CHRISTINE BUCKLEY ALEXIS HERSHKOWITZ NICOLE MOINHOS CALDWELL COLLEGE GRADUATE PROGRAMS IN APPLIED...

CHRISTINE BUCKLEYALEXIS HERSHKOWITZ

NICOLE MOINHOS

CALDWELL COLLEGEGRADUATE PROGRAMS IN

APPLIED BEHAVIOR ANALYSIS

A Review of The Miller Method for Autism

Treatment

The Miller Method® Philosophy

“We maintain that each child--no matter how withdrawn or disorganized--is trying to find a way to cope with the world. Our task is to help that child use every capacity or fragment of capacity to achieve this.”

(www.millermethod.org)

History of The Miller Method®

Founded by Arnold Miller and wife Eileen Eller-Miller in 1965 Language and Cognitive Development Center (LCDC) in

Boston With the help of research and demonstration grants from the

U.S. Department of Education, the Millers have created a wide variety of strategies to help developmentally challenged children

Currently, center is being headed by Dr. Arnold Miller and his senior staff

Affiliate in Los Angeles, California called the Los Angeles Miller Method Resource Center (LAMMRC), directed by Rebecca Sperber (a parent)

LCDC is internationally known

Who are Dr. Arnold Miller & Eileen Eller-Miller?

Married for 45 years, together created The Miller Method® and founded the LCDC

Dr. Arnold Miller1. Director of the LCDC of Boston2. Affiliate Professor of Psychology at Clark University where he

received his doctorate in clinical psychology3. Research appointments at Boston University & Harvard Medical

School4. Was a faculty member of the University of Montana5. Directed the Language Development Laboratory at Wrentham State

School, Massachusetts Eileen Eller-Miller

1. Education Director of the LCDC2. M.A. in speech and language pathology from Columbia University3. B.A. in psychology from City University of New York4. Worked at Flower Fifth Avenue Hospital, Beth Abraham and Hunter

College in New York City

The Millers (cont’d)

Eileen Eller-Miller passed away on June 18, 2004 from colon cancer

Her obituary read: “Eileen Eller-Miller, wife and colleague of Arnold Miller for 45 years, died on June 18, 2004 after a long and courageous battle with colon cancer. She died at home as she wished. Throughout her devastating illness she maintained her optimism and wish to help children with autism achieve a meaningful life. Just weeks before she died -- with barely enough strength to sit up -- she participated in a videoconference with Dr. Miller to help an autistic child and his family. Over the years she partnered with Arnold Miller in founding the Language and Cognitive Development Center and in developing the Miller Method. Before she died, she urged that her husband continue the mission of the Center. “

Cost, Time, Location & Certification

Length of treatment varies

Fee: $150 per one hour session.

50% scholarships are available

Takes place in private and public schools in Massachusetts, New York, New Jersey, Ohio, Pennsylvania, California, Canada, Israel, and secondarily in the homes of families equipped for videoconferencing

Authorized Miller Method® School Programa. Certified Miller Method specialist or therapist on

staffb. Ongoing consultative relationship with a senior

staff member from LCDC

Certification (cont’d)

Appropriate candidates for certification1. Clinical/Developmental Psychologists2. Psychiatrists3. Social Workers4. Pediatric nurses5. Occupational therapists6. Physical therapists7. Special educators8. Speech and Language Pathologists

Several ways to train 1. 4-Day Workshops at LCDC2. Videoconference Workshops

Qualifications for certification1. 4-day training workshops at LCDC2. 50 weeks (1 hour per week) of supervised training3. Cases covered4. Written examination

Goals of The Miller Method®

Assess the adaptive significance of the children's disordered behavior

Transform disordered behavior into functional activity

Expand and guide the children from closed ways of being into social and communicative exchanges

Teach professionals and parents how to guide the children toward reading, writing, number concepts, symbolic play and meaningful inclusion within typical classrooms

Problems with ABA according to The Miller Method®

ABA makes no assumptions about the sources of autism or the inner life of the child

Addresses the atypical behavior using the tools of the learning theory Reinforcing with rewards for desired behaviors (Ex. Food or

praise) Extinguish “unacceptable” behaviors with “time-out,” “turning

away,” or aversive procedures

Emphasis on compliance

Children seem to be acting appropriately but without any clue as to what they are doing.

Assume that if they can get a disordered child to behave like a typical child, then the child will be typical.

ABA vs. The Miller Method®

ABAChild remains seated

to learnTurning away from

acting out childrenDivert or extinguish

unacceptable behaviorEstablish compliance

with the help of rewards

The Miller Method®Learn best through

actionTurning towards and

engaging the acting out child

Transform unacceptable behavior into functional, interactive exchanges

Establishes repetitive rituals (systems) to elicit spontaneous initiatives from the children

Ritual Systems

Based on cognitive-developmental systems theory

MM works with systems

a. System: any organized behavior with an object or even that the child produces

b. Are directed, are organized, and lead to some outcome c. Viewed as organized “chunks” of behavior, perception, or thought d. Rituals are systems

a. Developed properly, can help a child move from atypical to more typical functioning

(Miller, A. & Chretien, K., 2007)

4 Types of Systems

1. Body systems: Coordinate sensory capacities with motor capacities in the service of a particular function.

2. Social systems: How two people interact with each other, whether by working together, turn-taking, competing, or bonding

3. Communication systems: The integration of words and actions around objects in relation to another person

4. Symbolic systems: The way in which a child organizes the relation between symbols and what they represent

Order and Disorder

Order: Predictable systems Disorder: Disruption of systems Two types of Disorder in children with autism

1. System-forming disorder: Children with autism who are quite scattered and have trouble ordering (systematizing) and making sense of their immediate surroundings and the people in it.

2. Closed system disorders: Children with autism who become over-preoccupied with routines (systems) and objects to the exclusion of people

Develop daily routines (ritual systems) in therapy and in school sessions

By developing ritual systems, the child can cope with disorder and change and is open to explore environment

Three Types of Disorder

1. Mild disorder: Evident when the teacher or therapist expands a system by changing the location of the object, the person involved in the system, the objects used in the system, or the position with which the child deals with the object.

2. Moderate disorder: The interruption of systems in a way in which induces a compensatory reaction on the child’s part to maintain the system

3. Dramatic disruptions: A strategy used in which the teacher messes up or dramatically changes something in a child daily routine

Characteristics of Systems

Once a system has been constructed, each system tends to maintain its reason

Differ from each other1. Rigidity: How urgent the child’s need is to

maintain a system unchanged 2. Complexity: Whether the system is simple (a

minisystem) or more complex (an integrative system)

3. Distance reality: Extent to which children substitute symbols for direct physical contact with a person, object, or event

Capacity

A search for the kinds of systems a child brings to a situation

Need to know to what extent a child is dominated by his/her systems

Need to know about the relative rigidity of these systems, their complexity, and the extent to which they can be altered

Assess the child’s relative emphasis on whether the child is engaged exclusively with action-object systems, with people systems, or with both

Assessment Test/Questionnaires1. Miller Diagnostics Survey (MDS)2. Miller Umwelt Assessment Scale

Miller Diagnostics Survey (MDS)

Questionnaire filled out by parents Assesses the child’s atypical functioning Establishes a ratio between a child’s overall

performance and his/her atypical functioning Produces a coping score which reflects the

extent to which a child’s performance is adversely affected by atypical functioning

Area covered by the MDS questionnaire1. Sensory reactivity2. Body organization3. Problem solving and tool use4. Communication5. Symbolic functioning

MDS: Unique Instrument

1. Organized developmentally in that each category includes specific questions about behaviors from both earlier and later stages of development, ranging from 18 months to about 7 yrs of age

2. Parents’ responses to MDS questions provide an estimate of the child’s functional capacities as well as an estimate of how atypical the child’s behavior is

3. Presents 107 questions which cover a broad range of functioning. To be completed by parents at the beginning and end of the academic year (gap between responses of 10 to 12 months)

MDS: Unique Instrument(cont’d)

4. Parents or caregivers who live with the child are continuously more fully aware of the child’s capacities and challenges

5. When gains which are first generated in school or clinic become apparent at home, this demonstrates that new learning has been generalized by the child beyond the confines of school and clinic

6. Probing questions which are part of the MDS may have positive effect of helping parents look more closely at exactly what the child can or cannot do

More about the MDS

Once a parent transmits her/his responses to the questions, a senior staff member at the LCDC will review them, construct a profile of your child, and send a report with recommendations.

Fee: $100

Miller Umwelt Assessment Scale

Assessment of the child in which the child’s behavior is examined in unstructured, interactive, and structured situations

“Umwelt” coined by Uexküll (1957) - “world around the child” or world perceived through the child’s eyes

During the assessment, therapist is interested in determining how close a child is to achieving the next step in development which is determined by the additional cues a child might require for success

Seek to determine the child’s emotional resourcefulness in initiating and maintaining ongoing interactive systems with adults in the manner described by Greenspan. (Miller, A. & Chretien, K.,

Miller Umwelt Assessment Scale(cont’d)

At the end of the 2-hour session, the parent receives an oral summary of findings and a videotaped copy of the assessment.

A detailed report with recommendations is sent within 2-3 weeks.

Fee: $1,000

Assessment

Miller Umwelt Assessment ScaleMiller Diagnostic Survey

Parent Survey Teacher/Instructor Survey

Umwelt Assessment

Coined by von Uexkull (1957) meaning “world around the child”

Components Parent Examiner Step slide Climbing equipment A soccer ball Large plastic container Large red ball suspended on a rope from the ceiling to

the child’s eye level Box of wooden blocks under the slide

Umwelt Assessment (cont’d)

Test measures 16 different tasksLooking for child’s capacity in:

Interation with people and objects Adapting to change Learn from experience “Testing the limits” to see their “zone of proximal

development.” Child’s emotional resourcefulness initiating and

maintaining ongoing interactive systems with adults.

Umwelt Assessment (cont’d)

First unstructured section to see what the child will interact with on his/her own Normal development: play with everything Autistic: run in circles, back and forth, etc.

16 tasks are all targeted for different components and to assess for closed or system forming disorders

Major Components

Suspended Ball Task Type A- child-object-adult Type B- child object = closed systems Type C- No object = system forming Goal: Interaction with person and object

Cups and bowls activity Stacking cups and bowls in different ways Goal: Adapting to change

Major Components (cont’d)

“Swiss Cheese” Board Avoidance of holes on Elevated Board 2.5 feet in air Goal: Awareness of space and body and ability to learn

from experience

“Croupier” Task Rake- Obstacle Goal: Problem solving ability and to learn from

experience

Contrasting Children with Closed-System and System-Forming Disorders

Disorder Type A Type B

Closed System •Minimal executivefunctioning and few systems•Poor shifting/scanning•People excluded fromsystems

•Executive functioning with many object systems•Ability to shift from one to another system•People excluded fromsystems

System Forming •Minimal executivefunctioning•Poor sensory-motorcoordination •limits system forming

• Little executive functioning•Salient properties of many sources induce repeated orienting, but not engagement

Use of Systems

Each system is a set of behaviors that accomplishes something (whether social or for self)

Interruption of Systems= language opportunity

3 Steps to Restore Typical Developmental Progressions

First Set of Interventions Systematic Body Work

Second Set of Interventions Transformation of aberrent systems

Third Set of Interventions Systematic and repetitive introduction of

developmentally relevant activities

Strategies for Applying The Miller Method

Elevated SquareTransforming Systems

Take pre-existing abberent systems and transform to more functional systems

Creating Systems Fill in developmental gaps

Inclusion PrincipleExtension Principle

Orienting, Engaging, and System Formation

Having child look at stimuliChildren may have aberrant behaviors that

distract from orienting Child then must have contact--physical or

emotional--with the person or object to create systems

Repetitive engagements are needed to create systems

Then, interruption of the newly acquired system creates language opportunities

The Elevated Square

2 ½ feet above ground and a 5 foot by 8 foot structure

Colorful and main focus of the room

Purpose of Elevated Squares

“Word Deafness” Spoken words not relevant to what is engaging them

at the moment

Solution: Enhanced reality by elevating children on the

Elevated Square so they can hear the words and focus on the manual gestures

Components

SquareWork stations in each cornerRemovable piece to make U-shaped structure

and be able to have instructor in the middleObstaclesSlide that can be removable

Reasons for the Elevated Square

Undefined reality to highly definedBody awarenessConstraint on child’s actions“Edge Experience”Eye contact leveled

Purpose for system disorders for the Elevated Square

Systems-Forming disorders External organization

Closed Systems disorders Framework taught to expand their systems

Andrew on the Elevated Square

www.millermethod.org

Transforming Systems

Find ways to channel energy used by children with autism to maintain their rituals into systems that are flexible and interactive

Autistic Systems e.g. Rocking, flapping, dropping things

1. Assess the casual dynamic that captures the child 2. Find a way to cast that dynamic as part of an

interactive and flexible system

But How?

Rocking Have child sit facing you Imitate rocking with child and maintain eye contact When child starts to anticipate, STOP! When child tries to communicate that they want to

rock again using direct eye contact and some rocking, begin again

Repeat game 10-12 times

But How? (cont’d)

Flapping Give child symbols for a more functional system Extend the system using other objects like sand blocks

Repetitive Dropping or Throwing things Have child throw things in different directions and

into different containers to “finish the experiment” Extend the system with different objects or containers

Goals: Get into what the child is doing Make it interactive Then, extend to a better functional skill

Creating Systems

Filling in developmental gaps or lagsAcceptable to use Hand over Hand (H.O.H.)

to first teach skillSpheres or Spheric ActivityBlock examples

Closed System Disorder System-Forming Disorder

Repetition and a gradual “taking over” or conversation of sphere into a system by child

The Inclusion Principle

Introducing new parts to the system Object/ Person Word Gesture

Assimilating new parts to the system Verbal prompt= child searches for other aspects

Extension Principle

Child learns a new property or aspect of a system Incorporates the newly extended system into the

original system

Plays an important role in the language system of spoken words to written words in the Symbol Accentuation Reading Program

Extending to Social Capacity

Play Games e.g. I’m going to get you, Peek a Boo, and Hide and

Mother-Child BondGrand Central Station4 interaction skills

Turn-taking Cooperating Competing Shifting to the other’s perspective

Communication

Extending System principles Uses Hand over Hand with words and a reinforcer

Come Example

Education

Building self/body awareness will lead to education

Uses same creating systems strategy

Support Systems

Parent/Instructor relationship to childFour different kinds:

High Support/Low Demand High Demand/Low Support Low Demand/Low Support High Support/High Demand ***

Angela

One of a few known “successful” casesBeautiful, blonde 5 year old from Toronto Umwelt Informal Assessment

2 parts of systematic behavior done while she was in Toronto Putting discs in a slit and was able to adapt to change Balloon blowing up and she made a social interaction by

pursing lips and moving forward

Parents decided to enroll Angela in Boston

Angela (cont’d)

Umwelt Assessment Ball Task- Level B Step-Slide Task (Step-Slide System)

Climb up the steps, sit down, hitch forward, go down, and return to steps

Created system quickly but would stomp feet at the top and threw blocks down the slide

Spontaneous expansion!! “Croupier” Task

Did an excellent job of adapting Cup-Bowl Task

Reverted halfway through putting cup into bowls Angela put her head down and turned toward the wall

But she showed social intention when Dr. Miller turned her head (she had an “impish” smile which showed she had a lot of promise!)

Angela (cont’d)

Umwelt Assessment (cont’d) Symbolic doll task

Imitate the instructor by feeding a baby doll a bottle then putting to bed

Angela added taking off all the doll’s clothes and inspecting the doll, then imitating the instructor

Mother-Child Bond Mother leaves room by saying, “Bye, Bye” and examiner

observes child’s reaction Angela ran over to mom when as she was leaving and

pulled her back into the room exhibiting a great mother daughter bond – High demand/High Support

Angela’s Progress according to Mother

First Week- screamed and tantrumedSecond Week- first sign

After this, signs and communication efforts were progressing quickly. Angela signed come, go, plate, give, and cup.

1 month- spoke come, give, plate, and cup3 months and 3 weeks- requested and made

simple sentences1 year later- returned to learn how to read Able to sustain herself in a typical classroom…able

to read and write better than typical 6 year olds!

Research Relevant to the Miller Method

• Cook, C.E. (1998) The Miller Method: A case study illustrating use of the approach with children with autism in an interdisciplinary setting. Journal of Developmental and Learning Disorders, 2, 2, 231-264.

• Messier, L.P. (1970) Effects of Reading Instruction by Symbol Accentuation on Disadvantaged Children. Unpublished doctoral dissertation, Boston University.

• Miller, A. (1968) Symbol Accentuation: Outgrowth of Theory and Experiment. In Proceedings of the First International Congress for the Scientific Study of Mental Deficiency, Montpelier, France, 766-772, Surrey, England: Michael Jackson.

• Miller, A. (1991) Cognitive-developmental systems theory in pervasive developmental disorder. Psychiatric Clinics of North America, 14, 1, 141-161.

• Miller, A. & Miller, E.E. (1968) Symbol Accentuation: The perceptual transfer of meaning from spoken to written words. American Journal of Mental Deficiency, 73, 1, 200-208.

More Research

Miller, A. & Miller, E. E. (1971) Symbol Accentuation, single-track functioning, and early reading. American Journal of Mental Deficiency, 76, 1, 110-117.

Miller, A. & Miller, E. E. (1973) Cognitive-developmental training with elevated boards and sign language. Journal of Autism and Childhood Schizophrenia, 3, 1, 65-85.

Warr-Leeper, G., Henry, S., Versteegh, T. Outcome Study: (1997) The Effect of the Miller Method on Five Severely Disordered Children with Pervasive Developmental or Communication Disorders. Unpublished Honors Study, University of Western Ontario.

Problems with References

Some references are unpublished dissertations/honors studies

Much of the “research” is dated (i.e. most is from the 1960s-1970s)

Not readily accessible to the public (i.e. consumers of treatments for autism)

Few references are empirical in nature

Why Study Cognitive-Developmental Systems?

• The Miller Method is based on a “cognitive-developmental systems” approach

• Helps us better understand typical versus atypical patterns of growth, change, and stability across the life spans of people with and without autism

More about Cognitive-Developmental Systems

Assumes that typical development depends on formation of systems

Becoming aware of the distinction between themselves and their surroundings, systems (previously triggered only by salient properties of environment) gradually come under their control

Systems are then combined in new ways leading to problem solving, social exchanges, and communication with themselves and others about the world

Cognitive-Developmental Systems Theory in Pervasive Developmental Disorders (Abstract)

• The concept of reality systems is introduced in context of cognitive-developmental systems theory. Examination of the parallels between the reality systems of normal infants and those of children with pervasive developmental disorders supports the view that the latter are stalled at an early stage of development. Evaluation of pervasively disordered children with closed-system and system-forming disorders indicates the aberrant manner in which such children orient toward and engage objects and events, a manner that precludes flexible adaptation to people or surroundings. Attention is given the role of interruption as it triggers a compensatory reaction to maintain systems and the contribution of such reactions in developing the intentional behavior so lacking in children with pervasive developmental disorders. Finally, the author discusses theory-driven strategies to correct deficits in the body schema, coping with surroundings, social development, and communication and representation.

Cognitive-Developmental Systems Theory in Pervasive Developmental Disorders

This is an information-only article; no experiment was performed

Author’s terms are subjectiveRestates previously stated information

Cognitive-Developmental Training with Elevated Boards and Sign Language

• “To test the relevance of this approach, elevated board-sign language procedures were applied with 19 intransigent, nonverbal, autistic children in several institutions at which we were consulting. Children who previously could not follow spoken language directions could do so when signs were paired with spoken words, and particularly when these signs and words were taught in the context of elevated board structures.”

Cognitive-Developmental Training with Elevated Boards and Sign Language

Is experimental in natureBut, article is difficult to obtain…Replication?

Significance of Elevated Boards

Miller observed a “dramatic change in behavior” when children stepped on planks between tables

“Edge experience:” Heightened awareness and increase in attention

Words paired with obstacles , generalization to other settings

However, Miller also says…

Range of concepts to be taught was limited Children seemed to turn vital involvement

into rituals (stereotypy)Continued to perform tasks, but

automatically and without alertnessWas it worth it, then?

Symbol Accentuation

Miller developed this technique as a reading program and has written 2 articles on it

Teaches symbolic function of printed words via object-word pairing

Eventually helps children understand that words can be meaningful without resembling their objects

Symbol Accentuation (cont’d)

Helps children learn how to sight-read sentences in both large and small type (generalization)

Helps children shift from sight-reading to phonetic reading

Helps children develop letter-sounds relationships and blending and sequencing of letter sounds into meaningful words

Encourages active participation by both students and teachers

Symbol Accentuation, Single-Track Functioning, and Early Reading

(Abstract)

“Accentuated conditions, during which animated motion pictures of objects blended into their customary printed words, was found more effective than the conventional look-say presentation of objects and words in teaching retarded persons to read.”

Looks (and sounds) a lot like stimulus shaping!

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