP Special educator,
paraprofessional
1
Horner, Sprague, OBrien,
and Heathfield (1990)
1 Destructive Multimodal Experimental,
descriptive
SP, SLP, GG Special educator 1
Hunt (1999) 8 Disruptive,
distracting
Aided, multimodal Descriptive CD Experimenter,
general educator
0, 2
Kelley, Lerman, and Van
Camp (2002)
3 Destructive Aided, unaided Experimental SLP, TD Therapist 2
Northup et al. (1994) 3 Destructive Aided,
unaided,
multimodal
Experimental SLP Special educator 0
ONeill and Sweetland-
Baker (2001)
2 Destructive,
disruptive
Aided Experimental CD Special educator 0
Peck Peterson et al. (2005) 1 Disruptive Unaided Experimental CD Experimenter,
special educator
0
0¼does not meet standards; 1 ¼meets standards with reservations; 2 ¼meets standards; SP: stimulus prompt; SLP: system of least prompts; MLP: most-to-least
prompting; TD: time delay; GG: graduated guidance; CD: cannot determine.
a
WWC standards applied to each student participant, thus some studies include different quality outcomes.
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 125
of the FCT intervention on challenging behaviour and aided
or unaided AAC replacement behaviour outcomes.
Additionally, the WWC design standards did not moderate
study outcomes. The effect of the studentsgender on chal-
lenging behaviour was statistically significant, v
2
(1,
n¼41) ¼4.84, p<0.05. Tau-U scores were significantly higher
for female (M¼0.98) than for male participants (M¼0.84).
Additionally, the effect of the priority level or intensity of
challenging behaviour on aided or unaided AAC use was
statistically significant, v
2
(2, n¼28) ¼6.44, p<0.05. Follow-
up pairwise comparisons suggested that Tau-U scores of
aided or unaided AAC replacement behaviour for participants
who engaged in distracting levels of challenging behaviour
(M¼0.97) were significantly higher than Tau-U scores for
those who engaged in destructive levels of challenging
behaviour (M¼0.79) (p<0.05/3).
The effect of the type of FBA on aided or unaided AAC
use was statistically significant, v
2
(1, n¼26) ¼5.18, p<0.05.
Tau-U scores were significantly higher when a descriptive FBA
was conducted prior to FCT (M¼0.96) than when an experi-
mental FBA was conducted prior to FCT (M¼0.77). Finally,
the effect of intervention setting on aided or unaided AAC
use was statistically significant, v
2
(1, n¼20) ¼4.77, p<0.05.
Tau-U scores were significantly higher when FCT was imple-
mented in inclusive school settings (M¼0.96) than when
implemented in non-inclusive school settings (M¼0.81).
Discussion
The purpose of this meta-analysis was to summarize single-
case intervention research studies in which FCT involving
AAC was implemented in school settings to address students
challenging behaviour. There were a number of noteworthy
findings that contribute to the literature on communication-
based interventions to address challenging behaviour for stu-
dents with disability who use AAC in school settings.
Summary of findings
Overall, the results of this meta-analysis suggest that FCT
involving AAC contributed to improved aided or unaided
AAC use and reduced challenging behaviour for students
with disability across school settings, as evidenced by aver-
age Tau-U scores representing large-to-very large changes
across both outcome measures. Furthermore, the average
Tau-U scores across all coded study characteristics fell within
the large-to-very large intervention effect range. These results
suggest that FCT is effective among students with disability
who have varying support needs and under a wide range of
intervention conditions, thus contributing to the current evi-
dence base supporting the overall effectiveness of FCT as a
communication-based intervention to address challenging
behaviour and promote appropriate replacement behaviour
in school settings (e.g., Andzik et al., 2016; Mancil, 2006;
Tiger et al., 2008).
Findings from analyses in this review revealed gender as a
potential moderating variable for challenging behaviour out-
comes, with intervention effect significantly higher for female
participants. In addition, the following three variables were
identified as potential moderators for aided or unaided AAC
use outcomes: (a) intensity of challenging behaviour, (b) type
of FBA tools used to develop FCT intervention, and (c) FCT
setting (non-inclusive, inclusive). Possible explanations for
these results are discussed in the sections that follow.
Implications of findings
The findings indicate that FCT involving AAC is an effective
practice for reducing challenging behaviour and increasing
aided or unaided AAC use in school settings. Caution must
be exercised in considering the potential implications of the
moderating effect of gender on reduction in challenging
behaviour, given that there was a disproportionate number
of male (n¼30) compared to female participants (n¼11).
This may have contributed to gender appearing as a moder-
ating variable for reductions in challenging behaviour.
Because other studies have not found similar results (e.g.,
Mancil, 2006; Walker et al., 2017), the extent to which conclu-
sions can be made based on this finding is questionable.
Nonetheless, males experienced very large improvements in
challenging behaviour upon receiving FCT.
The moderator analysis indicated that participants who
engaged in less intensive behaviour (distracting; e.g., non-
participation, non-compliance, stereotypy) had significantly
greater improvements in aided or unaided AAC use as com-
pared to those who engaged in the highest priority behav-
iour (destructive; e.g., physical aggression toward others,
property damage, self-injurious behaviour). This outcome
suggests that students exhibiting less intensive challenging
behaviour may be able develop socially appropriate commu-
nicative behaviour at a higher rate. Additionally, destructive
behaviour may be more resistant to change, due to its sever-
ity and the relatively short duration of single case interven-
tion studies (Dunlap & Carr, 2007). Thus, the period of time
necessary to observe improved behaviour may need to be
prolonged for students who engage in destructive levels of
challenging behaviour.
The finding that participants receiving FCT in inclusive
school settings experienced greater improvements in aided
or unaided AAC use compared to those in non-inclusive set-
tings suggests that communication-based interventions may
result in better outcomes when taught and supported in set-
tings with peers without disability. This finding is promising
and in alignment with other reviews, suggesting that func-
tion-based intervention can be successfully implemented in
inclusive school settings across a range of participant and
intervention conditions (Andzik et al., 2016; Goh & Bambara,
2012; Walker et al., 2017). Nevertheless, readers are encour-
aged to exercise caution when interpreting this result, as
other unknown factors (e.g., student characteristics, specific
intervention conditions) potentially contributed to more pro-
nounced outcomes in inclusive environments as compared to
non-inclusive settings. Continued research is required to
explore these possibilities.
Unlike other reviews (e.g., Walker & Snell, 2013), the
results of the current study revealed that FCT informed by
126 V. L. WALKER ET AL.
descriptive FBA methods resulted in significantly greater
improvements in aided or unaided AAC use than FCT
informed by experimental FBA methods. The effect of FBA
method on challenging behaviour is unknown, because the
limited cases across studies did not permit such analyses.
Descriptive FBA methods, although less rigorous than experi-
mental methods, are more practical for school practitioners
who are responsible for developing and implementing FCT
with students who use AAC. In fact, Walker et al. (2017)
found function-based interventions were more effective
when FBA was conducted by teachers as opposed to highly
qualified therapists or researchers. If school practitioners can
use descriptive FBA that results in effective FCT interventions,
this may improve the feasibility of FCT, because there could
be less need to hire outside experts to conduct FBA and
develop FCT interventions.
Similar to findings from previous FCT reviews (e.g., Andzik
et al., 2016; Mancil, 2006), most participants in the current
review were diagnosed with intellectual disability or ASD.
This is not surprising, as these individuals experience high
prevalence rates of challenging behaviour (Lloyd & Kennedy,
2014; Sigafoos, 2000) and, consequently, often require inten-
sive, individualized behavioural supports. The results of the
current study provide additional evidence of FCT as being
effective for students with these diagnoses. Given this
mounting evidence, practitioners should consider FCT as a
strategy to address challenging behaviour among this popu-
lation of students who use AAC.
The instructional procedures used to implement FCT
involving AAC were not well described within the studies.
Specifically, the prompting and reinforcement procedures for
teaching aided or unaided AAC use were not well docu-
mented. This is particularly concerning, as research is
intended to inform practice, but, without specific information
about implementation procedures, practitioners cannot be
expected to implement effectively research-informed FCT
practices in schools. For those studies in which instructional
procedures were described, a range of strategies (e.g., con-
trived and natural establishing operations, different prompt
and prompt-fading systems) were found to be effective com-
ponents of FCT. As such, practitioners are encouraged to use
a student-centred approach (Holburn, 2002) in which a
students specific learning needs and history guide the selec-
tion of individualized strategies for teaching FCT involving
AAC. The current review also suggests that different
approaches for responding to challenging behaviours can be
effective. However, practitioners are encouraged to avoid
using punishment-based approaches (Reichle & Wacker,
2017), and focus instead on contextually-appropriate positive
behaviour support strategies to respond to challenging
behaviour in school settings, while carefully monitoring the
effectiveness of such strategies and consulting with experts,
if necessary. For further information on the use of FCT in
school settings, Mancil (2006) and Tiger et al. (2008) offer
practical guidelines that include suggestions for data collec-
tion procedures, arranging learning environments, planning
for generalization, prompting procedures, reinforcement, and
fading procedures. These guidelines can provide practitioners
with critical information necessary to successfully develop
and implement FCT.
Although a majority of the reviewed studies met the
WWC design standards with reservations, over 25% failed to
meet the minimum standards. In addition, the studies were
limited in their reporting of implementation fidelity, general-
ization, maintenance, and social validity. The lack of attention
to generalization and maintenance of FCT skills is a
concerning limitation, but not uncommon across literature
addressing individualized behavioural supports and commu-
nication-based interventions for students with disability (Goh
& Bambara, 2012; Heath et al., 2015; Snell et al., 2010; Walker
& Snell, 2013). When addressing challenging behaviour, it is
important that behaviour change is maintained to ensure
continued use of appropriate behaviour longitudinally (Lloyd
& Kennedy, 2014). Furthermore, the ultimate goal of FCT is
for students to use appropriate communicative behaviour
across multiple settings, conditions, and implementers
(Durand & Carr, 1991; Tiger et al., 2008). Practitioners are
strongly encouraged to plan and program for maintenance
and generalization during FCT intervention. If these strategies
are not used with FCT, students will likely resort to engaging
in challenging behaviours that were once effective in achiev-
ing the identified function(s).
Limitations and future research
There are several limitations that should be considered in
relation to this review. The review was limited to single-case
intervention research studies and excluded group design
studies. Furthermore, entire categories or coding items were
at times excluded from the moderator analyses due to the
small number of cases (e.g., FBA method for challenging
behaviour measures). Some coding items that qualified for
inclusion in the moderator analysis included a small number
of cases (e.g., inclusive vs non-inclusive settings), which
potentially limits the confidence with which the results can
be interpreted. Furthermore, studies included in the current
review often failed to provide adequate descriptions of the
participants, thus limiting the ability to analyse participant
characteristics as variables contributing to study outcomes.
Another limitation was the inclusion of cases in which
study quality was not confirmed. Although meta-analytic
researchers can handle cases representing poor study quality
in a variety of ways (Cooper et al., 2009), including them
within analyses can compromise meta-analytic findings.
Nonetheless, findings from the current study not only sug-
gest that study quality did not affect intervention outcomes,
but also provide an important descriptive account of study
quality that supports the need for continued high-quality
research related to FCT involving AAC within school settings.
Finally, the use of Tau-U as an intervention effect metric for
single-case research is a limitation, given the current lack of
consensus in the field regarding the appropriateness of dif-
ferent effect size indices for the purposes of meta-analytic
research (e.g., Kratochwill et al., 2010; Vannest & Ninci, 2015).
As such, comparisons across meta-analyses are challenging
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 127
when different intervention effect indices have been used to
summarize effect.
Future research is needed to explore further school set-
ting, student, and intervention characteristics that contribute
to positive FCT outcomes for students who use AAC. For
example, it was not possible in this review to conduct analy-
ses to detect differences in intervention effect based on com-
munication characteristics, because this information was
omitted in a majority of studies. It will be critical for research-
ers to report the communication characteristics of partici-
pants to allow for these types of analyses, especially given
that FCT is an intervention focused on communication. In the
current review, moderator analyses revealed differences in
intervention effect across three study characteristics for
measures of aided or unaided AAC use but not for measures
of challenging behaviour. Additional research is needed to
determine whether the type of FBA tool used to develop FCT
interventions affects reductions in challenging behaviour and
to identify variables that contribute to effective FCT imple-
mentation in inclusive school settings. Finally, the effective-
ness of specific instructional procedures (e.g., prompting,
reinforcement, schedule thinning) should be analysed in
future research to generate more informed guidelines for
practitioners.
Conclusion
The results of this study provide evidence that FCT involving
AAC can lead to improvements in aided or unaided AAC use
and a reduction in challenging behaviour for students with
disability who use AAC in school settings. FCT was effective
across participants with diverse characteristics and under a
wide range of intervention conditions. Several study charac-
teristics that moderated the effectiveness of FCT were identi-
fied. With the goal of developing guidelines for practitioners,
continued research to more fully explore potential variables
contributing to effective implementation of FCT across a
range of school settings for students with disability who use
AAC is encouraged.
Disclosure statement
No potential conflict of interest was reported by the authors.
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AUGMENTATIVE AND ALTERNATIVE COMMUNICATION 129
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Purpose Telepractice has become a popular service delivery option for young children with autism spectrum disorder (ASD), especially as a result of the COVID-19 pandemic. However, practitioners can face some unique challenges when delivering interventions to young children and their families via telepractice. Furthermore, the use of telepractice requires specific practitioner skills, technologies, and family participation to ensure that interventions are effectively delivered. Drawing on the existing literature and our collective experience implementing telepractice-based interventions with families, we provide five practical tips for supporting families of children with ASD while implementing effective interventions via various telepractice modalities. Telepractice tips include the following: (a) think beyond video conferencing formats, (b) establish a meaningful and culturally responsive relationship with the family, (c) select appropriate interventions to support the child's development, (d) adhere to ethical and professional standards when implementing telepractice, and (e) gain knowledge and skills through professional development to enhance telepractice delivery. Conclusion Using each of these tips will help practitioners support families with children with ASD in effective implementing telepractice interventions.
... FCT is a communication intervention designed to teach an alternative, usually communicative, response that functionally replaces an inappropriate response emitted by the student when encountered with a problem (Walker et al., 2018). By emitting the more socially appropriate response, the student obtains access to a functionally equivalent outcome. ...
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... In the study, 16 findings of 113 AAC procedure efficacy subjects, 12 months to 34 years old, who were deaf and blind, were conducted by Bourque (Bourque, 2020). There were three different AAC styles, while 92% of the respondents had enhanced communication abilities, they concentrated on teaching essential core skills, not even on spoken/oral performance (Walker et al., 2018). ...
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... As such, it is important to develop function-based interventions by using operant conditioning procedures, which help to establish alternative appropriate behaviors and decrease SIB (Carr & Durand, 1985). Since ASD is characterized by deficits in language and communication skills, researchers (e.g., Carr & Kemp, 1989;Hagopian & Frank-Crawford, 2018) have explored the relationship between communication deficits and SIB and found that providing communication-based supports for students exhibiting SIB is imperative because communication skills can give students a socially valid approach that meets their needs (Walker et al., 2018). ...
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This study investigated effects of a positive behavior support plan accompanied by an augmentative and alternative communication (AAC) intervention on the reduction of challenging behaviors manifested by children with moderate and severe mental retardation. A multiple-probe design across participants was used for collecting data on various challenging behaviors exhibited by students including: self-injurious behaviors, pinching, pulling, screaming, and crying. All behaviors were assessed using functional assessment, followed by a positive AAC support plan created by the school team. Participants were taught to use more appropriate alternative means to communicate. Results indicated a reduction in the percentage of intervals of challenging behaviors. The positive support plans created by the whole school staff used AAC for enhancing communicative behaviors. This plan provided students with alternatives, which also enabled them to enhance the learning of class material.
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Functional communication training (FCT) is an intervention frequently used for students with developmental disabilities to reduce problematic behaviors and to increase prosocial behaviors. This intervention appears to be very effective when the communication responses trained are matched to the function of the student's problematic behaviors. In most cases, however, FCT is implemented as pan of an intervention package. As a result, there is little research showing FCT to be effective without additional treatment components. In this investigation, the results of a brief functional analysis conducted with a student with autism in an inclusive school setting revealed that the student's self-injury served as a negative reinforcement function. We used a multiple baseline design across classrooms to evaluate the effects of FCT in the absence of augmentative procedures. The results of this study indicate that ameliorating the student's self-injury occurred with implementing the FCT procedure in isolation, providing growing support for using FCT without augmentative procedures.