As professionals in the field of psychology and speech and language we are frequently asked about the usefulness of various techniques and interventions for developing communication in children with autism. Tonight, there is a documentary on RTE 1 called ‘Autism and Me’ which features a communication aid called Rapid Prompting Method (RPM). The documentary features Fiacre Ryan, a 16 year old with autism who is using RPM to communicate his thoughts and feelings. As a result, many parents and professionals may be left wondering if RPM will work for children in their care.
What is Rapid Prompting Method (RPM)?
RPM is a parent-developed method of communication for children with Autism Spectrum Disorder (ASD) who do not speak or have difficulty using speech communicatively (Chen, Yoder, Ganzel, Goodwin & Belmont, 2012). The method was developed by Soma Mukhopadhyay, parent of Tito, her autistic son, who has featured in a number of documentaries and news articles . Arising informally from working with her son, Soma has refined the method and instructs hundreds of families and their children in RPM. The method has gained traction in the United States (US) and beyond and has recently arrived in Ireland with over 100 families currently using and advocating the method. According to the Autism Self Advocacy Network (ASAN) the mode of communication is spelling words and sentences by pointing to letters on a letter-board held by a trained supporter who then writes down or reads out loud to the intended communication recipient the letters to which the learner has pointed. Tools include books, letter boards, stencils, and teacher drawings and writings.
What evidence is there that RPM works?
The conversation regarding the effectiveness of RPM has been ongoing over the last decade and has attracted renewed interest in recent times due to ASAN filing a complaint in March 2016 with the US Department of Justice, seeking state funded support for RPM for five non-speaking students with ASD in Arlington, Virginia. This has sparked widespread debate on twitter and online as to the whether state-support should be offered for RPM.
See here https://twitter.com/jimtemu/status/707759400623144961
and here https://twitter.com/autismcrisis/status/784491665369206785
Anecdotal reports that RPM is already being used in schools in Ireland add impetus to this debate. The crux of the argument rests on the degree of evidence available that demonstrates the effectiveness of RPM and the theoretical propositions on which it is based. If RPM is not evidence-based or does not have a sound theoretical basis then it is against ethical guidelines, best practice and logic to use the technique with children with ASD.
An examination of the literature reveals that whilst anecdotal testimonies abound, hard evidence of the effectiveness of RPM is completely lacking. In science, anecdotal testimonies constitute the weakest form of evidence available as, although often well-intentioned, they are usually based on observations that lack the basic features of robust research design. When interventions are offered as legitimate but offer no evidence they are considered to be pseudoscience. For example, a once widely-used and acclaimed technique Facilitated Communication (FC) was completely debunked when it was held to rigorous testing. FC proponents claimed that individuals communicated with the aid of a ‘facilitator’ who guided their hands over a keyboard to type messages and the method was extolled as opening a means of communication for non-verbal people with autism. Yet when subjected to well-controlled experiments, researchers found that unless the facilitator already knew the answer to the question the correct answer couldn’t be provided. There are echoes of FC in RPM, particularly in the use of a ‘trained supporter’ as the medium through which the individual with autism communicates (see Normand, 2008 for more extensive discussion on pseudoscience and facilitated communication).
But let’s examine the available evidence.
According to the creators of RPM themselves, only one research study has been conducted on RPM. This article appeared in Frontiers in Psychology in 2012 and describes itself as an exploratory study on the technique. The study reports that upon analysing video footage of RPM sessions with nine autistic children aged 8-14 years, there was a decrease in repetitive behaviours and an increase in the number of multiple choice options presented. Importantly though, there is no evidence presented as to the effectiveness of RPM. In fact the authors themselves state clearly that it this is not the purpose of the study, as highlighted in other commentaries on this topic.
‘We defer, for the moment, the crucial question of whether the communications produced during RPM therapy are genuine. Our aim in this preliminary, case-based study is only to test for behavioural effects that would be consistent with RPM’s claimed strategy and mechanism: is there any plausibility to RPM’s anecdotal reports? If the measured effects are consistent with the claimed mechanisms, the question of whether, for whom, and under what circumstances RPM produces valid communications would be the proper subject of a future, separate, larger study.’
So, in the only study on RPM there is no information as to whether it is effective or not. In addition researchers have highlighted a series of major flaws with the study (see Lang, Tostanoski, Travers & Todd, 2014 for an in-depth exploration) and also raise serious concerns as to the authenticity of the messages generated by people with people with ASD who use letter boards held by facilitators.
In another review of the available information, researchers could find only three articles that discussed the use of RPM and only one of these was peer-reviewed (the Frontiers article mentioned above). Of the others one was a short postdoctoral report that is only available through the RPM creators’ website and the other is a non-peer reviewed article on a variation of RPM (See Deacy, Jennings & Halloran, 2016 for a description of the studies). Both were subject to bias, and serious methodological concerns with the studies have been raised by Bronwyn Hemsley, Associate Professor of speech pathology at the University of Newcastle, Australia (Hemsley, 2016). Importantly, neither demonstrated evidence of effectiveness. Hemsley concludes that not only is there a lack of evidence for the use of RPM but that there is no justification for the exposure of children with autism to the method.
‘On the basis of literature on RPM to date, and the findings of this summary and commentary appraisal, further research that exposes students with ASD to RPM is not justified.’
So what should we conclude about using RPM?
As highlighted, there are scientific reasons to be wary of RPM. Whilst the creators are strong advocates for the method they are resistant to calls for objective and rigorous testing and rely solely on testimonial and anecdotal support. As such, in line with current scientific reflections on RPM, we do not support it as a method of communicative intervention. Indeed we strongly advise parents and others to be cautious when considering it. Those with autism deserve the highest standards of care and education and to date RPM has not been demonstrated to fall within this remit.
Dr. Jennifer McMahon, Psychologist and Lecturer in Educational Psychology & Special Education
Dr. Carol-Anne Murphy, Speech & Language Therapist and Lecturer in Speech and Language Therapy.
Dr Arlene McCurtin, Speech & Language Therapist and Lecturer in Speech and Language Therapy.
The authors are all lecturers at the University of Limerick.
Chen, G. M., Yoder, K. J., Ganzel, B. L., Goodwin, M. S., & Belmonte, M. K. (2012). Harnessing repetitive behaviours to engage attention and learning in a novel therapy for autism: an exploratory analysis. Frontiers in Psychology, 3, 12.
Deacy, E., Jennings, F., & O’Halloran, A. (2016). Rapid Prompting Method (RPM): A suitable intervention for students with ASD? REACH Journal of Special Needs Education in Ireland, 29, 92–100.
Hemsley, B. (2016). Evidence does not support the use of Rapid Prompting Method (RPM) as an intervention for students with autism spectrum disorder and further primary research is not justified. Evidence-Based Communication Assessment and Intervention, 1-9
Lang, R., Harbison Tostanoski, A., Travers, J., & Todd, J. (2014). The only study investigating the rapid prompting method has serious methodological flaws but data suggest the most likely outcome is prompt dependency. Evidence-Based Communication Assessment and Intervention, 8(1), 40-48.
Normand, M. P. (2008). Science, skepticism, and applied behavior analysis. Behavior analysis in practice, 1(2), 42