Research in Developmental Disabilities 32 (2011) 2935–2942

Contents lists available at ScienceDirect

Research in Developmental Disabilities

An analysis of functional communication training as an empiricallysupported treatment for problem behavior displayed by individualswith intellectual disabilities

Patricia F. Kurtz a,b,*, Eric W. Boelter c, David P. Jarmolowicz d, Michelle D. Chin a,Louis P. Hagopian a,b

a Kennedy Krieger Institute, United Statesb The Johns Hopkins University School of Medicine, United Statesc Seattle Children’s Autism Center, United Statesd Virginia Tech Carilion Research Institute, United States

A R T I C L E I N F O

Article history:

Received 3 May 2011

Accepted 4 May 2011

Available online 21 June 2011

Keywords:

Functional communication training

Empirically supported treatments

Intellectual disability

Autism

Problem behavior

Aggression

Self-injury

Property destruction

A B S T R A C T

This paper examines the literature on the use of functional communication training (FCT)

as a treatment for problem behavior displayed by individuals with intellectual disabilities

(ID). Criteria for empirically supported treatments developed by Divisions 12 and 16 of the

American Psychological Association (Kratochwill & Stoiber, 2002; Task Force, 1995) and

adapted by Jennett and Hagopian (2008) for evaluation of single-case research studies

were used to examine the support for FCT. Results indicated that FCT far exceeds criteria to

be designated as a well-established treatment for problem behavior exhibited by children

with ID and children with autism spectrum disorder, and can be characterized as probably

efficacious with adults.

� 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Individuals with intellectual disabilities (ID) are at increased risk for the development of problem behavior such asaggression, self-injury, and property destruction. These behaviors may emerge out of the interaction of multiple factorsincluding deficits in adaptive behavior, predisposing biological factors including autism and psychiatric conditions, as wellas environmental events that occasion and reinforce these responses. Research spanning four decades has demonstrated theefficacy of behavioral approaches for treatment of problem behavior associated with ID and autism (DeMyer, Hingtgen, &Jackson, 1981; Didden, Duker, & Korzilius, 1997; Kahng, Iwata, & Lewin, 2002; Matson, Benavidez, Compton, Paclawskyj, &Baglio, 1996; Sturmey, 2002; Weisz, Weiss, Han, Granger, & Morton, 1995).

Functional communication training (FCT) is a commonly used and researched intervention for such problems (Tiger,Hanley, & Bruzek, 2008). FCT is a function-based differential reinforcement procedure that involves teaching the individualto use an appropriate communication response to access the reinforcer responsible for maintaining problem behavior (Carr& Durand, 1985). Thus, FCT seeks to establish the skills and create the environmental conditions under which a socially

* Corresponding author at: Department of Behavioral Psychology, Kennedy Krieger Institute, 707 N. Broadway, Baltimore, MD 21205, United States.

E-mail address: Kurtz@kennedykrieger.org (P.F. Kurtz).

0891-4222/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ridd.2011.05.009

P.F. Kurtz et al. / Research in Developmental Disabilities 32 (2011) 2935–29422936

appropriate communication response, rather than problem behavior, will be used to access reinforcement. FCT is primarilyused to treat a variety of problem behaviors maintained by social reinforcement (e.g., access to attention, access to materials,and escape from demands) in persons with ID (see Tiger et al., 2008 for a review). FCT is typically used with extinction forproblem behavior, and a number of studies have described the use of additional treatment components, including alternativeor competing reinforcers, and punishment. Although FCT is one of the most widely used interventions for problem behaviorexhibited by persons with ID, it has not yet been formally characterized in terms of the American Psychological Association(APA) criteria for ‘‘Empirically Supported Treatments’’ (Kratochwill & Stoiber, 2002; Task Force, 1995). As defined byDivisions 12 (Clinical Psychology) and 16 (School Psychology) of the APA, these criteria consider both the number ofexperimentally rigorous studies and the outcomes achieved. Depending on the level of empirical support, interventions canbe classified as well-established, probably efficacious, or experimental. Although this approach (see Chambless & Hollon, 1998)has been used to evaluate the empirical support for numerous treatments used with typically developing individuals,relatively few interventions used with individuals with ID have been similarly evaluated. Differential reinforcement met thecriteria to be considered a well-established treatment for teaching skills to young children with autism (Odom et al., 2003).Rogers and Vismara (2008) found that Lovaas’ comprehensive treatment approach for very young children with autism(Lovaas, 1987) met criteria as a well-established intervention. Carr, Severtson, & Lepper (2009) concluded that noncontingentreinforcement, another commonly used intervention for problem behavior exhibited by individuals with ID, met the criteriato be considered a well-established treatment. Similarly, Jennett and Hagopian (2008) found that behavioral treatment forphobic avoidance displayed by individuals with ID could be characterized as well-established.

The purpose of the current review was to critically examine the existing literature on FCT as a treatment for problembehavior (e.g., aggression, self-injury, and property destruction) displayed by persons with ID. Criteria for empiricallysupported treatments as described by Divisions 12 and 16 of APA for evaluating the empirical support for interventions wereapplied. Because none of the studies on FCT used group designs, additional criteria developed specifically for studiesemploying single-case designs described by Jennett and Hagopian (2008) were used.

2. Method

2.1. Article selection

Articles were initially located by reviewing published studies listed in the PsychLit and PubMed databases betweenJanuary 1985 and October 2009. Three search terms used were: (1) functional communication training; (2) functionalcommunication; and; (3) alternative communication. Two search terms were always combined and each term wascombined with every other term. Following this initial step, the abstracts of the articles meeting the above criteria werereviewed to determine if the authors had implemented FCT as a treatment for aggression, self-injury, or property destruction(referred to in this manuscript collectively as ‘‘problem behavior’’). Next, results sections of the articles were reviewed todetermine if treatment efficacy data were reported. Studies were either included or excluded in the current review based onthe criteria described below. Included articles were subsequently reviewed and coded for the purpose of determining if FCTmet criteria as an Empirically Supported Treatment.

2.2. Article review and coding

This search yielded 64 articles: of these, the 29 studies that presented or reported data on percent reduction of problembehavior were included for review. All the articles were coded in accordance with criteria for empirically supported treatmentsdescribed by APA Divisions 12 and 16. Because all 29 studies employed single-case experimental designs rather than groupdesigns, the adaptations to the criteria described by Jennett and Hagopian (2008) were used. All articles were coded for (1) thespecification of participant characteristics, (2) study characteristics (number of participants, description of dependent andindependent variables, etc.), (3) experimental design, (4) an analysis of experimental control, and (5) treatment efficacy.

2.3. Interobserver agreement

Three graduate students in applied behavior analysis were trained in coding definitions and procedures. A second personindependently coded the data of 58.6% (17 of 29) of the studies. Inter-observer agreement was calculated using the exactagreement formula (number of agreements/(number of agreements + number of disagreements)) � 100. An agreement wasdefined as both coders scoring the presence or absence of experimental control (good experimental design and treatmentsuperior to baseline with replications), demonstration of treatment efficacy, detailed description of treatment procedures,and clear specification of participant characteristics. The average reliability coefficient was 94.0% (range 87.5–100 across the4 categories listed above).

2.4. Criteria for determining empirically supported treatments

Division 12 of APA established the following categories for the level of empirical support: well established, probably

efficacious, and experimental (Task Force, 1995). For treatments to be considered well established there must be at least two

P.F. Kurtz et al. / Research in Developmental Disabilities 32 (2011) 2935–2942 2937

good between-group design studies or more than nine single-case studies that have been found to be statisticallysignificantly superior to another treatment, pill, or placebo, or equivalent to an already established treatment. The criteriastipulate that experiments must be conducted using treatment manuals or contain clear descriptions of the treatmentprocedures; characteristics of the sample must be specified; and the effects must be replicated by independent researchgroups such that at least two different research teams have found the treatment to be efficacious. Treatments are classified asprobably efficacious if at least two experiments using group designs show that the treatment is statistically significantlysuperior to a wait list control group; or at least one group design experiment meets the well established criteria; or at leastthree well-controlled single-case design experiments meet the well established criteria. Treatments that do not meet thecriteria for well established or probably efficacious categories are considered experimental treatments.

These criteria lack some specificity with regard to single-subject experimental designs – which is the type of designemployed in all FCT studies reviewed. Therefore the current analysis adopted the specific modifications to Divisions 12 and 16criteria for judging the quality of baseline, appropriate use of measurement, and evaluation of treatment outcome throughvisual analysis modeled after those used by Jennett and Hagopian (2008). These criteria are based on established principles andconventions for using single-case experimental designs (Barlow & Hersen, 1984; Kazdin, 1982). Jennett and Hagopiandelineated the following: (1) criteria for evaluating the quality of baseline by examining the length of the baseline (which shouldbe at least three data points), the stability of the data, whether there is an overlap of data with the treatment phases, if the level ofbehavior was severe enough to warrant intervention, and if the trends in the data were stable or in the opposite direction of adesired treatment effect. (2) Criteria for appropriate measurement of behavior, including operationally defined targets, and thecollection of inter-observer agreement data. (3) Use of visual analysis of graphically depicted data with consideration of thefollowing factors: change in the level of behavior relative to baseline, change in the trend of the data to the desired direction, thelength of the treatment phase (which should be at least three data points), the stability of data, and minimal overlap in the levelof behavior between the baseline phase and the treatment phase; and (4) criteria for determination of treatment efficacy: an80% or greater reduction in problem behavior relative to baseline levels was used as the criterion. In the case of multipleparticipants within a study, at least two-thirds of participants had to meet these criteria.

3. Results

Each study was coded in terms of whether it met criteria for good experimental control (i.e., good experimental design,including replication of treatment effects), sufficient treatment efficacy (i.e., whether the participants attained at least an80% reduction in problem behavior relative to baseline), the adequacy of the description of treatment (at a level sufficient topermit replication), and the specificity of client characteristics. The results indicated that 28 of the 29 identified studies metall the criteria (see Table 1). One study used non-experimental designs (e.g., AB designs with multiple participants) thus itwas removed from further analyses. Based on these findings, FCT can be characterized as a well-established treatment forproblem behavior in persons with ID.

3.1. Participant characteristics

There were a total of 80 participants described across the 28 studies examined (see Table 2). The majority of participants(75%) were children. Over half of the participants were diagnosed with an autism spectrum disorder (ASD), and the majorityhad some level of intellectual disability. Participants displayed a range of target problem behaviors, including self-injury,aggression and destructive behavior.

3.2. Study characteristics

The 28 studies were coded for the setting, assessment of problem behavior, therapist conducting assessment andtreatment sessions, function identified for problem behavior, and type of single-case design (see Table 3). The averagenumber of participants per study was 3 (range 1–19). The majority of studies had one to two participants; while two studieshad 14 and 19 participants (Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998; Kurtz et al., 2003, respectively). FCTinterventions took place in a variety of settings, with the highest percentage being conducted in inpatient settings (48%).Clinical therapists/behavior analysts served as therapist in the majority of cases (60%), while parents or teachers served astherapist for a quarter of the cases. Functional analyses of problem behavior (using experimental designs and directobservation of behavior) were conducted for 67 participants (84%) across 23 of the 28 studies. Antecedent analyses wereused for 12 participants, and with one case, only a descriptive analysis was conducted. With regard to functional assessmentoutcome, 53% had problem behavior maintained by access to positive reinforcement, 25% by negative reinforcement, and15% by both positive and negative reinforcement. The most frequently used single-case design for evaluation of FCT was areversal design (45%). All studies had interobserver agreement data on the dependent variables.

3.3. Evaluation of empirical support

To further examine the effectiveness of FCT as an intervention for individuals with ID, three additional analyses wereconducted. First, participant characteristics of the 28 studies were coded for the variables of age and primary diagnosis. FCT

Table 1

Empirically supported treatment criteria and the status of studies employing single-case designs to evaluate FCT as treatment of problem behavior in

individuals with intellectual disabilities.

Demonstration

of experimental control

Determination

of efficacy

Treatment

manual

Client

characteristics

Good

experimental

design

Treatment

superior to

baseline

w/replications

Attainment of

80% reduction

relative to

baseline

Description

of treatment

equivalent to

treatment manual

Clearly

specified

Bowman, Fisher, Thompson, & Piazza, 1997 Yes Yes Yes Yes Yes

Braithwaite & Richdale, 2000 Yes Yes Yes Yes Yes

Carr & Durand, 1985 Yes Yes Yes Yes Yes

Derby et al., 1997 Yes Yes Yes Yes Yes

Doughty & Anderson, 2006 Yes Yes Yes Yes Yes

Durand, 1999 Yes Yes Yes Yes Yes

Durand & Carr, 1987 Yes Yes Yes Yes Yes

Durand & Carr, 1991 Yes Yes Yes Yes Yes

Fisher, Adelinis, Thompson, Worsdell, & Zarcone, 1998 Yes Yes Yes Yes Yes

Fisher et al., 2005 Yes Yes Yes Yes Yes

Fisher, Kuhn, & Thompson, 1998 Yes Yes Yes Yes Yes

Fisher et al., 1993 Yes Yes Yes Yes Yes

Fisher, Thompson, Hagopian, Bowman, & Krug, 2000 Yes Yes Yes Yes Yes

Fyffe, Kahng, Frittro, & Russell, 2004 Yes Yes Yes Yes Yes

Hagopian et al., 1998 Yes Yes Yes Yes Yes

Hagopian, Toole, Long, Bowman, & Lieving, 2004 Yes Yes Yes Yes Yes

Hagopian, Wilson, & Wilder, 2001 Yes Yes Yes Yes Yes

Hanley, Iwata, & Thompson, 2001 Yes Yes Yes Yes Yes

Hanley, Piazza, Fisher, Contrucci, & Maglieri, 1997 Yes Yes Yes Yes Yes

Kahng, Iwata, DeLeon, & Worsdell, 1997 Yes Yes Yes Yes Yes

Kurtz et al., 2003 Yes Yes Yes Yes Yes

LeBlanc, Hagopian, Marhefka, & Wilke, 2001 Yes Yes Yes Yes Yes

Lindauer, Zarcone, Richman, & Schroeder, 2002 Yes Yes Yes Yes Yes

Mildon, Moore, & Dixon, 2004 Yes Yes Yes Yes Yes

Perry & Fisher, 2001 Yes Yes Yes Yes Yes

Roane, Fisher, Sgro, Falcomata, & Pabico, 2004 Yes Yes Yes Yes Yes

Shirley, Iwata, Kahng, Mazaleski, & Lerman, 1997 Yes Yes Yes Yes Yes

Thompson, Fisher, Piazza, & Kuhn, 1998 Yes Yes Yes Yes Yes

Wacker et al., 2005 No No Yes Yes Yes

Table 2

Participant characteristics.

Category Number of participants

Age

Children (age 0–6) 29

Children (age 7–12) 31

Adolescents (age 13–18) 11

Adults (age > 18) 9

Total 80

Primary diagnosis

Autism spectrum disorder 23

Other 42

Not reported 15

Total 80

Level of intellectual disability

None 5

Mild 9

Moderate 10

Severe 16

Profound 15

MR unspecified 12

Not reported 13

Total 80

Topography of problem behavior

Self-injurious behavior 54

Aggression 49

Destructive behavior 38

Combined problem behavior 13

Pica 4

Stereotypy 8

Other 10

P.F. Kurtz et al. / Research in Developmental Disabilities 32 (2011) 2935–29422938

Table 3

Study characteristics.

Category Number of participants

Study setting

Inpatient 38

Outpatient/day treatment 20

School 13

Home/community 8

Not reported 1

Therapist

Clinical therapist 47

Parent 13

Clinical therapist and parent 1

Teacher 7

Other/not reported 12

Type of functional assessment

Functional analysis 67

Descriptive analysis 1

Antecedent analysis 12

Function of problem behavior

Attention 21

Tangible 13

Escape 20

Attention + tangible 7

Attention + escape 5

Tangible + escape 5

Attention + escape + tangible 2

Other 5

Unknown 2

Type of treatment design

Reversal 36

Multiple baseline 21

Multi-element 5

Combined designs 4

Unknown 14

P.F. Kurtz et al. / Research in Developmental Disabilities 32 (2011) 2935–2942 2939

can be characterized as a well-established treatment for problem behavior in children (a total of 24 studies with participants0–18 years of age), and as probably efficacious with adults (a total of 5 studies with adults, falling short of the required 10studies). FCT also can be characterized as a well-established treatment for individuals diagnosed with an autism spectrumdisorder (ASD) as 16 studies were identified that included participants with ASD.

Second, the specific FCT interventions used in the 28 studies were also coded for treatment components used incombination with FCT (see Table 4). FCT far exceeded the criteria as a well-established treatment when used in combinationwith extinction as 21 studies demonstrated FCT with extinction to be effective. There were an additional 10 studies whereFCT with extinction and additional treatment components (e.g., noncontingent reinforcement, choice) was effective. FCTwith punishment can be characterized as probably efficacious as 7 studies met criteria, however, it bears mentioning thatthese studies included many participants, and FCT with punishment was effective in 100% of cases. FCT alone conversely hadlittle support (3 studies), thus its use without extinction cannot be supported at this time.

Finally, Table 5 depicts the total number of studies and the total number of applications of FCT plus additional treatmentcomponents (extinction, punishment), and those studies and applications by function identified for problem behavior. FCTplus extinction can also be characterized as well established for problem behavior maintained fully or in part by attention,escape, and access to tangible items. FCT plus punishment can also be characterized as probably efficacious for these threefunctions.

Table 4

Number of studies and applications utilizing FCT and other treatment components.

Category Number of studies Number of applications

FCT 2 2

FCT + other 1 2

FCT + extinction 21 53

FCT + extinction + other 10 11

FCT + punishment 7 31

FCT + punishment + other 1 7

Table 5

FCT interventions by function of problem behavior.

Total Total: attention

function

Total: tangible

function

Total: escape

function

Total: other

function

Studies Apps Studies Apps Studies Apps Studies Apps Studies Apps

FCT

FCT 2 2 0 0 1 1 1 1 0 0

FCT + other 1 2 1 1 1 1 0 0 0 0

Total 3 4 1 1 2 2 1 1 0 0

FCT + extinction (EXT)

FCT + EXT 15 40 7 12 6 10 9 16 2 2

FCT + EXT + Sch. Thin. 6 13 4 5 4 5 2 2 1 1

FCT + EXT + other 5 5 2 2 1 1 1 1 1 1

FCT + EXT + other + Sch. Thin. 5 6 1 2 2 2 2 2 0 0

Total 31 64 14 21 13 18 14 21 4 4

FCT + punishment (PUN)

FCT + PUN 5 16 4 8 1 4 2 2 2 2

FCT + PUN + Sch. Thin. 2 15 1 5 2 2 2 8 0 0

FCT + PUN + Other 1 7 1 2 1 2 1 1 1 2

Total 8 38 6 15 4 8 5 11 3 4

Note: Apps, applications; Sch. Thin., schedule thinning.

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4. Discussion

FCT is a highly individualized intervention. The specific reinforcer(s) that the communication response produces, theform of the communication response, and the method of training used to establish the communication response vary widelyacross participants. At the same time, there is a generally uniform treatment algorithm for FCT. It involves (1) functionalanalysis to identify the reinforcers maintaining problem behavior; (2) selection of a communication response (based ongeneral communication skills, and prescribed augmentative communication systems); (3) a shaping procedure to establishthe communication response; (4) the application of differential reinforcement (for communication) and extinction forproblem behavior; (5) the addition of other treatment components, when necessary; and (6) programming for generalizationthrough exposure to other therapists, environments, and reinforcement schedule thinning. Generally, the same is true forother functional-analysis-based behavioral interventions for problem behavior: a general treatment algorithm provides aframework upon which an individualized intervention is built.

This review reveals that there is sufficient empirical support to characterize functional communication training (FCT) as awell-established treatment for a range of problem behavior exhibited by persons with ID; and for problem behaviormaintained by attention, access to tangible items, and escape from demands. In fact, 28 studies of sufficient quality wereidentified, far exceeding the criteria needed to characterize an intervention as well established. In particular, it is a well-

established treatment for children and adolescents with ID, and individuals with ASD. FCT with adults (over 18) can becategorized as probably efficacious.

The adaptations to Divisions 12 and 16 criteria described by Jennett and Hagopian (2008) for use with studies employingsingle-case designs were applied in the current analysis. Although the adaptations are arguably logical extensions of theoriginal criteria, the Jennett and Hagopian criteria have yet to be formally accepted or applied by other researchers – otherthan implicitly through their publication. Thus, the current study is limited in that regard. The current analysis illustratesthat the designation of interventions as well-established, probably efficacious, and experimental refers to the amount ofevidence supporting its efficacy, rather than an appraisal about the comparative effectiveness. In the case of FCT, FCT withextinction was found to meet criteria as a well-established treatment, but FCT with punishment was classified as probably

efficacious. However, FCT with punishment was effective in all cases described, whereas FCT with extinction was not.Furthermore, previous studies directly comparing the effects of FCT with extinction to FCT with punishment found FCT withpunishment to be more effective (Fisher et al., 1993; Hagopian et al., 1998; Wacker et al., 1990). Thus, findings of this andother analyses examining the level of empirical support for interventions must also take into consideration findings fromcomparative studies.

There is an extensive body of literature demonstrating the effectiveness of function-based behavioral interventions forindividuals with ID, but most are small-n studies employing single-case experimental designs. Althoughmethodologically rigorous with regard to demonstration of treatment effects at the individual level, an analysis ofmultiple studies involving numerous participants in the aggregate has value in making broader conclusions about theeffects of the intervention. This study adds to the limited literature employing empirically supported treatment criteria toevaluate the level of empirical support for interventions for persons with ID (Carr et al., 2009; Jennett & Hagopian, 2008).The potential benefits of classifying interventions in these terms include, but are not limited to, enhancing the careprovided by keeping clinicians informed about effective practice, guiding clinical training, and directing clinical researchefforts (Chambless & Ollendick, 2001).

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