RPM and DIRFloortime at What Cost?
The journal Exceptional Children recently published a study called “An Economic Evaluation of Emerging and Ineffective Interventions: Examining the Role of Cost When Translating Research into Practice” by Gretchen Scheibel, Thomas L. Lane, and Kathleen N. Zimmerman.
The purpose of the study was to examine the time and financial costs associated with two interventions: DIRFloortime Therapy and Rapid Prompting Method (RPM). Both were identified in a survey of special educators for their popularity and “lack of strong empirical evidence of effectiveness.”
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The authors reviewed economic reports associated with supporting individuals with Autism Spectrum Disorder (ASD) and determined that the average lifetime cost of additional education, therapies, and caregiving for a child with ASD is significantly higher (an estimated $20,000 more annually) than raising a neurotypical child. School districts spend between $8,000 to $12,000 annually per child with ASD, providing many of the special education services needed for K-12 students. The costs involved with these services punctuates the necessity of providing individuals with practices that are scientifically based and optimize students’ progress towards annual education goals. The evidence status of an intervention, generally, includes “evaluation of the design, quality, quantity, and outcomes of the body of research supporting the intervention.”
Despite efforts by the National Professional Development Center on Autism Spectrum Disorders and the National Autism Center (NAC) to systematically identify evidence-based interventions, roughly a third of surveyed special educators working with children with ASD use DIRFloortime Therapy and Rapid Prompting Method on at least a weekly basis. Systematic reviews of these interventions confirmed “weak or lack of empirical support for each intervention.”
The authors in this study posed the following questions to guide their inquiry into the economic costs of using these interventions:
1) What are the estimated costs associated with implementing DIRFloortime, an intervention with emerging evidence and potentially positive effects?
2) What are the estimated costs of implementing RPM, an intervention with evidence of neutral or harmful effects?
Further, the authors identified several areas or “ingredients” with which to provide a cost-analysis: personnel, training, facilities, materials, and student/parent costs. The total financial costs of these interventions included the “implementation costs and the opportunity cost of the child’s time for the initial implementation and materials) and on-going use of the intervention.” Additional details are in the report.
Due to “limited quality and consistency of outcome measures across studies” for DIRFloortime and “lack of studies with sufficient methodological rigor to allow for calculation of an omnibus effect size” for RPM, the authors were unable to calculate a cost-effect ratio for either intervention.
Despite this, the authors were able to provide an estimated “categorical representation of the resources consumed during intervention implementation.” These costs are incurred above and beyond existing costs for special education programs.
Costs Associated with DIRFloortime
An estimated $9,976 in initial costs
$958 to attend minimal level of specialized training (required)
Additional $795 for advanced training
Additional $597 to become an “expert” provider
Travel and per diem costs for in-person vs. online training
Costs Associated with RPM
An estimated $13,978 in initial implementation
Opportunity costs (equal to the cost of providing evidence-based interventions) $18,180
Additional costs: lost instruction time, exposure to ineffective or harmful interventions, potential student exploitation
Further recommendations by the authors:
Include economic evaluation as a companion consideration to empirical evidence when comparing and selecting interventions
Increase use of cost-analysis of interventions to compare the financial costs of available resources and feasibility of implementation
Use of cost-analysis to identify the “ingredients” necessary for “high fidelity implementation and calculation of cost ratios.” This may be helpful to decision-makers in determining whether the outcome (of a particular intervention) justifies the cost of implementation.
For those of us who follow FC closely, these findings are not necessarily surprising, but this study is an important milestone, nonetheless. The authors highlight the financial impact and burden RPM in particular has on school systems and parents or guardians of individuals with ASD. Not only does RPM lack empirical proof of efficacy, it is now documented as a financial drain as well. What more do administrators need to understand that RPM has no legitimate place in our school systems?
Moving forward, we encourage school administrators and policy makers to take this study to heart. We continue to support the implementation of proven, evidence-based methods and techniques that optimize learning for students with ASD.
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