About six weeks ago I wrote the following post on Rapid Prompting Method (edited for this current piece); it garnered a lot of attention from avid parent supporters and from the inventor of the method herself. There was a fair amount of conjecture that RPM was cheap as far as autism therapies went, and that parents should leave no stone unturn. One of the last comments left was a suggestion that I bring my oldest to Austin to try the method; I just might be surprised.

One of the things that has continued to be of surprise is just how fervently followers of various dubious treatment modalities can believe in them and just far they are willing to take those beliefs. I spend a fair amount of time countering the misinformation that is put out there by parents who believe vaccines caused their children’s autism. These people are true believers, and these treatment supporters are no less avid in their beliefs.

In other words, they won’t be swayed by evidence; anecdote and their own self-justification hold supreme. They’ve invested time, money, and effort into these treatments and they have absolutely no reason to admit that they were wrong and have wasted their time, money, and effort while someone profited off of them.

The number of potential autism treatments is truly mind-boggling. And parents are desperate to make their children better. Many really will go all out, all the way down the woo-hole in an effort to cure their children.

The Rapid Prompting Method was recently featured on HBO’s A Mother’s Courage: Talking Back to Autism.

The Rapid Prompting Method was created by a mom in an attempt to help her autistic son communicate. According the organization Soma Mukhopadhyay set up, her rapid prompting method, or Soma® RPM, “is academic instruction leading towards communication for persons with autism.”

Lisa Jo Rudy, on About.com’s site for autism, writes about Soma Mukhopadhyay’s Rapid Prompting Method that it is “a successful technique for teaching and communicating with her autistic son.” Rudy tempers that somewhat with the acknowledgement that it is untested and expensive: “While RPM and pointing carry no risks, nor are they backed by any kind of focused research. 
In fact, even the "research" link on HALO's site provides almost nothing in the way of outside evaluation of efficacy. As a result, parents who travel to Austin for Soma's services do so on the basis of anecdotal evidence and hope -- and at considerable expense. It is, however, possible to start RPM and "pointing" on your own, by working from manuals, videos and instructions provided on the HALO and Strange Son websites.”
According to HALO, “RPM is an empirical and rational teaching method, based upon how the brain works. Academic lessons are intended to stimulate left-brain learning, leading towards communication. "Behaviors" or stims are used to help determine the student's open learning channels.” 

Despite the claim of empiricism and rationalism, there are only two mentions of RPM in the scientific literature: Van Ackers and a brief mention in a case study by Gernsbacher in 2004 (thanks to Dr James Todd for pointing this out in a comment left in the Facilitated Communication article).

Van Acker (2006) writes this about Rapid Prompting: “RPM is an instructional technique designed to develop academic and communication skills in individuals with severe autism (CBS Broadcasting, 2003). This intervention program was designed by Soma Mukhopadhyay, a teacher and a mother of a child with autism. RPM elicits responses from persons with autism through a combination of intensive verbal, auditory, visual, and tactile prompts. As in FC, the RPM employs the facilitation of the person's hand or arm as he or she types, points, or writes the responses. To date, PPM has yet to be empirically validated."

Gernsbacher (2004) briefly mentions RPM and Soma Mukhopadhyay: “RH’s mother then had the opportunity to visit with the mother and son in the United States (Mukhopadhyay, 2000). Although RH’s mother was unwilling to go to the extreme measures that the Indian mother had used with her son, RH’s mother was very motivated to explore the possibilities of RH using even a gross style of handwriting for augmentative communication” (88).

No explanation of how this instructional method mirrors how the brain works is made, and it should be noted that Mukhopadhyay does not have a psychological or neurological background: she holds degrees undergraduate degrees in education and chemistry and a master’s degree in chemistry. Instead, vague phrasing abounds through the FAQ and, I guess the hope that asserting that, yes indeed, “Of course RPM is real” will be enough to win folks over.

What are parents to do when looking for treatments for their nonverbal autistic children? If there is a paucity of scientific evidence for a treatment method, then the next best thing to do is to look at the financial incentive for a person to push a particular therapy. Since there is no scientific evidence that RPM works, I turned to looking at the tax returns.

If the 2007 tax return is any indication, Soma’s splashy website with its promises that contained within their nonverbal child is a smart, capable, already knowledgeable child just waiting to get out is more than enough to get parents to part with a sum total of $156,915 in session fees with Mukhopadhyay and $51,260 in training and workshop fees. HALO only brought in $8,955 in membership fees, so 2008 was a better year, all in all. In 2008, HALO, the non-profit organization (which is claiming non-profit status as a school) managed to rake in $10,692 in membership dues. Currently on their webpage, their dues are $25 per year. If those were the dues 2 years ago, then they had 438.38 members. Okay, they had approximately 438 members; I don’t know what the dues were in 2008 that they managed to get that exact number.

Here is what is known about RPM: it provides Soma with her living. When I first wrote this article, one parent argued in the comments that Soma deserved what she could make because she worked with difficult kids that few others would. For doing that, Mukhopadhyay earned $108,300 in 2008 for her work at HALO, a paycut from 2007 when she earned $112,300. It should be noted that total revenue was significantly down: from $333,137 in 2007 to $266,666 in 2008. One has to wonder what the income in this next year will be with HBO’s documentary giving Soma a name-recognition boost.

Austin, Texas, for some reason is a hotbed for autism woo. Thoughtful House and other treatments centers (one closed down last year) are located in Austin, as is Soma’s Halo School.

If you don’t want to send your child to Halo School, though, you can jump through some hoops and pay $725 for RPM training. There are two videos of RPM available to nonmembers; I sat through both and found them to be incredibly abrasive to the senses, with the nonstop chatter by Mukhopadhyay and the constant ripping of paper. Perhaps the actual implementation is less abrasive, and certainly parents could and would modify their approach.

I am sure, though, that if this is how the sessions really go, that this would act as an aversive to a child/person with noise sensitivities. I would personally be unable to function or think in such an environment, with an individual standing on top of me, ripping paper and constantly chattering.

As an explanation of the paper ripping, HALO’s FAQ offers the following: “Paper tearing acts as an auditory, visual and kinesthetic prompt to initiate the student to focus on the written learning activity. For those concerned about paper use, we are quite certain that RPM students do not utilize more paper than typical students. In fact, after RPM students advance to pointing to letter boards, the paper use decreases.” One can only hope.

Apparently, I’m not the only one who would have issues with the space issues, as one of the questions in the FAQ relates to how Soma deals with kids who don’t sit at the table, and it’s an answer that ought to have autistic adults who have issues with the aversives that some forms of ABA use equally up in arms: “In most cases, she would use a confined workspace, with the wall on the student's left side, and Soma sitting to the right.” I’m neurotypical (with issues, I admit), and I would have a problem with this, although the sitting by the instructor is certainly preferable to the instructor standing on top of the student, chattering and ripping paper. If they need some space, though, Soma is willing to accommodate some: “Soma will sometimes work from behind, or sometimes from the front to slow the movement (if the student is not sitting).” I’m just me, me with my issues, but if I had problems with you next to me, I sure am going to have problems with you behind me, too. To the front is preferable, at least.

As you read through the FAQ, if you’re evidence-based, what you see is a dearth of evidence. You do get a bit of woo dressed up in fancytalk:

“How does Soma determine a student's dominant learning channel?
Soma observes the students reactions to his environment as well as the student's primary stim, which can be the best indicator. Example: How does the student respond to a book?.... Does he flip the pages? (kinesthetic/visual) Does he focus on a specific part? (visual) Does he bang the book against something? (auditory) Does he tear the pages? (auditory/tactile) Any of these behaviors would help point to open learning channels.”

The constant chattering is also explained:

“Will constant talking during instruction be distracting to the student?
Auditory learning is important, regardless of whether the student is used to it or not. Some students are more comfortable listening to environmental sounds than spoken language, so they must become accustomed to attending to the teacher's voice.”

Now, if you begin to get a bit critical as to whether this is actually a valid way to teach and what to do if the child doesn’t begin to respond on his own, here’s a sure sign that what’s going on may not be a legitimate sign of actual learning going on:

“Prompt dependency is preferred to the alternative of allowing no response or no learning to occur. In most cases, once motor skills are learned, the need for and frequency of prompts decreases.”

In other words, if the child doesn’t respond, do it for him and keep doing it. It won’t be the child’s communication, though.

Let’s say you have an extremely noise-sensitive autistic child and you decided to do a Soma-style RPM. You crowd the child, because that’s always a good thing to do with space-sensitive people (and many autistic children are; let’s ramp up their anxiety), then let’s start talking rapidly and constantly and begin to rip paper. Repeatedly. Then let’s hold their left hand so they have to use the right (hell to a left-handed kid), because, after all, “Soma encourages right-hand response to stimulate left-brain learning, and to curb a student's stimming with the left hand. Occasionally a student picks both choices using both hands. Then it becomes necessary for the teacher to hold the left hand just to have the child pick one choice.” Then, don’t allow them to not respond; force the response, instead. Why on earth would someone who is empirical and rational think this is designed to get a productive response out of a child?

Rapid Prompting Method has been around about a decade. There are no studies whatsoever on this method. There are testimonials. That’s it. There is no way to assess whether autistic individuals who are the recipients of RPM really benefit and gain skills from this method. There is no way to assess whether responses are a result of the prompter’s co-opting.

I’m fairly sure of one thing. If it were me, and I had an adult doing RPM on me, and I could learn to type, respond, communicate, I sure as all get out would do it as fast as I could just to make the noise and the personal space crowding stop. And I’d have a fair bit of trauma as a result of the experience. But that’s just me. 

Soma and her ardent supporters insist that she really has helped hundreds upon hundreds of autistic kids. We’ll never really know, though, if she really helped them. I mean, if RPM hasn’t undergone testing in a decade, is it really ever likely to? Especially as long as she can make a good living from it? Soma and her supporters insist that it will undergo and is undergoing scientific testing.

Rapid Prompt Method doesn’t pass the evidence test because it has never been subjected to the rigor of a scientific study. It’s unlikely that it would, either.

Parents need to be wary of those who promise them the world but have nothing but testimonials to back it.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

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