Alternative medicine | |
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Claims | Non-verbal people may express written language if given prompts by a facilitator. |
Related fields | Alternative medicine |
Year proposed | Late 20th century |
Original proponents | Soma Mukhopadhyay |
This article is part of a series on |
Alternative medicine |
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The rapid prompting method (RPM) is a pseudoscientific technique that attempts to aid people with autism or other disabilities to communicate through pointing, typing, or writing. [1] [2] Also known as Spelling to Communicate, [3] it is closely related to the scientifically discredited [4] [5] [6] technique facilitated communication (FC). [1] [7] [8] Practitioners of RPM have failed to assess the issue of message agency using simple and direct scientific methodologies, saying that doing so would be stigmatizing and that allowing scientific criticisms of the technique robs people with autism of their right to communicate. [2] [9] The American Speech-Language-Hearing Association has issued a statement opposing the practice of RPM. [10] [11]
Soma Mukhopadhyay is credited with creating RPM, though others have developed similar techniques, known as informative pointing or alphabet therapy. [1] RPM users report unexpected literacy skills in their clients, [2] as well as a reduction in some of the behavioral issues associated with autism. As noted by Stuart Vyse, although RPM differs from facilitated communication in some ways, "it has the same potential for unconscious prompting because the letter board is always held in the air by the assistant. As long as the method of communication involves the active participation of another person, the potential for unconscious guidance remains." [9]
Critics warn that RPM's over-reliance on prompts (verbal and physical cuing by facilitators) may inhibit development of independent communication in its target population. [12] As of April 2017, only one scientific study attempting to support Mukhopadhyay's claims of efficacy has been conducted, though reviewers found the study had serious methodological flaws. [12] [13] Vyse has noted that rather than proponents of RPM subjecting the methodology to properly controlled validation research, they have responded to criticism by going on the offensive, claiming that scientific criticisms of the technique rob people with autism of their right to communicate, [9] while the authors of a 2019 review concluded that "...until future trials have demonstrated safety and effectiveness, and perhaps more importantly, have first clarified the authorship question, we strongly discourage clinicians, educators, and parents of children with ASD from using RPM." [14] [15]
RPM founder Mukhopadhyay purports to base RPM on psychological, developmental and behavioral theories put forth by Jean Piaget (developmental psychology) and Anna Jean Ayres (sensory integration), the goal of which is to "establish functional independent pointing-based communication in people who are otherwise nonverbal due to severe autism or other developmental disabilities." [1] [12] RPM users employ elements of Applied Behavior Analysis (ABA), but reject the documentation and evaluation procedures integral to ABA as being unnecessary and stigmatizing. [1] Mukhopadhyay postulates that, by observing student's self-stimulatory behaviors (as in the case of autism, the "sensory preoccupations that drive and develop them"), she can identify each student's "dominant learning channel" (visual, tactile, or auditory) [2] and individualize a program to match his or her needs. [2] [12] RPM facilitators "presume competence" in their (often nonspeaking) communication partners; the assumption being that people with autism "are likely to possess considerable hidden knowledge that they cannot express" and that prompting will address these individuals' hypothesized difficulties with motor planning [1] and self-stimulatory behaviors. [2] RPM is a "low-tech approach that requires only an instructor, student, paper, and pencil". [2]
As of April 2017, RPM is not recognized as a clinical profession nor does it have recognized standards for registering, licensing or certifying treatment providers. Practitioners appear to be self-taught or have participated in workshops and camps offered by Mukhopadhyay, Heather Clare (Informative Pointing), or Vanderbilt Kennedy Center Angelman Program (Alphabet Therapy). [1]
Professionals applying for RPM workshops are required to submit 10-min video samples of the use of rapid prompting, a resume, and a letter explaining the "reason for wanting to attend course". [1]
RPM literature indicates that, along with autism, the technique has been tried with people who have Fragile X syndrome, blindness, deafness, Angelman syndrome, Down syndrome, Williams syndrome, and Prader-Willi syndrome. [12]
Beginning with a "teach-ask" protocol, the facilitator presents the student with a concept (i.e., The chair is yellow), then immediately follows up with a question (i.e., "What color is the chair?"). The student is then given prompts (i.e., two pieces of paper, with choices written on each) to represent the answer. [1] [2] [12] This procedure is repeated, using a combination of prompts provided by the facilitator to elicit a response. Prompts may include physical (i.e. words written on paper), auditory (i.e. the sound of paper tearing), verbal (i.e. spoken directives), and visual (i.e. gestures by the facilitator). Choices move from two, three, to four and so on, with increased difficulty. The student progresses from making choices, to spelling on a letter board held by the facilitator, to spelling on a letter board (flat on a table or held by the student) or voice-output device, independently. [1] [2] [16]
The rapid prompting method (also known as RPM, Rapid Prompting, Soma®RPM, Informative Pointing, Spelling To Communicate (STC) and Alphabet Therapy) [1] is largely credited to Soma Mukhopadhyay, who has a master's degree in chemistry and a bachelor's in education. [8] By trial and error, Mukhopadhyay combined various behavioral and communication techniques to help her son, Tito, who has a diagnosis of autism and exhibits limited speaking abilities. [1] [2] Mukhopadhyay posits that autism is a manifestation in which a child's cognitive abilities are undermined by poor sensory integration abilities and that RPM serves to "activate the reasoning part of the brain" and, therefore, distracts the student into learning. [1] Proponents of RPM and related techniques claim to be able to help people with disabilities express untapped intellectual abilities and advance communication skills through a system of pointing, typing, or writing with verbal and physical prompts from a facilitator. [2] This is, purportedly, "the most direct and unlimited path to learning and communicating." [2] RPM proponents point to the "sole study of RPM", "Harnessing repetitive behaviours to engage attention and learning in a novel therapy for autism: An exploratory analysis", published in the journal Frontiers in Psychology (2012), [17] as proof of the method's efficacy. [2]
In 2001, Mukhopadhyay brought RPM to the United States, in conjunction with a fellowship from the Cure Autism Now Foundation, [2] led by Portia Iversen and Jon Shestack. [1] [8]
In 2004, Mukhopadhyay and Helping Autism through Learning and Outreach (HALO) collaborated to expand RPM's reach nationally. [2] Mukhopadhyay owns the trademark for RPM. [12]
In 2005, Mukhopadhyay moved from California to Austin, Texas, where she established the Halo-Soma Institute. There, she provides clinical services, offers workshops and promotes RPM internationally. Evaluation research is not conducted by the institute. [1] Mukhopadhyay is the author of Rapid Prompting: an Instructional Guide, Understanding Autism through Rapid Prompting (2008) and Curriculum Guide for Autism Using Rapid Prompting Method: with Lesson Plan Suggestions (2011). [1]
After some initial collaboration with Mukhopadhyay, Iversen developed the Informative Pointing Method. [1] She also wrote a book called Strange Son: Two Mothers, Two Sons, and the Quest to Unlock the Hidden World of Autism, which, as one reviewer stated, expresses her "absorbing and speculative views" on autism which are "at once compelling and controversial." Iversen spends much of the book discussing Tito's communications and documenting her own son, Dov's, introduction to RPM. [18]
Alphabet Therapy was developed and is promoted by Vanderbilt University and focuses specifically on people with Angelman Syndrome. [1]
The Board of Directors concludes that rather than helping people express their thoughts, desires, and choices, FC and RPM have the potential to effectively take away people's voices. This is due to the risk of facilitator influence/authorship as well as the potential to displace efforts to access scientifically valid communication modes, such as those associated with the field of Augmentative and Alternative Communication (AAC).
— AAIDD [19]
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.
— ASHA [10]
While the lack of evidence from previously conducted studies does not necessarily indicate that RPM is not effective at developing communication skills and reducing stereotypic behaviors in learners with autism, use of this intervention should not be used or recommended by practitioners until the claims made can be substantiated by peer reviewed research studies.
— ASAT [23]
Since the broadcast of the RTE documentary ‘Autism and Me’ on March 13th 2017 there has been much discussion about the Rapid Prompting Method (RPM) which was used to facilitate communication for one teenage boy featured on the programme. IASLT wish to put on record our position in relation to this method - primarily our concern that there is no evidence to support its use.
— IASLT [24]
There is a lack of substantive research evidence demonstrating that FC and RPM are valid forms of augmentative or alternative communication ... Research studies show that facilitators consciously and/or unconsciously influence the message being communicated ... thereby exposing people with communication disorders to risk of harm by preventing genuine self-expression ... For these reasons, SAC members and associates should not use FC and RPM in clinical practice.
— SAC [25]
RPM proponents point to one study to support their claims of efficacy: "Harnessing repetitive behaviours to engage attention and learning in a novel therapy for autism: An exploratory analysis, as proof of the method's efficacy". [17] [2] In this peer-reviewed, quantitative study using videotaped sessions of Mukhopadhyay working with clients, the study authors attempted to measure how RPM influenced participants' attention to their facilitator and the materials being presented (joint attention) and the effect of RPM on restrictive and stereotypic behaviors (RSB). Although RSBs reduced as joint attention increased, the authors were unable to show that RPM itself had a direct correlation to the behaviors exhibited by the participants or that joint attention increased as a result of its use. [12] Correct answers were observed while students were not engaged with the activity, leading reviewers of the study to ask: "How does the client know how to answer, what the answer options are, or where the letters are located if the client is not looking at the facilitator or at the moving letter board?" [2] The study authors postulated that "direct gaze [at the facilitator or letter board] may actually inhibit the ability to respond correctly," [2] [12] The authors did not investigate authorship of the communications produced during the RPM sessions. [2]
According to reviewers, RPM method does make use of concepts such as errorless learning, response interruption, and redirection. However, these behavioral intervention components are not implemented in a manner consistent with the research-base. [12] Practitioners claim to be responsive to each individual's dominant open sensory channel, the "basic features of training" to not appear to be distinctively different across the channels. [1] Studying RPM's efficacy is made difficult by policies that prevent videotaping of RPM sessions (even of one's own child) and instructional workshops. [2]
Jaswal et al. also continued the pattern of proponents studying the issue of agency in the use of RPM by using indirect, rather than direct (message passing) methodologies. [26] [27] [28] The study [26] found that the non-verbal (according to their reports) autistic individuals in their study (1) made anticipatory eye movements to the next letter in a word prior to touching the letter, (2) had longer pauses in their letter-touching within words than between words, and (3) were faster at touching common letter patterns in sequence than was the case for less common letter patterns. Based upon these indirect indices of message agency, it was concluded that the autistic individuals, rather than the assistants who held the letter boards, were the agents of the messages. Vyse, [27] however, argued that none of these findings provides clear evidence regarding message agency. For example, the longer pauses between words could simply have resulted from the fact that the assistant voiced each word aloud after the final letter of each word was touched. [27] Vyse also argued that the authors have not provided a compelling reason why simpler, and more direct, methods of assessing message agency (some form of message passing methodology) were not used in the study, and why simple controls that could bolster the authors' claims (e.g. placing the letterboard on a stand instead of it being held by the assistant or putting a blindfold on the assistant) were not utilized. [27]
Accordingly, to date, RPM proponents, by resisting participation in studies, [7] [11] have failed to produce methodologically sound, evidence-based studies demonstrating that RPM provides people with autism and other developmental disabilities a reliable and independent method for communicating. [1] [13] [14] [27]
Critics of RPM are concerned that, sometimes even on the first attempt at using the method, people with profound communication and/or developmental disabilities achieve levels of communication or understanding of subject matter beyond what their expected age or exposure to formal education would predict. [1] [2] In some cases, students, with prompting, produce results in a language other than the one he or she has been exposed, indicating facilitator, rather than student authorship. [1] Facilitators, sympathetic to the RPM goals of ensuring student success, may unknowingly, unintentionally, or unconsciously move the letter board to achieve the desired communication outcome. [2] [12]
In order to point, type or write using RPM, people with disabilities rely on an aide or facilitator to give verbal or gestural prompts and/or hold a letter board during the sessions, which precludes independent communication. [12] Prompts may include verbal reprimands, trial termination, physical redirection, slapping or shaking the letter board against the subject's face or chest, and blocking escape by positioning the subject between the table and walls. [1] Some of the verbal and gestural prompting procedures used in RPM are similar to the Pinchbeck Technique used by conjurers to "create the illusion of letter-by-letter communication." [1]
"It is possible that no actual academic skills are taught to participants in RPM. Instead, participants may only learn how to better follow subtle, rhythmic, and frequent prompts. The danger, of course, is that an untrained observer might not be able to readily recognize such subtle prompts and may mistakenly assume that prompted responses accurately reflect the true preferences, academic abilities, and emotions of the individual. Such an outcome would make RPM equally as dangerous and inhumane as facilitated communication (FC), a thoroughly debunked method that creates a powerful illusion that seems notably similar to RPM."
— Lang, et al. (2014) [12]
Critics point out that there are no procedures in place to prevent students' over reliance on their facilitator. [1] [28] Likewise, there is no purposeful or systematic fading of prompts with RPM, [2] though research-based techniques exist to support transference of prompt-reliant behaviors to "naturally occurring discriminitive stimuli". [12] This reliance on prompts creates a dependency that, essentially, reduces independent communication and increases the chances that the facilitators are authoring the messages. [11] In other words, "accurate responding may not occur unless the aide knows the answers." [1]
Proponents assert that "prompt dependency is preferable to no response" from the subjects. [2]
With advanced computer technology capable of allowing people access to communication with eye movements, critics also question "the validity of any communication method that requires the physical help of someone else." [7] Critics counter this assertion. Prompt dependency creates an active participation in the communication process. Therefore, the "potential for unconscious guidance remains". [9] [28]
Facilitated communication, a technique in which a facilitator supports a person with disabilities at the arm, wrist or hand during the process of typing on a letter board, is closely related to RPM. Controlled studies in the 1990s determined that, when facilitators did not know the answers to questions being asked through FC, the answers were "routinely inaccurate". Facilitators were (unconsciously) authoring the messages. [7]
Proponents of RPM deny similarities with FC because the aide or facilitator in RPM holds the letter board but "does not touch the person typing" [7] and that the prompts are "nonspecific." [8] However, critics of RPM point out that subtle cuing takes place during RPM that makes it "highly susceptible to facilitator influence." [7] [28]
Other similarities between RPM and FC include: reluctance or refusal to test facilitator/client pairs in controlled settings (purportedly because the process breaks the trust between the pair), presumed competence, reliance on anecdotal accounts as proof of efficacy, maintenance of practices, techniques and claims that are inconsistent with the known body of work around the behavior and communication skills of individuals with developmental disabilities or proven remediation techniques, claims of extraordinary literacy or intellectual breakthroughs, unconscious verbal or physical cuing by facilitators to obtain the expected responses, inadequate or non-existent protocols to fade supported or facilitated prompts. [2] [1]
RPM has been featured in several documentary and on several television news programs including: 60 Minutes II , [2] CNN, [2] PBS (How does the autistic brain work?), [1] and National Geographic (Mind Tree Poems, 2005). [1] Mukhopadhyay's son, Tito, featured prominently in a BBC Documentary, Tito's Story, [1] and is given credit for co-authoring (with his mother using RPM), "two poetry books, a collection of short stories, and a book describing his sensory experience." [2] Print sources discussing RPM and the Mukhopadhyays, include The New York Times and Scientific American , the latter of which criticized active proponents for not attempting a scientific study of the method. [2]
The August 2014 documentary film, A Mother's Courage: Talking Back to Autism, was adapted from a 2009 Icelandic film entitled Solskinsdrengurrin (The Sunshine Boy) by Margrét Dagmar Ericsdóttir and Friðrik Þór Friðriksson. [12] [2] The film follows Margret, an Icelandic woman, in her quest to find answers for her 11-year-old son who is severely impaired. Her search leads her to Austin, TX, Mukhopadhyay and RPM. [29] [30]
RPM was featured in an Apple Inc. commercial, which led to criticism of Apple for promoting pseudoscience. [31] [32]
Critics of this type of media attention point out that these programs portray autism as "mysterious in nature", offer anecdotal evidence (i.e., Tito's poetry) as proof that RPM works, and downplay the fact that RPM "does not have research to support it at this time." [2]
Facilitated communication (FC), or supported typing, is a scientifically discredited technique, which claims to allow non-verbal people, such as those with autism, to communicate. The technique involves a facilitator guiding the disabled person's arm or hand in an attempt to help them type on a keyboard or other such device which they are unable to properly use if unfacilitated.
Developmental disorders comprise a group of psychiatric conditions originating in childhood that involve serious impairment in different areas. There are several ways of using this term. The most narrow concept is used in the category "Specific Disorders of Psychological Development" in the ICD-10. These disorders comprise developmental language disorder, learning disorders, developmental coordination disorders, and autism spectrum disorders (ASD). In broader definitions, attention deficit hyperactivity disorder (ADHD) is included, and the term used is neurodevelopmental disorders. Yet others include antisocial behavior and schizophrenia that begins in childhood and continues through life. However, these two latter conditions are not as stable as the other developmental disorders, and there is not the same evidence of a shared genetic liability.
Diagnoses of autism have become more frequent since the 1980s, which has led to various controversies about both the cause of autism and the nature of the diagnoses themselves. Whether autism has mainly a genetic or developmental cause, and the degree of coincidence between autism and intellectual disability, are all matters of current scientific controversy as well as inquiry. There is also more sociopolitical debate as to whether autism should be considered a disability on its own.
Autism Is a World is an American short subject documentary film by Academy Award Producer and Director Gerardine Wurzburg and allegedly written by Sue Rubin, an autistic woman who is said to have learned to communicate via the discredited technique of facilitated communication. It was nominated in the 77th annual Academy Awards for Best Documentary Short Subject.
Discrete trial training (DTT) is a technique used by practitioners of applied behavior analysis (ABA) that was developed by Ivar Lovaas at the University of California, Los Angeles (UCLA). DTT uses mass instruction and reinforcers that create clear contingencies to shape new skills. Often employed as an early intensive behavioral intervention (EIBI) for up to 25–40 hours per week for children with autism, the technique relies on the use of prompts, modeling, and positive reinforcement strategies to facilitate the child's learning. It previously used aversives to punish unwanted behaviors. DTT has also been referred to as the "Lovaas/UCLA model", "rapid motor imitation antecedent", "listener responding", errorless learning", and "mass trials".
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Augmentative and alternative communication (AAC) encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language. AAC is used by those with a wide range of speech and language impairments, including congenital impairments such as cerebral palsy, intellectual impairment and autism, and acquired conditions such as amyotrophic lateral sclerosis and Parkinson's disease. AAC can be a permanent addition to a person's communication or a temporary aid. Stephen Hawking, probably the best-known user of AAC, had amyotrophic lateral sclerosis, and communicated through a speech-generating device.
The following outline is provided as an overview of and topical guide to autism:
Developmental disability is a diverse group of chronic conditions, comprising mental or physical impairments that arise before adulthood. Developmental disabilities cause individuals living with them many difficulties in certain areas of life, especially in "language, mobility, learning, self-help, and independent living". Developmental disabilities can be detected early on and persist throughout an individual's lifespan. Developmental disability that affects all areas of a child's development is sometimes referred to as global developmental delay.
Douglas Paul Biklen is an American educator, fine art photographer, leading proponent of facilitated communication, a scientifically discredited technique which purports to allow non-verbal people to communicate; and an advocate of educational inclusion. A graduate of Bowdoin College, Biklen joined Syracuse University in 1969 and completed his doctorate there in 1973. He was controversially appointed Dean of the Syracuse University School of Education in 2005 and retired in 2014. Biklen has authored and co-authored several books and served on production teams for several documentary films, including 2004's Autism Is a World.
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Pivotal response treatment (PRT), also referred to as pivotal response training, is a naturalistic form of applied behavior analysis used as an early intervention for children with autism that invented by Robert Koegel and Lynn Kern Koegel. PRT advocates contend that behavior hinges on "pivotal" behavioral skills—motivation and the ability to respond to multiple cues—and that development of these skills will result in collateral behavioral improvements. It's an alternative approach to ABA from the more common form, sometimes called discrete trial training (DTT).
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Strange Son: Two Mothers, Two Sons, and the Quest to Unlock the Hidden World of Autism is a 2007 book by Portia Iversen. It concerns the development of her second son, Dov, who started expressing autistic characteristics around age two, and how she used the pseudoscientific technique rapid prompting method with him and believes it has helped him.
The Picture Exchange Communication System (PECS) is an augmentative and alternative communication system developed and produced by Pyramid Educational Consultants, Inc. PECS was developed in 1985 at the Delaware Autism Program by Andy Bondy, PhD, and Lori Frost, MS, CCC-SLP. The developers of PECS noticed that traditional communication techniques, including speech imitation, sign language, and picture point systems, relied on the teacher to initiate social interactions and none focused on teaching students to initiate interactions. Based on these observations, Bondy and Frost created a functional means of communication for individuals with a variety of communication challenges. Although PECS was originally developed for young children with autism spectrum disorder (ASD), its use has become much more widespread. Through the years, PECS has been successfully implemented with individuals with varying diagnoses across the aged span. PECS is an evidence-based practice that has been highly successful with regard to the development of functional communication skills.
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Soma Mukhopadhyay is credited with creating rapid prompting method, a pseudoscientific technique that attempts to aid people with autism or other disabilities to communicate through pointing, typing, or writing. It is also known as RPM and Spelling to Communicate.
Ido Kedar is a non-speaking autistic author, memoirist, essayist, educator, and autistic advocate. His written works include the essay collection Ido in Autismland.
Vikram Kenneth Jaswal is a developmental psychologist known for his work on autism, particularly augmentative communication supports for nonspeaking autistic people using the discredited method of facilitated communication. He holds the position of Professor of Psychology at the University of Virginia.