Systematic Review of Rapid Prompting Method presented at the 10th European Congress of Speech and Language Therapy Estoril Portugal 10-12 May 2018

1. Bronwyn Hemsley1, Ralf Schlosser2,3,4 Mark Mostert,5 Scott Lilienfeld,6 Samuel Odom,7
James Todd,8 David Trembath,9 Howard Shane 2,10,11
Russel Lang,12 & Seraphina Fong1
4
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A systematic review of the Rapid Prompting
Method: Findings and Implications for
Speech Language Therapists worldwide
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Paper Presented at #CPLOL18 10th European Congress of Speech and Language
Therapy, Estoril, Portugal on 12th May 2018

2. Disclosures
The authors have no relevant financial or
nonfinancial relationships to disclose.
2#CPLOL18

3. Our audience at #CPLOL18
New to
RPM
Uncertain
either
way
Evidence
Aware
RPM
Advocate
3#CPLOL18

4. BACKGROUND
4#CPLOL18

5. Video: Example of RPM
5#CPLOL18
Table provides a good frame of reference square to show board is being moved.
Removed for slideshare

6. According to Soma Mukhopadhyay,
as distilled from her Halo-Soma website and books,
Rapid Prompting Method (RPM) is:
• A brain-based teaching and assistive method
designed to establish and promote pointing-
based textual communication in people who
cannot speak, usually autism.
• Involves a series of “teach-ask” trials of
graduated difficulty, starting with the pupil
choosing a correct answer from two written
options, progressing through composing
responses by pointing to printed letters on a
card.
• Linguistic competence is presumed even if
not evident, and learning materials are
presented verbally and textually at age level.
6
Image credit: Halo website
#CPLOL18

7. RPM theory:
An ‘unusual’ way of looking at autism
• The Sensory Integration Theory of A. Jean
Ayers is foundational; teachers are to assess
and use the “open sensory channel.”
• Some problems of autism result from a failure
of the child to move from earlier to later
Piagetian stages.
• Teaching does not require explicit rewards as
these are built into success.
• Autism is fundamentally a “failure of
initiation.” Thus, prompts are a necessary and
probably permanent feature of RPM
assistance.
• Self-stimulatory and other common features
of autism may be used in assessing the
“open sensory channel,” but usually can be
otherwise ignored.
7
Images credit: Halo website
#CPLOL18

8. Why the urgency to
systematically review RPM?
1. Anecdotal reports that it is growing in popularity in US and Ireland
2. Appearance in Ireland senate (Senator Rónán Mullen) (2016) and Irish Media
(Jan 2017)
3. Front page article, Washington Post (March 2017)
4. YouTube - search ‘Rapid Prompting’ yields about 1210 results (Nov 2017)
5. Appearance in occupational therapy open access literature 2017
6. Parents have a right to the highest level of evidence available in making
decisions
8
#CPLOL18

9. Previous Review of RPM
(Deacy et al., 2016)
Three studies were included and
“findings were summarised into
four categories. Findings appear
to indicate an association
between RPM and a decrease in
repetitive behaviours.” (p. 92)
“Further research in the area of
RPM is warranted in order for it
to be considered as a qualifying
evidence-based practice” (p. 92)
9
Deacy, E., Jennings, F., & O'Hallorhan, A. (2016). Rapid Prompting Method (RPM): A
suitable intervention for students with ASD?. Reach, 29(2), 92-100.
#CPLOL18

10. Gernsbacher (2004)
Retrospective case study of
1 child.
“The RPM core element of
‘repetitive prompting’ is not
referred to in this study, so it
is unclear if the method used
is closer to ‘facilitated
communication’ which has
been discredited in the
literature” (p. 94). 10
Solomon (2006)
Descriptive-ethnographic
study, Compared
practice of RPM at HALO
vs. at home.
Chen et al. (2012)
Descriptive study of
RPM and repetitive
behavior.
Deacy, E., Jennings, F., & O'Hallorhan, A. (2016). Rapid
Prompting Method (RPM): A suitable intervention for students
with ASD?. Reach, 29(2), 92-100.
Previous Review of RPM
(Deacy et al., 2016)

11. Not all reviews are equal
Commentary on Deacy et al., review
• Numerous methodological flaws identified in Deacy et al., 2016
• Conflicts of interests identified for its included studies
11#CPLOL18

12. Aim
To determine whether RPM is effective for
individuals with ASD in terms of:
(1) improving body motor skills, speech
skills, communication skills, and
communication-related cognitive skills,
and/or
(2) reducing challenging behaviors
12#CPLOL18

13. Aim in PICOS Format
P (Person/Population) => Individuals with ASD
I (Intervention) => RPM
C (Comparison) => None required, any allowed
O (Outcomes) => Body motor skills, speech skills,
communication skills,
communication-related cognitive,
challenging behaviors
S (Study Design) => Single-case experimental
designs or group experimental
designs capable of showing
a functional relation between
RPM and outcomes
13#CPLOL18

14. METHODS
Systematic Review
14#CPLOL18

15. A priori Registration of Protocol
15

16. Inclusion Criteria
• Participants with a documented diagnosis of ASD
• Design that establishes a functional relationship
between RPM and outcomes
 If qualifying group design:
 (a) if only group level data were provided, all participants met ASD
criteria
 (b) if only some participants met ASD criteria, subgroup analyses
were provided
 If qualifying single-case experimental design:
 At least one participant met ASD criteria and data are provided for
that participant
• RPM was the intervention studied
• Published in a peer-reviewed journal, as a master’s
thesis, as a dissertation, or full-length unpublished
manuscript
16#CPLOL18

17. Literature Search
17
• Bibliographic databases
• Cochrane Library
• ComDisDome (ProQuest)
• Cumulative Index of Nursing & Allied Health
Literatures (CINAHL, EBSCOhost)
• Education Journals (ProQuest)
• Education Research Complete (EBSCO
Host)
• Education Resources Information
Clearinghouse (ERIC, ProQuest)
• Google Scholar
• Linguistics and Language Behavior Abstracts
(LLBA, ProQuest),
• Medline (via Pubmed)
• ProQuest Dissertations and Theses Global
• PsycINFO (ProQuest)
• Psychology and Behavioral Science
Collection (ProQuest)
• Web of Science
#CPLOL18

18. Literature Search
18
• Publisher-specific databases
• Sage Journals Premier
• ScienceDirect Elsewier
• SpringerLink Journals
• Taylor & Francis Online
• Trial Registers
• EU Clinical Trial Register
• Australian New Zealand Clinical Trial Registry
• Clinical Trials
• ClinicalTrials.gov
• ClincalTrialSearch.org
• Ancestry Searches
• of included and relevant other studies, reviews, book chapters, and books
• Forward citation searches
• Of included and other studies/papers that referenced RPM
• Contact authors of select published peer-reviewed articles

19. Literature Search
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Lessons from Preliminary Search
• “RPM” not a viable acronym to search
• Author search only viable if the database
permitted a search of the full name, i.e., last
name (“Mukhopadhyay”) with first initial (“S”)
• Not necessary to combine “Rapid Prompting
Method” with an autism-related keyword
Search Strategy
• “Rapid Prompting Method” as a free text
word in title, abstract, and/or full text
• “Informative pointing” as a free text word in
title, abstract and/or full text
#CPLOL18

20. Inclusion Reliability
• First author (Schlosser) screened search results by title and
abstract
• All documents (100%) submitted to the inclusion checklist were
evaluated by the first and second author (Hemsley)
independently from each other
• Percent agreement on Inclusion Decision (“in or out”) = 100%
• Percent agreement on item-specific ratings before consensus
building: 91.18%
• Percent agreement on item-specific ratings after consensus
building: 100%
20#CPLOL18

21. RESULTS
#CPLOL18

22. PRISMA Flow Diagram
22
From:MoherD,LiberatiA,TetzlaffJ,AltmanDG,ThePRISMAGroup(2009).PreferredReportingItemsforSystematicReviewsandMeta-
Analyses:ThePRISMAStatement.PLoSMed6(7):e1000097.doi:10.1371/journal.pmed1000097
Formoreinformation,visitwww.prisma-statement.org.
PRISMA2009FlowDiagram
Recordsidentifiedthrough
databasesearching
(n=75)
Screening IncludedEligibilityIdentification
Additionalrecordsidentified
throughothersources
(n=75)
Recordsafterduplicatesremoved
(n=91)
Recordsscreened
(n=91)
Recordsexcluded
(n=84)
Full-textarticlesassessed
foreligibility
(n=7)
Full-textarticlesexcluded,
withreasons
(n=7)
Studiesincludedin
qualitativesynthesis
(n=0)
Studiesincludedin
quantitativesynthesis
(meta-analysis)
(n=0)
Removed for slideshare

23. Reasons for Exclusion
of the 6 full texts
Study – Full-text Review Checklist item/s
not met
Exclusion notes
Chen et al. (2014) # 2 Descriptive study
Cleveland (2008) # 5 Although Mukhopadhyay’s work is reviewed in the literature
section, the procedure described (p. 11) has components of
RPM but is not specifically RPM as described by
Mukhopadyay.
Gernsbacher (2004) # 2, # 5 Descriptive case study (# 2);
The mother had met with Mukhopadhyay and as a result
adapted some of her modalities. For example, she tried
handwriting as a form of AAC. It is stated she wouldn’t go
through the procedures at great length as described by the
developer (# 5).
Solomon (2006) # 2, # 5 Ethnographic study (# 2);
Even though RPM was studied it was examined as a
practice rather than an intervention – comparing the
practices of RPM at HALO versus by parents elsewhere (#5)
Van Acker (2016) # 1, # 2, # 5 Discussion paper without participants or design (#1, # 2);
RPM was mentioned in the text but was not studied as an
intervention (#5)
Van der Meer (2012) # 5 RPM was mentioned in the text but not studied as an
intervention (#5)
23

24. Result
There are NO studies establishing a
relationship between RPM and:
1. Improvements in body motor skills,
speech skills, communication skills,
and communication-related cognitive
skills, and/or
2. Reduction in challenging behaviors
24#CPLOL18

25. DISCUSSION
25#CPLOL18

26. Empty Review
• There is no evidence that RPM results in
the claims purported by its developer and
proponents
• RPM is an unsupported technique
26#CPLOL18

27. Evaluating the Proclaimed
Underlying “Theory of Action”
A neurological examination of RPM suggests:
• Mukhopadhyay’s statements about mirror neurons, brain
anatomy, and other aspects of neurology bear little relation
to actual neurology.
• In addition to its reliance on Ayers’s doubtful theories of
sensory integration, RPM provides no specific or reliable
method to assess or employ the “open sensory channel.”
• The strong recommendation to teach from the right in order
to engage the left side of the brain reveals a profound
reliance on pop psychology rather than actual neurology.
27
Todd, J.T. (2015). Old horses in new stables: Rapid
prompting, facilitated communication, science, ethics,
and the history of magic. In R. M. Foxx & J. A. Mulick
(Eds.). Controversial Therapies for Developmental
Disabilities: Fad, Fashion, and Science in Professional
Practice (2nd ed.). Mahwah, NJ: Routledge
Hickok, G. (2014). The myth of mirror
neurons: The real neuroscience of
communication and cognition. New York:
WW Norton & Company

28. Evaluating the Proclaimed
Underlying
“Theory of Action”
A learning theory examination of RPM suggests:
• The pointing-based communication is actually simulated,
authored by the aide rather than the pupil.
• The “teach-ask” teaching trials contain no real linguistic
instruction, and should not be expected to establish genuine
expression.
• Rather, the trials are an errorless program by which the pupil is
taught to respond to increasingly subtle cues given by the aide
via letterboard movements, gestures, and verbal prompts.
• The aide gradually loses awareness of giving the cues to the
point doing so is likely to become unconscious.
28
Todd, J.T. (2015). Old horses in new stables: Rapid prompting, facilitated communication,
science, ethics, and the history of magic. In R. M. Foxx & J. A. Mulick (Eds.). Controversial
Therapies for Developmental Disabilities: Fad, Fashion, and Science in Professional
Practice (2nd ed.). Mahwah, NJ: Routledge

29. Proposed consumers of RPM most likely can initiate
movement. Watch them:
• Cross mid-line
• Independently point – occasionally require modeling
• Often point independently to common items represented by a
symbol, but not to corresponding words or letters
• Manipulate iPad / smart phone (point, swipe, etc.)
• Grasp and release small objects
• Accurately place small objects on targets
• Eat independently
• Handle small manipulatives (e.g., string beads, operate tv
remote, open containers, complete puzzles) 29
Evaluating the Proclaimed
Underlying
“Theory of Action”Inability to initiate movement is a (convenient) red
herring
Evaluating the Proclaimed
Underlying
“Theory of Action”

30. Given state-of-the-art
contemporary technology, almost
no person is too physically
disabled to communicate using
language -- If they have psycho-
linguistic competence.
30
Just to be clear …

31. Facilitated Communication (FC)
& RPM
FC’s mechanism of action
• Ideomotor Effect
• Expectancy Bias
• Confirmation Bias
FC by any other name…
• Supported Typing
• Assisted Typing
• Inventive Spelling
Despite minor procedural variations, the
above interventions share the same
mechanism of action and are thus rightfully
grouped together.
RPM is in the (expanding) group of
facilitated communication methods.
31
Same
action
RPM
FC
Supported
typing
Assisted
Typing
#CPLOL18

32. RPM & FC:
Procedural Differences and Similarities
RPM has a “Teaching” phase
before letter board introduction.
• intentional, acknowledged,
prompting
• letter board is held by the facilitator
while the facilitated person is not
touched.
In RPM, there is no meaningful
change to FC’s mechanism of
action.
32
Same
action
RPM
FC
#CPLOL18

33. Abuse and RPM:
Not just sexual exploitation
• Educational mistreatment
– wasted time not learning useful / functional skills
• Parental exploitation
– unrealistic expectations planted by FC & RPM
evangelists
• Child ‘mishandling’ of identity
– loss of own voice and actual person
• Professional manipulation
– of those teachers/SLPs who unwittingly become
believers
33#CPLOL18

34. RPM is Pseudoscientific
 FC and RPM are “untestable”
• proponents say that research breaks the trust between facilitator
and facilitated; or research is said to be unnecessary
 Evidence that does not support pre-drawn conclusions is
dismissed (despite sufficiently rigorous research procedures),
and supportive “evidence” is accepted
 FC and RPM are largely supported by anecdotal accounts
 Inconsistent with well established replicated findings regarding
the communication and language development in people with
ASD/ID
 Extraordinary claims
• unexpected literacy
 Reliance on “vaguely described holistic framework”
• the mechanism of action suggested by proponents is unclear and
lacks parsimony
34
Finn, Bothe, & Bramlett’s (2005) Criteria for distinguishing Science from Pseudoscience*.
* Adapted from Lilienfeld, Lynn, and Lohr (2003, revised edition 2014) “Science and pseudoscience in
clinical psychology.” New York, Guilford.

35. CLINICAL IMPLICATIONS
35#CPLOL18

36. Our audience is now …
New to
RPM
Uncertain
either way
Evidence
Aware
RPM
Advocate
36#CPLOL18

37. Code of Ethics
Each association’s code of ethics is applicable in
terms of avoiding harms and making ethical
decisions in relation to treatments.
37
Ethics
Aware
#CPLOL18

38. 1. Refrain from using RPM
or supporting RPM
Use evidence-based AAC interventions and
ABA
• Wong, C., Odom, S. L., et al. (2015). Evidence‐ Based
Practices for Children, Youth, and Young Adults with Autism
Spectrum Disorder: A Comprehensive Review. Journal of
Autism and Developmental Disorders, 1‐16.
• National Autism Center (NAC) (2015). Findings and
conclusions: National Standards Project, Phase 2.
http://www.nationalautismcenter.org/national-standards-
project/results-reports/
Using RPM or UNCERTAIN?
Ask us about testing authorship. 38
Uncertain
either
way?
#CPLOL18

39. • Promoting Rapid Prompting Method (e.g., in social
media) could contravene the professional’s code of
ethics, and is irresponsible.
• Speech language pathologists should not promote or
support the use of RPM.
• Refer to your professional association if uncertain how to
respond to authority figures pressing you to use RPM.
• Families, teachers, therapists and other decision-makers
(e.g., funding bodies, administration of schools) should
be advised of the findings of this review, as per ‘duty of
care’ ‘duty to warn’ (professional responsibility).
• Ask the authors of this paper for updates (see last slide)
39
2. Be Aware & Advise
#CPLOL18

40. 3. Read studies CLOSELY
❓Participants with a documented diagnosis of ASD
❓Design that establishes a functional relationship
between RPM and outcomes
❓If qualifying group design:
❓(a) if only group level data were provided, all participants met ASD
criterion
❓(b) if only some participants met ASD criterion, subgroup analyses
were provided
❓If qualifying single-case experimental design:
❓At least one participant met ASD criterion and data are provided for
that participant
❓RPM was the intervention studied
❓Published in a peer-reviewed journal, as a master’s
thesis, as a dissertation, or full-length unpublished
manuscript
40#CPLOL18

41. 4. Be an evidence champion
#ResNetSLT #SLPeeps @WeSpeechies #WeSpeechies
#AugComm
41
Evidence
Champion

42. Is further research needed?
Testing of authorship
“The paramount question to be addressed by researchers
investigating RPM should pertain to authorship of the
messages … evidence is needed regarding the authenticity of
messages generated by people with ASD who use a
letterboard held by facilitators” (Lang et al., 2014, p. 46).
42
Lang, R. Harbison Tostanoski, A, Travers, J., Todd, J., Todd,
J., & Shane, H. (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, 40–48.
Although Hemsley (2016) contended that further primary research was not
warranted, would research on ‘authorship’ in RPM protect the interests of person
with autism?
#CPLOL18

43. Conclusion
43
Rapid Prompting Method has no evidence, is not
supported, is pseudoscientific, and - because of the
influence of facilitators, loss of the human right of
communication, and loss of opportunity to treatments that
work - is harmful to people with autism who are exposed
to it.
Rapid Prompting Method should not be used in the
treatment of communication or behavior for people with
autism.
#CPLOL18

44. Ask the Authors for Autism
Research & Evidence Updates
• Prof Bronwyn Hemsley Bronwyn.Hemsley@uts.edu.au
• Prof Ralf Schlosser R.Schlosser@northeastern.edu
44