Yale Study MilieuCommunication Teaching

IntroductionKim Gilbert, Ph.D.Paul Yoder, Ph.D.

Overview

• Milieu Communication Teaching = PMT MLT• Rationale for treatment

– Child and parental predictors of languagedevelopment in prelinguistic children withdevelopmental delays

– Transactional model of development duringprelinguistic period

Overview continued• PMT

– Prompt hierarchy– Consequences– Facilitating play routines– Facilitating requests and turn taking– Facilitating eye contact– Facilitating gestures– Facilitating vocalizations– Facilitating comments– Suggested adaptations for (hyper?)active

children

Overview continued

• Milieu Language Teaching• Efficacy of Milieu Communication

Teaching

Note the following “before” and“after” parent-child sessions (child

with autism)

After Milieu CommunicationTeaching (child with autism)

What are child and family characteristicsthat predict growth rate of productive

vocabulary in children with DD ?Growth over 12 months

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100

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Time in study

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ord

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Transactional model in the prelinguisticcommunication period

Child object-

engagement&

communication

Adult descriptive talk,compliance &

linguistic mapping

Child vocabularyacquisition

Video example of talk about children’sfocus of attention & wait

Adult compliance & linguistic mapping

Comments

Requests

Predictors of linguisticcommunication

• Defined as number of different words used tocommunicate in a conversational sample

• Parent:– Those after child object attention

• Descriptive talk– Those after child communication

• Linguistic mapping• Compliance

• Child– Comments– Requests

When could parent respond?

When could parent respond?

When could parent respond?

Coordinated attention to object andperson

• Can be either simultaneous or sequentialattention to object and person

• Can be shown in many ways:• Spoken word referring to an object and look

to adult.• Shifting gaze from object to person• Showing object to person• Giving object to person• Giving pictorial representation of object to

person

Why is nonverbal communicationimportant?

• The pragmatic aspects of communication are aprimary deficit of children with autism.

• Nonlinguistic pragmatic aspects ofcommunication might be easier to learn ifseparated from the (also difficult) symbolicaspects

• Provides the opportunity for parental responsesthat “teach” language.

• Functional communication via “easier” formsmay happen earlier in development than“harder” symbolic communication.

Another predictor of linguisticcommunication in initially nonverbal

children with ASD (Yoder, 2006)

• Diversity of object play

Which if the two next video displays achild with whom it would be easiest to

use descriptive talk?

Easy to use descriptive talk?

Summary of rationale for PMT

• Targets– Object play, Requests and Comments

• So parents can use…– Descriptive play, linguistic mapping, and

compliance• Which in turns help children learn to use

words to communicate.

Finding the child’s currency(reinforcers)

• Reading children’s behavior as indicativeof what delights them

• Being creative with a variety of toys– Activity for brainstorming before a session

• It changes

Suggested sequence of goals• Building routines

– If needed, object play expansion– if needed, increase frequency and diversity of noncommunicative

vocal acts– if needed, component building (without attn to adult)

• Simultaneous coordinated attention– Give, show, upturned palm to adult

• Sequential coordinated attention– Reach+gaze, clap+gaze, move object to adult and gaze, 2 point

gaze and voc• Combining all three components or conventional

gestures– Gesture, gaze, and voc– Distal point

(

Routine without object

Routine without object

Routine without an object

Routines with objects

Routine with objects

Vocal play

Vocal play

Prompts for communication

• Prompt when child shows communicativeintent or need or primitive communicativeact.– Teachable moment

• Prompt hierarchy for every targetcommunicative form.

Consequence of communication

• Emphasis on functional reinforcement– Defined by child’s wants/communicative

intent.• Compliance (respond) to child’s requests• Linguistically map EVERY intentional

communication act IMMEDIATELY.– Watch the competitors for the favored

temporal sequence of act-map

Comments are difficult to teach directly

• “Direct” teaching often involves prompting andrewarding desired behavior.

• Can’t directly prompt comments– Declaratives are intrinsically self-initiated.– Over-use of “unexpected events” are less

evocative over time.• Can’t differentially reward comments using

functional rewards (i.e., adult attention).– Particularly in children who don’t use

comments much.

Adult modeling of comments mayindirectly facilitate child comment

development• Siller and Sigman, 2002

– 16 4-year olds with autism and theircaregivers.

– Parents’ nonword comments about theirchildren’s already-established focus ofattention at time 1 predicted…

– children’s gain in nonword comments over a12 month period.

– r = .67

Proposed ways treatments mayfacilitate commenting development

• Adult prompts and functionalreinforcement ->child coordinated attention to request–Transfer of stimulus control theory.

• Pairing functional rewards with socialrewards ->

child experiencing social interactions asrewarding–Acquired reward value hypothesis.

Proposed ways treatments mayfacilitate commenting development

(continued)• Acquisition of play skills may result in child

finding more events/objects of interest innatural environment.– Acquisition of broader interest hypothesis.

• Adult models of comments ->child using recently acquired forms tocomment.– Social learning theory.

Video example for demonstratinggasp and show to “demonstrate”

commenting

Prompt for gaze to face

Prompt for gaze to face

Prompt hierarchy for gaze shiftfrom object to person (least to

most)• Time delay (wait) with desired object

naturally held• Calling name• Time delay with desired object held near

face.• Time delay with desired object held in front

of eyes• Insect gaze

Prompt for give

Prompt hierarchy for give

• Time delay• Upturned palm• “Give x to me”• Physical prompt

– Message recipient does physical prompting– Person behind child does physical prompting

• Like PECS

Prompts for upturned palm request

• When child reaches, turn his palm up.

Physical prompt for reach

Prompt hierarchy for reach

• Two levels– Distance of object from child

• Proximal• Distal• Distal and gradually up

– Prompts for reach behavior• Time delay• Verbal prompt• Demonstration• Physical prompt

– By message recipient

Prompts for reach and gaze to face

Prompt for reach and gaze

Proximal pointing

• Demonstrating• Physical prompt

Prompting proximal point

Model and physical prompts fordistal point

Prompt hierarchy for distal point

• Time delay• Verbal prompt (rarely used)• Demonstration• Physical prompt (by message recipient)

Prompts for vocal communication

Prompt for vocal communication

• Time delay• Point to mouth or mouth “gesture” for

sound.• Spoken word demonstration (but word use

not necessarily expected)

Prompts for 3 components ofcommunication

Adaptations of PMT for children withhyperactive styles

• When child is rapidly shifting from one object toanother– Stay in one place, entice, and

differentially reward proximity of child toself.

– Create small work space• Tables and need to fade them

– Use smaller number of toys per session

Criteria for moving children fromPMT to MLT

• From treatment sessions– 1 unprompted nonverbal request/min + 1

unprompted nonverbal comment/min within atreatment session

OR– 5 unprompted, nonimitative grammatical words

used communicatively and referentially (can beused across several treatment sessions).

OR– 1 vocal communication with consonant/minute

within a treatment session

MT following PMT clips withchildren with autism.

Milieu teaching principles• All teaching episodes begin with child communicative intent or

need• Avoid power plays

– How long is the teaching episode?– Why many prompts along the hierarchy or repetitions of

the same level prompt before “giving in” or “complying”.• When a child has never used a word or not used it in a

particular activity,– Use elicited imitation prompts

• Consequences in MLT include…– After child communication

• Linguistic mapping, expansion or phonemic recast– After non-response

• Corrective feedback

Efficacy of (R )PMT• Replicated evidence of effect on generalized and

maintained– Requesting– Comment– Comprehension of language– Use of words to communicate

• In children with DD.• Nonreplicated evidence of effect of generalized

and maintained– Requesting– Commenting– Use of words to communicate

• In children with ASD