Spelling to Communicate Goes on Trial: Part III
This is the third part in a series on a Spelling to Communicate (S2C) lawsuit against a school district. You can read more about the background in my first post, but, in brief, the lawsuit arose because the school district, the Lower Merion School District of Lower Merion PA, refused to hire an S2C “communication partner” for the parents’ non-speaking autistic son (A.L.).
This series focuses, specifically, on a hearing that occurred last December that I now have permission to write about. The hearing was a Daubert hearing, aka a “voir dire” (an oral questioning/examination) of several of the plaintiff’s expert witnesses whom the School District sought to disqualify.
The facilitator controls access to the letter board/stencil during an S2C session. (Image from Spellers, 2023)
In my previous two posts (here and here), I described and excerpted the “direct” examinations (as opposed to cross-examinations) of two people:
Dr. Anne Robbins, the neuropsychologist whom A.L.’s parents hired to do an independent, neurocognitive assessment of A.L.: an assessment that was based, in part, on output that A.L. generated via S2C
Dr. Wendy Ross, a highly celebrated figure in the Philadelphia autism and neurodiversity scene and A.L.’s former developmental pediatrician, who testified under oath that she believes that S2C works for A.L.
Takeaways from the previous posts were, from Dr. Robbins:
That A.L. has average or above listening comprehension capabilities but (on certain nonverbal subtests) didn’t understand what she was asking him to do.
That A.L. couldn’t point to a numbered choice on a stationary surface but could point to a number on a held-up letterboard.
A.L.’s scores, based on S2C-generated output, were much higher on verbal subtests than on nonverbal visual pattern subtests: a striking reversal of what’s generally found in autism.
And, from Dr. Ross:
That apraxia is something that affects “any body part that moves” (not really), and that bodily apraxia is associated with autism (not really).
That A.L.’s autism social reciprocity improves when he is subjected to S2C.
That she’s witnessed evidence of facilitator control over messages in some of her patients: the first public admission of facilitator control that I’m aware of by someone who believes that S2C is valid.
That at a visit with his new doctor, with his mother holding up the letterboard, A.L. typed out that his ears were hurting, and the doctor subsequently verified that he indeed had an ear infection. This ear infection story, which has been recounted by A.L.’s mother in a blog post she wrote for a pro-S2C website about why A.L. won’t participate in message-passing (authorship) tests, is the only specific example I’ve heard recounted of an S2Ced person communicating information that the communication partner purportedly didn’t have access to.
I now turn to what happened right after the direct examination of Dr. Ross by one of the plaintiff’s lawyers: the cross-examination of Dr. Ross by one of the school district’s lawyers. The lawyer conducting this examination was Mike Kristofco, and in the context of this Daubert hearing, his objective was to call into question Dr. Ross’s credentials as an expert witness for the plaintiffs.
As is the case throughout this hearing, A.L. is referred to as “Alex.” And as before, I’ve put my commentary in bracketed italics and elided the parts of the examination that are more procedural in nature and/or less relevant to the questions that concern us here at FacilitatedCommunication.org. These questions are, as before: what can we learn about the validity of the instances of S2C that have arisen in this case? And, in the case of the cross-examination of Dr. Ross: what leads an accomplished medical professional who is highly experienced in autism to believe in the validity of S2C? And what sorts of justifications for this belief does this autism professional provide while being cross-examined under oath?
Even in so-called “no touch” forms of FC (like S2C/RPM), facilitators often use visual, auditory, and tactile cues to aid in letter selection. Facilitators may or may not be fully aware of the extent to which these “cues” influence and control letter selection.
Kristofco begins with an allusion to the direct examination of Dr. Ross that had just concluded.
Kristofco: Good morning, Dr. Ross. I want to ask you to clear up a couple of things from the direct examination before I get into my questions. One of the questions that you were asked was about how Alex communicated prior to using the letter board. And I think that your response was something along the lines of “Not as well.” But what I want to ask specifically about is how he actually did communicate before he was using the letter board. So let me ask you: prior to him using the letter board, would he ever answer any questions verbally?
Ross: No.
Kristofco: Did he ever speak at all?
Ross: Yes.
Kristofco: And in what context did he speak?
Ross: It would more be a vocalization. It would not necessarily be in the form of a functional, communicative word.
Kristofco: Were you aware that when he was at school he could ask to go to the bathroom or ask to go to the nurse verbally?
Ross: Yes.
[In other words, A.L. has some functional oral language—language about which there’s little question of authorship, i.e., about who’s doing the talking. That’s because A.L.’s oral language comes straight from A.L.’s mouth rather than from a letterboard held up by someone else. Proponents of S2C, as I discussed in earlier posts (e.g., here), routinely dismiss oral language as unreliable, sometimes calling it merely “reflexive,” and there are reports of S2C practitioners actively discouraging speech.]
Kristofco: Okay. And is he capable of writing anything down?
Ross: He is hyperlexic, so he can write things down, but he usually does not write down a lot of spontaneously put-together things.
[The judge then asks for a clarification of hyperlexia.]
Ross: ... So a lot of kids with autism, they can fixate on letters and words. They can echo them. They can have what is called a stereotypical repetitive behavior with them.
[Ross goes on to discuss the autism diagnostic observation schedule (the ADOS), considered the gold standard for measuring autism severity, and the various aspects of language that make it communicative rather than repetitive and echoic—e.g., joint attention behaviors (though Ross does not use that term). Ross then turns to echolalia.]
Ross: There is people who have echolalia, which is one thing that we score on the test, so that is when they repeat the last word that they have heard. There is something where people can have stereotypical or repetitive phrases, which is something people script, that they repeat phrases that they have heard before but not sort of functionally. And then sometimes it's called gestalt language development when they would script, but they have moved on from scripting non-functionally to using the script to actually get their needs met. So they might answer questions using a script, which, you know, is like a repeated kind of thing, but they have answered in the way it was still a response that was functional for them....
[Ross’s use of the term “gestalt language development” suggests that she may have fallen for a second autism pseudoscience (besides S2C): namely, the theory that non-speaking autistic individuals are “gestalt language processors.” For a systematic review of the lack of evidence for this theory, see here; for commentary on how it undermines evidence-based speech-language therapy, see here.]
[There follows a long discussion by Ross of kids who carry on about preferred topics in a non-social way and how she tries to help make these communications more interactive.]
Kristofco: And so prior to him using the letter board, the information you needed to treat Alex, did you get that primarily from his parents?
Ross: I would either get it from his parents or from observing him.
Kristofco: Okay. And you had testified about an interaction with—when you were transitioning Alex to Dr. Stevens [Dr. Mary Stevens, the doctor he was transitioned to after aging out of pediatric care] I believe you said his mother was Alex's communication partner and he indicated that he had—through the use of the letter board, that he had some issue with his ears. Do you recall that?
Ross: Yes.
Kristofco: And what was—was Alex—do you recall anything about how Alex was behaving during that meeting?
Ross: I mean, just—he seemed fairly typical Alex to me.
Kristofco: And is it your belief that there is no way that his mother would have known that he had an ear infection?
Ross: I do believe that, because if that had been the case, she would have come in and said, “I think Alex has an ear infection.” She would not have waited for him to generate it. Most parents would do that, if they thought their child was sick and whether or not they could or could not communicate and figure out what they are saying.
[It’s curious that Dr. Ross expects A.L.’s mother to be the one to share any concerning medical symptoms rather than leaving that up to A.L.—who at the time of this appointment was old enough to be aging out of pediatric care.]
Kristofco: Let me show you a document. We can mark this as defendant's exhibit 1. And I have a copy for your honor as well.
[Some logistics ensue pertaining to the passing out of the document.]
Kristofco: Dr. Ross, this document has been represented to be a declaration that was prepared by Alex. And on the last page of this document it has been purported to be his signature. And what I want to do is just draw your attention to paragraph five, which is on the first page, where it says—the very last sentence, “Sometimes I used to pull my mom's hair when I have an ear infection.” Do you see that?
Ross: Yes.
Kristofco: And what you are saying is that you don't believe that it's possible that Alex was behaving—exhibiting some behavior that his mother picked up on that ended up being communicated through the letter board?
Ross: I do not, because sadly to say, Alex pulled his mom's hair fairly often when he was upset or frustrated. So the fact that he is communicating this does not mean that there weren't other times when he pulled her hair. He pulled her hair, sadly, a lot.
Kristofco: And he had a long history of ear infections as well, correct?
Ross: I mean, he has a history of many things. You know, I was not his general pediatrician, I was his developmental pediatrician. So I didn't treat ear infections in Alex.
[Whether or not Ross treated A.L.’s ear infections, of course, isn’t relevant; what’s relevant is that A.L. had both a history of ear infections and a history of signaling those ear infections to his mother—albeit via a behavior that often occurred for other reasons as well.
And this is a key point. Consider:
the association of hair-pulling with ear infections
the frequency of those ear infections, and
the fact that all parents are acutely sensitive to signs that their children are unwell or experiencing pain in particular parts of their bodies—and that this sensitivity may be largely subconscious and more acute than many people realize.
All this is enough to cast serious doubt on the ear infection story as a convincing instance of A.L. typing out information that his mother-cum-facilitator didn’t have access to.]
Kristofco: You prepared a report in this matter, did you not?
Ross: Yes.
Kristofco: Okay. And I have a copy here. I will mark this as defendant's exhibit 2. Is that a copy of the report you prepared in connection with this matter?
Ross: I have not seen this in a long time, so I don't—I am just looking at it.
Kristofco: By all means, take a minute to look at it. I realize it has been a number of years since this was created.
Ross: I mean, it looks like—I have not seen it in a long time. I don't know.
Kristofco: Do you recall providing testimony at the due process hearing that was conducted concerning Alex's education?
Ross: Yes.
Kristofco: Okay. And the testimony you provided during that due process hearing was true and correct, correct?
Ross: Yes.
Kristofco: Let me ask you a little bit about your qualifications. You do not have any educational degrees in speech-language pathology, correct?
Ross: No, but I routinely have trained—when I trained at Children's Hospital of Boston, all of our assessments were interdisciplinary. And at Einstein, our assessments were interdisciplinary with the speech-language pathologist. So I am not formally trained in speech and language pathology, but I have worked for a prolonged period of time in interdisciplinary. And that would have been one of the professionals that I worked with. And also, developmental and behavioral pediatricians, as part of an autism assessment, we do look at using other forms of tools, like the ADOS, to look at some aspects of communication. So while I am not a speech-language pathologist, I am not completely speech-language pathology naive.
Kristofco: You said you were not formally trained as a speech-language pathologist. When is the last time you had any training in speech-language pathology through those rotations that you mentioned?
Ross: Probably when I worked at Einstein. I worked with the speech-language pathologist in our autism program.
Kristofco: And you don't hold any state or governmental licensure as a speech-language pathologist, correct?
Ross: No.
Kristofco: You don't hold yourself out as a speech-language pathologist?
Ross: No.
Kristofco: You don't have a certificate of clinical competence from the American Speech-Language-Hearing Association?
Ross: I don't.
Kristofco: You have not published any peer reviewed research in the field of speech-language pathology?
Ross: No.
Kristofco: And you have not taught any speech-language pathology classes, correct?
Ross: Well, I have presented on speech-language pathology in the context of autism. And it's the role of the developmental and behavioral pediatrician to be familiar with occupational therapy, physical therapy and speech-language pathology in terms of understanding how they interplay with autism.
Kristofco: So does that mean you have not taught any speech-language pathology classes?
Ross: No.
[An ambiguous “No,” but I assume she means “No, I haven’t taught any speech-language pathology classes,” as opposed to “No, I have taught speech-language pathology classes.”]
Kristofco: And the places where you have lectured, you have been brought into a class to lecture about autism, correct?
Ross: Yes.
Kristofco: And you have not been trained in Spelling to Communicate, correct?
Ross: No.
Kristofco: What information did you gather to prepare your expert report?
Ross: I mean, I don't remember when I prepared this, but it looks like, you know, I—I mean, I would have to really look at it. I didn't see this before I came today, and I have not looked at it in a number of years. But it looks like some of it talks about my experience and training, and some of it talks about some of the work that I did. Some of it talks about my experiences with Alex and participating in the community programs and the presentation that we gave together. I guess that's it.
Kristofco: Anything else?
Ross: I mean, it looks like there's some articles. Looks like there is something about stereotype bias here. There is something about epigenetics in here.
[Stereotype bias has been evoked to explain the failure of autistic individuals to retrieve the words needed to describe pictures presented to them during message-passing tests. It was evoked, for example, by Vikram Jaswal in a highly problematic eye-tracking study that purported to find an alternative source of evidence for S2C.]
Kristofco: Did you conduct any examinations of Alex to come to your—the opinions that you have expressed in the report marked as D2?
Ross: That's this? Yeah, I have seen Alex in multiple contexts, both in the community when giving presentations with him and in my office.
Kristofco: When was the last time you examined Alex?
Ross: I mean, prior to him transitioning to Mary Stevens, so it would have been a long time ago.
[Some clarifying questions about dates ensue.]
Kristofco: It's fair to say that the last time you actually examined Alex was some time prior to April of 2019?
Ross: I think so.
Kristofco: Okay. And did you conduct any testing of Alex to prepare your report?
Ross: A developmental and behavioral pediatrician does not always do testing. Sometimes we interact with the patient.
Kristofco: Is that a “No”?
Ross: There was no formal assessment.
Kristofco: So was there an informal testing that you did of Alex in order to prepare your report?
Ross: Yes, I spoke to him and we interacted with him in that way.
Kristofco: Did you conduct any testing of Spelling to Communicate to prepare your report?
Ross: In having a conversation with him and with his communication partner, which was his mom. I guess that was an informal interaction.
Kristofco: I'm not asking about an interaction. I am asking you whether you conducted any testing of whether the Spelling to Communicate methodology works in order to prepare your report?
Ross: No, I did not do formal testing.
Kristofco: Have you ever conducted any testing of whether Spelling to Communicate works for Alex?
Ross: No.
Kristofco: Did you do any research on whether Spelling to Communicate is a generally accepted methodology in order to prepare your report?
Ross: I would have to look at this report to say exactly what I looked at... I spoke with other people that worked with him, like Susan Chaplick and Anne Robbins and Dr. Ghaffari, to make sure that what I was seeing reflected what they were seeing as well.
[As a reminder, these individuals are:
Neuropsychologist Dr. Anne Robbins the person whom A.L.’s parents hired to do an independent, neurocognitive assessment of A.L that was based, in part, on S2C-generated output.
Speech-language pathologist Susan Chaplick, whom A.L.’s parents introduced to S2C several years ago and who accepts S2Ced output as valid, and
Child and adolescent psychiatrist Dr. Manley Ghaffari, who testified in an earlier hearing that the letter board was “extremely effective in allowing [A.L.] to express his thoughts and feelings.”
]
Ross: [Continuing] I will say that I think there were articles by Jaswal where he looked and it showed that eye tracking, when people are spelling to communicate, their eyes are looking at the word, at the letters as they and I will say that since then, there are several self-advocates that are spelling to communicate that are part of—that are going to college that are on the self-advocate board of the autism board of the Society of America.
[As suggested by her use of the term “stereotype threat”, Dr. Ross is indeed familiar with Jaswal’s eye tracking study. This highly problematic publication, along with the fact that some people who are subjected to S2C are now attending college or listed as board members of autism organizations, seems, in Dr. Ross’s mind, to count as evidence that S2C is an accepted methodology.]
Kristofco: And that's the research that you did as to whether the Spelling to Communicate was an accepted methodology?
Ross: I looked at the literature that existed at that point, and I continued to look at ongoing literature.
[Apparently that literature did not include the published critiques of Jaswal—i.e., this and this—even though the former was published shortly after Jaswal’s paper came out.]
Kristofco: Now, in your report, you do not give an opinion that Alex has apraxia, correct?
Ross: I may not have.
Kristofco: Okay. In your report, you do not provide any scientific or medical opinion as to why Spelling to Communicate works for Alex, correct?
Ross: I don't know why it works for him. I don't know why lots of things work, but I still believe that it does work for him.
Kristofco: Now, during the due process hearing when you testified, and I can show you the testimony if you would like, but you said, “I cannot say specifically why having somebody beside him holding the board helps him communicate.” Is that still your opinion today?
Ross: I mean, I can hypothesize as to why that's the case. I think it's sort of the case for a lot of us. And when we have—if I had a person at a basketball game that looks to the stands and sees his parents and then makes a layup versus seeing that they are not there and doesn't. You know what I mean? I don't have an actual method. I could hypothesize. But again, I don't know why a lot of things work or how, but I still know that they do.
[This is a comparison I hadn’t heard before.
On one hand: an S2C practitioner holding up a letterboard to a minimally-speaking autistic person’s index finger while the person points to letters.
On the other hand: parents in the audience of a basketball game being visible to a basketball player who then makes a successful shot.
]
Kristofco: Those hypotheses, you have not tested any of them?
Ross: No.
Kristofco: And you also testified at the due process hearing that, scientifically, “I don't know why this is working for him.” Is that still the case?
Ross: That's still the case. But I also don't know why people have autism, and a lot of people have been studying that. And I don't know why it presents different ways in different people, but it still presents that way.
[Another bizarre comparison:
On one hand, the unknowns about what autism is and why it presents itself in different ways in different people.
On the other hand, the unknowns about how A.L. has bypassed the limitations of profound autism (which include minimal tuning in to speech and, therefore, minimal opportunities for acquiring language) to become fully literate. Fully literate, that is, not when he “writes things down” on his own, but only when someone holds up a letterboard to his index finger.
Apparently the latter set of unknowns (A.L.’s purported attainment of full literacy) does not strike Dr. Ross as any more mysterious than the former set (what autism is and why it’s heterogeneous).]
Kristofco: If you could turn to page 7 of defendant's exhibit 2. On page 7, you say, “Based on my observations and clinical judgment, the letter board is effective communication for Alex.” It's the second sentence in the first full paragraph there on page 7. Do you see that?
Ross: Mm-hmm.
Kristofco: Now, when you say the letter board is effective communication for Alex, do you mean just the letter board by itself or do you mean the whole Spelling to Communicate methodology?
Ross: I guess for my perspective, they are the same.
Kristofco: Okay. So from your perspective, it's the same thing if you put a letter board on the table in front of Alex versus if somebody holds the board?
Ross: No, I think Alex needs a communication partner.
Kristofco: So your opinion then is that you believe that the letter board with the communication partner is effective communication for Alex?
Ross: Yes.
Kristofco: And what is the definition of an effective communication?
Ross: I don't have a specific definition, but for Alex I will say he can use the letter board and ask for something. And when he gets it, he agrees that's what he wanted and he uses it. So inasmuch as communication is getting your needs met or communicating a thought or, you know—and having a reciprocal conversation with Alex using the letter board, I’ve had a question; he's answered. I've said something based on his answer; he has said something based on what I asked. Do you know what I mean? I feel like it's communication.
[Here we see the some circular reasoning so often resorted to by supporters of S2C, followed by a non-sequitur.
The circular reasoning: S2C seems valid because some of the messages it generates communicate that other messages it generates are valid.
The non-sequitur: S2C seems valid because the messages it generates function as part of a reciprocal conversation and feel like communication. Of course, messages will seem reciprocal and feel like communication whether they’re controlled by the minimal speaker or by their communication partner.
But Kristofco is about to make a very different point—one I had not anticipated.]
Kristofco: So in using that phrase in your report, you did not mean effective communication as that phrase is used under the Americans with Disabilities Act?
Ross: I'm not completely familiar with exactly how it is used in the Americans with Disabilities Act. But for me, inasmuch as Alex was communicating his thoughts and needs, I felt like he [it?] was.
Kristofco: Why did you use the phrase "effective communication" at all in your report?
Ross: Because that was my perspective.
Kristofco: Okay. Are you aware that to be effective, an aid or a service must be provided in such a way to protect the privacy and independence of the individual with the disability?
[Not just independence, but privacy. I’m reminded of Janyce’s post on Four in the Bedroom. We’re so focused on independence that we probably don’t give privacy the attention it deserves.]
Ross: I was not specifically aware of that nuance, no.
Kristofco: Using the letter board and communication partner, it's true that Alex cannot have a private conversation with his doctor, correct?
Ross: I guess not.
[This clarifies a question I had about something Dr. Ross said during her direct examination: “...if it's just he and I in my office and his statements tend to be longer, , sometimes I will write it and then I will look at it...” Was Dr. Ross the one holding up the letterboard at A.L.’s appointments with her, I had wondered. Her answer here suggests not. It seems that, during A.L.’s doctor’s visits, his mother-cum-communication partner was always present.]
Kristofco: And using the letter board and communication partner, it's true that Alex is always relying upon the presence of a third person to communicate, correct?
Ross: At this time.
Kristofco: You say, "At this time." Alex has been using Spelling to Communicate over seven years, and he is still not able to communicate independently, correct?
[I hadn’t done the math. Seven years is a very long time.]
Ross: But that's not unlike other people that have used Spelling to Communicate that have taken many, many, many years to communicate independently.
[“Communicate independently.” Among S2C proponents, this is a common fallacy. It amounts to the assumption that having the letterboard/keyboard is on a stationary surface and no one touching the person who types on it is enough to guarantee that the typing is independent.
But most people would agree that truly independent communication includes the ability to produce accurate, unrehearsed answers to spontaneous questions without the same few familiar people hovering within auditory, visual and/or tactile cueing range.
In fact, there is no evidence that anyone who has been subjected to FC or any of its variants has ever gotten to truly independent communication that comes anywhere near the linguistic sophistication of their FC-generated messages.
What is true is that some individuals, after many years of FC/RPM/S2C, get to a point where those auditory, visual, and/or tactile cues are so subtle that many naïve observers, including autism experts, can’t see them.
And what’s also true is that some of the individuals who have been subjected to FC/RPM/S2C are able to produce lengthy rehearsed and memorized letter sequences (some individuals with profound autism have demonstrated tremendous rote-memorization skills), possibly without any cueing. See, for example, Tito Mukhopadhyay typing out a 154-letter poem on this segment of 60 Minutes.]
Ross: [Continuing] And Alex has also had a lot of other health issues, including incapacitating migraine headaches and other issues. And there has also been COVID, which has impacted a lot of people.
Kristofco: Just to make sure the record is clear, Alex has been using Spelling to Communicate for over seven years, and he is still not able to communicate independently, correct?
Ross: That's my understanding.
Kristofco: And isn't it true that the opinion that you provide in your report, that this letter board and communication partner is effective communication for Alex is based exclusively on the fact that you have seen it and based on what you have seen you believe that it works?
Ross: It's also based on my interactions with the other providers that care for him. And when I see it, there is no nobody moving the board, there is nobody touching him. So I don't know why—what else could explain that he is spelling words and sentences.
[The fact that Dr. Ross isn’t aware of any board movements doesn’t mean they don’t happen: training in cue detection probably didn’t figure into any of her coursework or practicums, extensive and impressive though these were.]
Kristofco: Who are the other providers that you mentioned?
Ross: Dr. Ghaffari, Susan Chaplick, Anne Robbins.
Kristofco: So because the other people believe it works, that bolstered your belief that it works?
Ross: It's not that it bolsters, but it's helpful. I mean, that's not my opinion, it's not based on their opinion. But when providers generally agree independently, that's sort of nice.
Kristofco: Well, let's just talk about what your opinion is based on. Is your opinion based on anything other than the fact that you have seen it in action and you believe it works?
Ross: Yes, that's what it's based on. I have seen it in action and I believe it works.
Kristofco: Would you agree with me that there's a difference between science and belief?
Ross: Sure.
Kristofco: And what facts or data is the opinion that you have given in your report about effective communication based upon?
Ross: Well, when Alex touches the letters and no one is touching him and nobody is touching the board, he spells words. He functionally answered questions that I asked him. He conveyed things about himself that other people did not know. He was able to request things and indicate that requesting them has led to him getting what he wants when people listen. And also, his behaviors changed because he was not quite as frustrated. Not every day, not on the whole, but to some degree based on his communication.
[As I noted earlier, the only specific example we have of Alex “conveying things about himself that other people did not know” is the ear infection story. In general, facilitators (especially if they are parents) can intuit what their client wants, especially if it’s something rewarding and/or predictable. And with autism, where “insistence on sameness” is one of the diagnostic symptoms, much of what’s rewarding or upsetting is highly predictable.]
Kristofco: Is it fair to say that everything that you discussed about Alex in your report from 2017 on, you learned through him communicating with the letter board and communication partner?
Ross: I think so. I don't really—it's hard to put myself—it was a number of years ago. I would not say everything, because I do also get information from other people. But I believe in terms of his communication that that was him.
Kristofco: You would agree with me that the basis for your opinion, the fact that you saw and believe it works, is something that is not testable, correct?
Ross: I think that might be true, but I think a lot of things are not testable.
Kristofco: So, on page 6 of your report, it's the first sentence of the second paragraph. You say, “When Alex began to communicate with a letter board and communication partner, I looked for any possible way that this might not be his own voice and found none.” Do you see that?
[Some clarification about where exactly in the paragraph that was.]
Kristofco: I will read the sentence again. It said, ‘When Alex began to communicate with the letter board and communication partner, I looked for any possible way that this might not be his own voice and found none.” Do you see that?
Ross: Yes.
Kristofco: What specifically did you look for?
Ross: I looked for somebody touching him, somebody moving the board, somebody saying letters that he was not pointing to.
Kristofco: Did you conduct a message passing test?
Ross: No.
Kristofco: Did you show Alex a picture that the communication partner could not see and then ask Alex questions about the picture?
Ross: No, but it's not my job to undermine his level of communication. I have a therapeutic rapport with him, so it wasn't that I was testing him, that would have eroded the trust. I was watching him. Nobody was moving the board, nobody was touching him, and he was touching the letters that were spelling the words. I don't test my patients to discredit them or to sort of express a disbelief in what they are doing or not doing. So that would be the purpose of doing a message passing test, and I don't know that there would have been a purpose or need to have done that. Based on what I saw, I felt convinced he was communicating.
[Here they are once again: the circular reasoning and the certainty that observation is reliable.
The latter is common enough to have a name: naïve realism. Presumably Dr. Ross would know not to apply this line of reasoning at a magic show, where she presumably wouldn’t conclude that rabbits can be conjured out of hats just because it looks that way.
As for circular reasoning, here it manifests itself in the notion that any test that assesses whether A.L. is generating the messages should be avoided because such a test would express disbelief in A.L. as a message-generator.]
Kristofco: So is it fair to say that for the purposes for which you were treating Alex, it was not in your interest to challenge whether this system actually worked?
Ross: I don't really think that's fair to say, actually. My goal is not to challenge my patients, it's to observe them. I use my 25 years of clinical experience on what is happening and my interrelationship with people from other disciplines to look at what is happening. And based on what I was seeing, I felt like he was communicating and I didn't really feel a need to sort of say, “Oh, Alex, I doubt you. I'm going to try to prove that you are not communicating.” It just didn't seem—
Kristofco: Well, if—
Ross: —meaningful to do that.
Kristofco: Sorry. If this isn't truly Alex's voice coming through the letter board, isn't that something that you would want to know?
Ross: I felt like it was his voice based on my experience and watching him. So I do feel like I know that, first of all. And second of all, my greater fear would be to say that somebody who is communicating is not communicating. To silence somebody by saying that they are not communicating and going after them as if I’m going to doubt you and I’m going to prove that you are not communicating, that's not a perspective that a clinician takes. And I would be terrified if somebody were actually communicating, even if it were one person, by using this letter board, I would be terrified of silencing them. I would think that that would be fairly horrifying.
[For Dr. Ross, the prospect of “silencing” someone by displaying doubt about whether it’s them communicating is more terrifying than the prospect that it’s not them communicating—and that their communications and very personhood are (however unwittingly) being hijacked and supplanted by their facilitator.]
Kristofco: And it would be worth it to allow people who were not really communicating to continue to believe so just so you didn't silence that one person?
Ross: Well, in my experience, the people who it did not work for did not continue it.
[This takes us back to the faulty implication that arose during direct examination: namely, that because Dr. Ross (unlike most S2C promoters) acknowledges that S2C doesn’t work for everyone, and because she has observed individuals for whom S2C doesn’t work, she must therefore be capable of accurately distinguishing the successes from the failures.
And we see here that, with the certainty that she can tell when S2C doesn’t work, and the certainty that everyone she knows for whom S2C didn’t work has stopped using it, Dr. Ross is apparently at peace with the absence of any message-passing assessments in A.L.’s case—or, presumably, in the case of any of her patients.]
Kristofco: I guess it's fair to say that you didn't ask Alex a question outside the presence of the communication partner and see if Alex could answer the question when the person came back?
Ross: No, there would be no purpose. That would be set up to sort of say to him, “I don't believe you are communicating, so I am going to try to trick you to see if this is real.” That's just not what a clinician does to a patient.
Kristofco: How is that tricking him?
Ross: It's not tricking him, but it's sort of testing. It would be like “I am going to set you up and see if this is real.”
[More circular reasoning: the test is only a testing of A.L.’s communications if A.L. is the one generating the communications. But the whole point of the test is to determine whether the person Dr. Ross thinks she is talking to and is afraid of offending really is A.L.]
Ross: [Continuing] From what I was seeing, it felt real. So to put him in a situation where the point–the perspective was, “I doubt you,” didn't seem–didn't even occur to me because I was convinced from watching him that it was his communication. So it would not have occurred to me to do that, because I was watching him, and it felt like spontaneous, real communication.
Kristofco: Isn't testing part of the scientific method?
Ross: Yes, but I was not a scientist studying Alex, I was his clinician.
Kristofco: I guess it's fair to say that the method that you used to arrive at your opinion, the, “I have seen it and based on my observation I believe it works,” that methodology has not been peer reviewed, correct?
Ross: Well, I think there are more studies of people using a letter board or Spelling to Communicate. And more and more—we are seeing more and more data to support it as a form of functional communication. Not for everyone, but for a lot of people.
[Vague allusions to “more and more studies” that supposedly support FC and its variants—we keep encountering this kind of hand-waving by S2C supporters. But when they cite specific examples, it’s always the same problematic studies: Jaswal et al.’s eye tracking study (critiqued here and here), and Jaswal et al.’s subsequent literacy study (critiqued here) and “studies out Cambridge University,” which aren’t actually studies, but rather a research proposal that has yet to go anywhere.]
Kristofco: That was not my question. My question was: the methodology that you used to arrive at your opinion, that methodology of, “I have seen it and I believe that it works based on my observation,” that has not been peer reviewed?
Ross: It is—that's what doctors do. I mean, that's what doctors do. They use whole body, listening to watch what patients do. So even if somebody had some kind of a medical condition, you watch how they are moving their body; you listen to what they are saying; you might even watch the people around him, because the truth is, we are kind of interdependent. So you wouldn't [would?] incorporate the perspective of somebody else. I don't know why somebody with a developmental disability should be expected to be less interdependent than the rest of us.
[This is not the first time I’ve seen people invoke vague notions of “holistic” assessments to bypass requests for solid evidence and precise measurements: this happens routinely throughout the education world. Nor is it the first time I’ve seen FC/S2C proponents invoke vague notions of how we’re all interdependent to anticipate/dismiss concerns about facilitator dependence.]
Ross: [Continuing] But that's a part of the art of medicine. That's what you do. And you don't test it scientifically every time you see a patient. You have experience and background, and that's what you do.
[It strikes me that, for many clinicians, it’s all about observation. And while clinical observation may work well in most situations, the moment an FC/S2C communication partner enters the scene, with all the subtle cueing that this inevitably introduces, everything changes. Most clinicians are neither primed nor trained to look for facilitator cueing. Their eyes, quite naturally, focus exclusively on their clients; not on the person holding up the letterboard board. The five clinicians involved in this case—two speech-language pathologists, a child and adolescent psychiatrist, a neuropsychologist, and a developmental pediatrician—are no exception.
Put another way: with medical symptoms, behavioral symptoms, or symptoms pertaining to spoken language use and comprehension, clinical judgments are appropriate. But where FC-generated communications are concerned, no one should be relying on judgments by clinicians.]
Kristofco: The observation piece that a doctor uses is part of an overall evaluation of a patient, correct?
Ross: Yes.
Kristofco: So you gather actual data when you examine the patients. You might test their body by pressing on parts of it; you might take their temperature; you might take their blood pressure; you might take tests, like x-rays or some other form of examination. But the observation part that you are talking about is part of the overall examination process, correct?
Ross: The practice of medicine is an art. It's not just based on scientific data like labs or numbers or signs.
[The practice of medicine as an art—as with holistic assessments, there’s a warm and cuddly feeling here. But when medical practice as an art and medical practice as a science come into conflict, I think most of us, when push comes to shove, would prefer for science to prevail. If the blood pressure monitor shows 150 but my doctor thinks I look perfectly fine, should I not worry?]
Kristofco: Are you familiar with the fact that the American Speech-Language-Hearing Association has come out with a statement warning against the use of the methodology that Alex uses?
Ross: Yeah. I think it's horrible.
[That’s quite a harsh judgment against what’s actually a rather carefully worded warning:
It is the position of the American Speech-Language-Hearing Association (ASHA) that use of the Rapid Prompting Method (RPM) is not recommended because of prompt dependency and the lack of scientific validity. Furthermore, information obtained through the use of RPM should not be assumed to be the communication of the person with a disability.
]
Kristofco: And you are aware, of course, that that is the nationwide association for speech-language pathologists, correct?
Ross: Yes. And I’m also aware that Barry Prizant, who has been given their highest honor, also disagrees with them. And many of us who are clinicians don't think that blanket statement should be made about all people under all circumstances. So I don't know what to say, but I disagree with ASHA, as do many other people.
[Barry Prizant, another of the plaintiff’s expert witnesses, is the highest profile speech-language pathologist to support S2C—and another example of a clinician who cites clinical observations as the basis for S2C’s validity. Indeed, Prizant joined a 2018 letter campaign against the ASHA position statement, writing “[I]n no, and I mean NO instances were they physically or gesturally directed to specific letter targets.”
It’s true that Prizant was honored by ASHA—back in 2014, four years prior to going public in support of S2C. These days, Prizant frequently promotes S2C on his Uniquely Human Podcast.]
Kristofco: So the fact that that statement has been issued, and the fact that you have several people who are—several patients who are using this methodology, none of this has led you to believe that you should, perhaps, test it to see if it works?
[Let’s pause to do the math. Presumably these several patients of Dr. Ross’s who are subjected to S2C are patients for whom she has deemed it to work. Combine these with the several patients of hers for whom she’s deemed S2C not to work, and we have to wonder how much of an S2C-magnet Dr. Ross’s practice has evolved into. Is she the main developmental pediatrician in the Philadelphia area with patients who are subjected to S2C? Are there others out there that are flying under the radar because they haven’t (yet) been called as expert witnesses in trials against school districts?]
Ross: I believe when I watch somebody, even though somebody is holding the board, if the board is not being moved and no one is touching them, I don't—I mean, to me that's enough evidence that it's working. And I don't understand how an organization like ASHA could make a global statement about a whole group, a heterogenous group no less, and not look at them one by one. I think no responsible clinician or medical professional or other person would make a decision on a person without seeing or interacting with them personally.
[ASHA’s position statement clearly pertains to methodologies: it makes no global statements about any groups. Dr. Ross’s claim that ASHA’s statement is about groups rather than methodologies is akin to her claim that message-passing tests are being about the person being facilitated as opposed to the methodology to which that person is being subjected.
As for Dr. Ross’s statement that decisions about individual people should include observations and interactions—that’s perfectly reasonable. But given the widely recognized concerns about facilitator influence in FC/RPM/S2C, it’s also perfectly reasonable to do a message-passing test of the methodology in every specific instance of its use. Indeed, given the high stakes involved—personhood and communication rights—it would be highly unreasonable not to do a message-passing test of the methodology in every specific instance of its use.]
Mr.Kristofco: I don't have any additional questions, your honor.
Thus concludes the cross-examination of Dr. Wendy Ross.
For me, the key takeaways are:
Dr. Ross’s implications that clinical observation trumps formal testing and that holistic assessments trump scientific measurements.
Her assumption that as long as her own observations tell her that “the board is not being moved and no one is touching him,” A.L.’s S2C-generated output must represent messages coming from A.L. rather than from his communication partner.
Her repeated resort to circular reasoning to justify S2C and to explain why it wouldn’t be appropriate for her to conduct a message-passing test.
How she seems more concerned about falsely accusing someone of not communicating than about the possibility that this person’s communication is being hijacked, and his personhood suppressed, however unwittingly, by someone else.
In my next post, I’ll return to the subjects of board movements, message-passing tests, and what’s more ethical than what. Stay tuned for the examination (and cross-examination) of the communication partner designated by the plaintiffs to facilitate A.L.’s testimony at the prospective trial.
