Facilitated Communication and Dyspraxia
by Alan Kurtz
The provision of physical support by another human being remains the most controversial aspect of facilitated communication. Critics and proponents all ask questions such as, "Why does the person need the facilitator's support?" and "If s/he can spell and point why can't s/he type independently?" It has been hypothesized that some people may have difficulty communicating through independent pointing because of motor planning problems (Crossley, 1988; Biklen, 1990). Recently, the term developmental dyspraxia has been used to describe the type of motor planning difficulties faced by some of those who have benefited from facilitated communication (Biklen, 1993). In this article I will briefly examine (1) the concept of dyspraxia, (2) the difference between motor planning and motor skills, (3) evidence for the existence of dyspraxia among people using facilitated communication - particularly individuals with autism, and (4) how facilitation may function as an accommodation for persons with dyspraxia.
Motor planning, or praxis, is "...the ability to conceive, organize, and carry out an unfamiliar sequence of movement " (italics added) (Kimball, 1992, p. 1). Dyspraxia is difficulty in planning a sequence of movements. Dyspraxia results, according to Kimball, when the motor system is not automatic. Everyone initially approaches new motor sequences cognitively. A person must think about what s/he is going to do and how to do it. After practicing an activity it usually becomes more automatic. When we drive a car for the first time, we have to think about everything we do but over time our responses become automatic. Skiing or dancing are other movements that initially require a great deal of concentration. With practice, though, we learn to perform these skills without having to think about each discrete movement.
For persons with dyspraxia the motor planning required to perform a task may remain cognitive. They must consciously think and plan each step. A limited repertoire of automatic skills can further complicate the process of trying to perform new motor sequences. Persons with dyspraxia frequently have difficulty with:
Even when a new sequence is similar to previous skills that a person has mastered, the person with dyspraxia may have to relearn each step in the new sequence (Ayres, 1989; Cermak, 1990).
Difficulty with motor planning is not the same as having poor gross and/or fine motor skills. An individual may demonstrate good motor skills in some tasks under certain conditions but still have problems making his/her body do what s/he wants it to do on a new sequence or under different conditions. This has led to some confusion in the discussion of the relationship of motor problems to facilitated communication. For instance, Rimland (1993, p.3) argues: "Most parents indicate that their children are average or above in the use of their hands. 'The idea that autism is, or typically involves, a "movement disorder" is ludicrous." Critics of FC argue that if a person lacks the motor skills to independently access a keyboard, mechanical adaptations can be made. Physical support by another persons is unnecessary (Shane, 1994).
Equating normal dexterity or good motor skills with the absence of motor disturbance seriously oversimplifies the issue. Many persons with autism who can demonstrate good motor skills in some situations may struggle when presented with a new or unique motor task. Likewise, a person who can complete a complex puzzle or show great dexterity at a mechanical task may be unable to write his or her name legibly between two widely spaced lines.
When I discuss motor planning in workshops, I start by showing participants an overhead with a diagram of juggling instructions. I explain the instructions and give a brief demonstration. When everyone has indicated that they understand the instructions I ask for a volunteer. First, I assess the volunteer's motor skills. I ask him or her to throw a ball from one hand to the other - a skill nearly everyone can perform. I then ask the volunteer if s/he remembers the directions for juggling. If so, I hand the person three balls and instruct him/her to juggle. Inevitably, the person attempting to juggle forgets to throw the second or third ball or the pattern that s/he claims to understand. The volunteer obviously has the motor skills to juggle and says s/he understands the directions. If people understand how to juggle and possess the requisite motor skills, why do they have so much difficulty? Why do people who can point and who know how to spell have trouble typing independently?
Ayres (1989) and Cermak (1990) point out that many persons with dyspraxia demonstrate adequate skills in tasks that are part of regular routines. Outside the specific task, though an individual may have difficulty re-sequencing previously learned motor skills.
Just as would-be jugglers have difficulty in their first attempt, persons with dyspraxia often have difficulty with any new motor sequence. With a little practice, however, most novice jugglers can quickly learn to make the skill an automatic one. Persons with dyspraxia might never learn the skill. Even more difficult for someone with dyspraxia would be generating an acquired skill to new situations. A person who juggles tennis balls, for instance, might have difficulty juggling clubs or learning to juggle in a new, unfamiliar pattern.
Each time we communicate an original thought we sequence a new series of motor responses. This is true both for speech and for writing or typing. Speech and/or typing are complex new motor sequences that may be affected by a person's dyspraxia.
Some of the symptoms of dyspraxia include: difficulty starting or initiating an activity (Miller 1986), difficulty stopping an activity, difficulty with new motor sequences (Ayres, 1989, Cermak, 1990), engaging in a fine motor skills while concentrating on something else such as writing while trying to express ideas (Kimball, 1992), modulating the pace of an action
(Kimball, 1992), sequencing (Cermak 1990), impulsiveness (Miller, 1986), difficulty in responding to verbal commands (Miller, 1986), inconsistent feedback from one's body (Kimball, 1992), and difficulty making unstructured choices (Kimball, 1992) and inconsistent performance (Miller, 1986; Kimball, 1992).
According to Miller (1985) the cooccurrence of dyspraxia with sensory or perceptual dysfunction is common. For occupational therapists the two are almost inseparable. In the sensory integration literature, some forms of dyspraxia have been associated with both sensory dormancy and sensory defensiveness including tactile, auditory, and visual defensiveness (Cermak, 1990; Royeen and Lane, 1990). Persons who have difficulty processing vestibular-proprioceptive information often demonstrate difficulty with bilateral integration and sequencing (Cermak, 1990). Ayres (1985) felt the ability to integrate sensory information forms the basis for knowledge of one's body andthe ability to make adaptive motor responses or plans.
For instance, in our juggling example, a juggler must integrate a great deal of sensory information while performing. S/he must visually perceive where the objects are well as judge their projected movement. The juggler must be aware of his/her body position and where his/ her arms and hands are in space -proprioception. Tactile discrimination is used to provide the juggler with feedback about when the object has touched his/her hand. The new juggler must integrate all this sensory information, think about how the three separate objects are supposed to move, and make the necessary adaptive motor responses. Good motor skills such as good eye-hand coordination can make learning juggling easier but an individual still needs to learn how to integrate all the sensory information and make the adaptive responses which make juggling possible. This is difficult to do for beginning jugglers because they have to also concentrate on what each hand does and when it does it.
Evidence for the presence of dyspraxia in persons with autism and other developmental disabilities
Many individuals with autism have reported difficulties in integrating various types sensory inputs (See for example, Grandin and Scaviano, 1986). Persons with autism and other developmental disabilities frequently demonstrate tactile defensiveness. Persons with autism often have proprioceptive and vestibular problems (Damasio and Maurer, 1978). Sensory integration problems, tactile defensiveness, and proprioceptive and vestibular difficulties have all been associated with dyspraxia. It would not be surprising, therefore, to see a high incidence of dyspraxia among this population.
Margaret Bauman, who has researched the neurology of autism, believes that many persons with autism are, in fact dyspraxic. In the Autism Society of America's newsletter, she says:
In regard to autism, many child neurologists, particularly those of us who see many autistic children in our practices, believe that there is a high incidence of dyspraxia in this population. This observation was fairly recently supported by a personal communication pertaining to a small study in which ten adults with autism were studied with this question in mind. All were found to be dyspraxic. (Bauman, quoted in ASA, 1993).
The reliance of persons with autism on strict routines and rituals might also be an indication of difficulty in developing motor plans for new and unique sequences. Persons with dyspraxia often overlearn activities and have difficulty deviating from established routines (Miller, 1986).
In first person accounts of autism motor planning difficulties are frequently discussed. Sean Barron (Barron and Barron, 1992), Temple Grandin (Grandin and Scaviano,1986) and Donna Williams (1992, 1994) each report difficulties with motor activities in their autobiographies.
As Donnellan, Sabin, and Majure (1992) claim, it is probably much too early to embrace dyspraxia or any other label to describe the complexity of motor differences in persons with autism and other developmental disabilities. Autism and other related developmental disabilities are not simply forms of severe dyspraxia.
Emotional, communicative, social and cognitive factors may interact with motor difficulties in ways we do not yet understand. Motor problems, themselves, are probably much too complex and varied to be described with a single term.
Damasio and Maurer (1978) were among the first to look at the complexities of motor disturbance in persons with autism when they wrote: "Disturbances of motility are an important aspect of the clinical picture of autism and constitute a clear indication of CNS [central nervous system] involvement." Among the neuromotor problems they identified were: dystonia, bradykinesia, hyperkinesia, emotion related facial asymmetry, posture and gait problems (including parkinsonian gait), vestibular and proprioceptive problems, obsessive/compulsive behaviors, and perseveration. Recently, Hill and Leary (1993) contributed to this growing body of literature compare the symptoms of autism and other developmental disabilities with other neuromotor conditions such as Idiopathic Parkinsonism, Tourette's Syndrome, and Catatonia finding remarkable overlap.
In Anne Donnellan and Martha Leary's (1995) new book Movement Differences and Diversity in Autism/Mental Retardation: Appreciating and Accommodating People with Communication and Behavior Challenges they further explore the complex connection between movement differences, communication difficulties, and strategies for accommodating those differences. (This is an excellent book and will be reviewed in the next issue.) While recognizing the complexity of motor differences that exist in persons using facilitated communication, I feel it can be concluded that: (1) persons with autism and other developmental disabilities who use facilitated communication demonstrate symptoms of dyspraxia, and (2) the provision of physical support by a facilitator is, in part, an accommodation for dyspraxia.
The purpose of Facilitated Communication In Maine is to promote the appropriate use of facilitated communication through education, technical assistance, and support to people with disabilities, parents, educators, speech and language pathologists support providers, and other interested individuals. The project provides up-to-date information on current best practices, introductory and advanced workshops on the technique, resources regarding theoretical and practical components of facilitated communication and ongoing support to a network of resource persons who provide local education and support to other facilitators.
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