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Enhanced Milieu Teaching

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Shannon Rensi

on 26 February 2014

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Transcript of Enhanced Milieu Teaching

Enhanced Milieu Teaching
Key Components
Milieu:
physical or social
setting
in which something
occurs or develops
Theoretical Basis
Additional Considerations
Outline
Why Should EMT Work?
3 Principles:
Social Interactionism
Parents as Teachers
Behaviorism
Social Interactionist Theory
3 Main Tenets:
3. Language exposure and interactions with language users vary widely among children.
Parents as Teachers
What are some possible arguments against parents providing language intervention for their children?
Parent involvement in intervention and intervention specifically targeting parent behavior and interactions with their child can result in better outcomes. (Abbeduto L, 2004)
Meta-Analysis Conducted by Roberts & Kaiser, 2011
Are parent implemented language interventions effective?
Empirical Basis
Children: 18-60 months with any language impairment
18 studies included
Main Outcome:
Parent-implemented intervention has a positive impact on expressive and receptive language outcomes of children with and without intellectual disability.
Limitations:
1. Small Samples
2. Fidelity
3. Description of Parent Training
4. Maintenance
1. Language develops because children are motivated to interact and participate in their world.
2. It is critical for children to have relationships and be exposed to interactions with language users.
Behaviorism: ABC
Create opportunities to teach language skills

How Targets are Selected:

Importance of acquisition, generalization and maintenance
Children with language impairment and/or intellectual disability have trouble generalizing
What will be functional in a child's environment?
What are appropriate developmental milestones?
&
How the Theory Translates to EMT
Social
Interactionist
Parents as Teachers
Behaviorism
Natural, responsive communication
Explicit use of strategies to elicit language
Responsive Interaction
Milieu Teaching
Intended Population
(Parents of) children in early stages of language development demonstrating significant delays
Goal of
Therapy

To prompt and expand language production
"to promote children's
functional
use of productive language skills in
naturalistic
interactions" (Hancock & Kaiser, 2006)
Evidence
Many, many, many empirical studies providing evidence of efficacy and effectiveness of EMT
Based on theoretical constructs which are grounded in empirical evidence
Methods/Components
...enhances naturalness of...
Hannah
42 months old
Diagnosis of ASD
Has some spoken language, but much of it is rote
PLS-3, PPVT-R, EVT, and language sample
All scores more than 2 SD below the mean
MLU=1.45

Culturally & Linguistically Diverse Populations
Consider norms around responsiveness and play
Use appropriate toys and materials
EMT can only be successful when the caregiver delivering treatment has a strong foundation in the language being targeted.
Naturalistic
Parent-implemented
3 components
Environmental Arrangement
Responsive Interaction
Milieu Teaching Strategies
Significant Note for All Populations
Hannah
Step 1:
Environmental Arrangement and Responsive Interaction
manipulate the environment for functional communication
balanced turn-taking
Step 2:
Continuing Responsive Interaction...
(5 sessions later)
Hannah's target level
2 word utterances (agent + action verb, action verb + object, adjective + noun, and "want" + object)

RI strategies
follow the child's lead
respond to verbal and nonverbal initiations
provide meaningful semantic feedback
expand the child's utterances
Step 3: Milieu Teaching
(12 sessions later)
modeling
mand-modeling
time delays
incidental teaching
Hannah's Posttest Data
PPVT-R: standard score=78
MLU=2.20
Root words=125

Case Study Reference
The previous demonstration was based on a case study performed by Hancock and Kaiser (2006) on Celia and Hunter, a young boy with ASD.
Target Population
Children in early stages of language development
preschool children with cognitive impairments
children with language delays
children with ASD
children from low-income, high risk families
Best Criteria for Identifying Appropriate Clients
verbal imitation
at least 10 words
MLU between 1.0 and 3.5
Using EMT with At-Risk Families
Peterson, P., Carta, J., & Greenwood, C., 2005
Cocaine use during pregnancy,
low income
, domestic violence,
single parent
, poor mental health,
minority group
, limited support, low education level
Final Thoughts
Scripted.
Detracts from “naturally occurring” parent-child interactions.

Time intensive!
Parents must commit 3-5 months to learn the intervention.

Costly.
Parent training not covered by all insurance companies.

Work in progress.
Still only a research project. Not currently used in your neighborhood clinics.

Ambiguous.
Unclear guidelines: when to use, how to implement, and when to stop.

One voice.
Most studies led by Kaiser and her team, affiliated with Kid talk.
Parent Characteristics:
High Risk = 4+ Factors
EMT Criticisms
EMT Positives
Child Characteristics:
P1: CA = 43 months, MLU = 1.77
ED: 7 months, RD: 11 months
P2: CA = 27 months, MLU = 1.53
ED & RD = 11 months
P3: CA = 24 months, MLU = 1.16
ED & RD = 8 months
Outcomes
Parents acquired EMT techniques
Verbal behaviors of all 3 children generally increased
Increased MLU:
P1: 1.77 to 2.68 (10 month intervention)
P2: 1.53 to 2.53 (7 month intervention)
P3: 1.16 to 2.53 (11 month intervention)

Accelerated Expressive & Receptive Language Development (PCI)

P1: Expressive +1.20, Receptive +1.34
P2: Expressive & Receptive +2.90
P3: Expressive & Receptive +1.63
Recommended Readings
Significant Take-Aways
Some techniques were better implemented than others
Importance of rapport
Length of intervention varies by family
Techniques led to different behaviors
My turn!
Want more.
Peterson, P., Carta, J., & Greenwood, C. (2005). Teaching Enhanced Milieu Language Teaching Skills to Parents in Multiple-Risk Families.
Journal of Early Intervention
. 27 (2): 94-109.
Functional language:

New vocabulary
Early syntactic and semantic forms
Appropriate use of requests
Target population:
ASD, SLI, Down syndrome, intellectual disabilities of unknown etiology
Most responsive :
Verbally imitative
At least 10 productive words
MLU 1.0-3.5
Parent-implemented Enhanced Milieu Teaching:
A naturalistic, conversation based strategy
Main assumptions:
Communication is learned in interactions with partners

Changing partner support for communication can change child outcomes
Environmental
arrangement
Milieu Teaching
Responsive Interaction
Select, arrange, and manage materials
Increase the child's engagement with the physical setting
Parent models target language in naturalistic conversation and play
Balanced communication:

Responsiveness
Following the child's lead
Turn taking

1. Modeling
2. Mand modeling
3. Time delay
4. Incidental teaching

Triadic intervention
parent, child, therapist
20-36 sessions

Typical session:

15 Min: Review progress, new info
15-20 Min: Practice
10-15 Min: Reflection and evaluation
Environmental
arrangement
Responsive
interaction
Milieu teaching
SESSION 1: General principles of interacting with your child, play and routines as a context for child learning, following your child's lead

SESSION 2: Choosing materials that interest your child and arranging the environment to promote your child's engagement and requesting.

SESSION 3 & 4: Turn-taking strategies: nonverbal turn taking and verbal turn taking

SESSIONS 5 & 6: Respond to what your child communicates

SESSIONS 7 & 8: Talk at your child's target level

SESSION 9: Expansions

SESSIONS 10 & 11: Expansions at the child's target level

SESSIONS 12 & 13: Principles of environmental arrangement to build child initiations and requests

SESSION 14: Identifying your child's verbal and nonverbal requests

SESSIONS 15-18: Incidental teaching I: using models after child requests

SESSIONS 19-22: Incidental teaching II: Using mand/models after child requests

SESSIONS 23-24: Choice-making mands/questions vs. open-ended mands/questions

SESSIONS 25 & 26: Time-delay procedure

SESSIONS 27-30: Putting it all together: balancing responsiveness and milieu teaching

Alpert, C. L., & Kaiser, A. P. (1992). Training Parents as Milieu Language Teachers.
Journal of Early Intervention
, 16(1), 31–52. doi:10.1177/105381519201600104

Franco, J. H., Davis, B. L., & Davis, J. L. (2013). Increasing Social Interaction Using Prelinguistic Milieu Teaching With Nonverbal School-Age Children With Autism. American
Journal of Speech-Language Pathology
, 22(3), 489–502. doi:10.1044/1058-0360(2012/10-0103)

Kaiser, A. P. (1994). Enhanced Milieu Teaching: An Analysis of Applications by Interventionists and Classroom Teachers. Retrieved from http://eric.ed.gov/?id=ED375546

Kaiser, A. P., & Hester, P. P. (1994). Generalized effects of enhanced milieu teaching.
Journal of Speech and Hearing Research
, 37(6), 1320.

Kaiser, A. P., & Roberts, M. Y. (2012a). Parent-Implemented Enhanced Milieu Teaching With Preschool Children Who Have Intellectual Disabilities.
Journal of Speech, Language, and Hearing Research
, 56(1), 295–309. doi:10.1044/1092-4388(2012/11-0231)

Kaiser, A., & Wright, C. (2013). Enhanced Milieu Teaching: Incorporating AAC Into Naturalistic Teaching With Young Children and Their Partners.
SIG 12 Perspectives on Augmentative and Alternative Communication
, 22(1), 37–50.

Olive, M. L., Cruz, B., Davis, T. N., Chan, J. M., Lang, R. B., O’Reilly, M. F., & Dickson, S. M. (2006). The Effects of Enhanced Milieu Teaching and a Voice Output Communication Aid on the Requesting of Three Children with Autism.
Journal of Autism and Developmental Disorders
, 37(8), 1505–1513. doi:10.1007/s10803-006-0243-6
&
&
Parent satisfaction
1
2
3
Bottomline
RI and MT can be effective
parent-directed tx approaches, when delivered independently

Both RI and MT can positively impact language
development among preschoolers with language delays

MLU < 1.8, MT
is generally more effective

MLU > 3.0, RI
is generally more effective
*as measured by Sequenced Inventory of Communication Development-Revised (SICD-4; Hendrick, Prather & Tobin, 1975)
Enhanced milieu teaching: an analysis of applications by interventionists and classroom teachers.
(Kaiser, et al. 1994)
Consistent intervention impacts

Poor generalization
From trainer-led intervention to teacher-led scenario
Improvements noted only after teacher mastery of EMT

Modest
MLU and semantic growth noted
EMT Clinical Applications
More effective t
han RI or MT alone

Can positively influence expressive and receptive language
, specifically MLU, syntax, and vocabulary knowledge

Better outcomes
with parent-led intervention (vs. clinician led)

Baseline MLU matters,
lower baseline measures yield greater gains

More not always better,
especially among children with low object interest and mild cognitive impairment (55-75)
On the Horizon
Emerging
application of EMT
to social language, behavioral, communicative intent, and AAC among children with autism and mild cognitive delay
EMT more effective t
han RI or MT alone

EMT can
positively influence expressive and receptive language
, specifically MLU, syntax, and vocabulary knowledge

Better outcomes
with parent-led intervention (vs. clinician led)

Baseline MLU matters,
lower MLU (<1.8 sees faster growth)

EMT can
positively impact social language and behavioral targets
for children with autism and associated mild cognitive delays

Intervention impacts on language are
greater
among children with
lower baseline measures

Higher dosage not always better,
especially among children with low object interest and mild cognitive impairment (55-75)

Emerging protocols for
specific populations (e.g. AAC)
Bottomline
Initial Mean Length of Utterance Predicts the Relative Efficacy of Two Grammatical Treatments in Preschoolers with Specific Language Impairment
(Yoder, Molfese, and Gardner 2011)
Parent mastery and generalization of EMT
(4/4) in-home
(3/4) to new conversation partners

Language targets improved
3/4 > 12 months (2 SD gain) in receptive skills
2/4 showed gains in expressive skills*
All children demonstrated spontaneous word growth (3/4 in a language sample)

Also
MLU improvements were not significant
Mild impairment at baseline performed better
High parent satisfaction
Enhanced milieu teaching: Effects of parent-implemented language intervention. Journal of Early Intervention
(Hemmeter and Kaiser, 1994)
vs.
Responsive Interaction
Milieu Teaching
MT
Parent
Competency
Generalization
Language Target
Impacts
Special
Populations
Clinical
Implications
Half empty
or
half full?
Training parents as milieu language teachers. Journal of Early Intervention
(Alpert and Kaiser, 1992)
Early efficacy, multiple baseline design
(n=6), Mother-child dyads
Mothers trained in 4 MT procedures
Preschool boys, DLD + artic
MT generalized
to non-trained situations
MT maintenance
> 3 months post
4 children improved
in 3/6 areas:
total novel words produced, communicative requests, MLU
2 children, no significant gains
The effects of teaching parents to use responsive interaction strategies. Topics in Early Childhood Special Education.
(Kaiser et al., 1996)
Multiple baseline design
(n=12), Parent-child dyads
One-on-one RI parent training
Preschoolers with DLD
RI generalized
to home environments
Follow up with 9/12 dyads > 6 months post
9/12 demonstrated maintenance

7/9 children
used target language at higher than intervention levels
Analysis of the primary and generalized effects of milieu and responsive-interaction teaching by parents. Presented at annual meeting of the Division of Early Childhood, Albuquerque.
(Kaiser et al., 1990)
Comparison study
Randomized group assignment, no control
(n=36), parent-child dyads
2 groups of 18
Both groups improved
No significant
between group difference
RI had better outcomes for MLU > 3.0
MT had better outcomes for MLU < 1.8
Supporting children’s communication development through parent-implemented naturalistic interventions. Presented at the 2nd Annual Conference in Research Innovations in Early Intervention (CRIEI), San Diego
(Kaiser and Hancock, 2000)
Lower MLU
(< 1.84) correlated with
faster growth
when treated with MT versus BTR
Findings:
Target language bx improved
MLU, productive syntax (SICD-E), and standardized test performance

Home generalization observed
> 6 months post

Parent-led i
ntervention groups (RI and EMT)
performed better**

Modest differences between parent-led intervention groups
EMT-parent: 1.2 month gain/month of intervention
RI-parent: 0.73 month gain/month of intervention
*Peabody Picture Vocabulary Test-Revised; Dunn & Dunn, 1981
**measured by SICD-E, MLU, effect size (d) = 0.3
RI
Hannah's targets:

Two-word utterances
agent + action verb
action verb + object
adjective + noun
requests (want + object)
Vanderbilt University
Courtney Wright, PhD, SLP-CCC
Milieu Teaching
Responsive
Interaction
Findings:
Findings:
Findings:
Unanswered questions
Accounting for variability?
Trainer/therapist variability and its impact on child outcomes.

Is it the best?
No larger scale meta analysis or RCT measuring EMT against other interventions.

Delivery format?
Some evidence more isn’t better but what’s the right balance between intensity, frequency, and administrator?

When to use it?
Some evidence that RI and MT have better outcomes based on baseline MLU but what about EMT as a whole?

When to stop?
No clear ceiling established.
Moves the needle.
Evidence EMT can positively impact a wide range of language targets.

Customizable.
From vocabulary, MLU, social communication to behavior, EMT is highly customizable to match child needs and skill levels.

Builds parent-child relationship
. Increases frequency and quality of parent-child interactions.

High satisfaction.
Parents who commit to it, like it.

Generalization:
Parents use the strategies at home.
"The modeling was great…no better way to learn, and then having ..... feedback, completed the learning process well. The video clips of our sessions were especially helpful in our teaching workshops."
[EMT]´s methods of teaching helped me become a better parent, teacher and playmate to my child.
"We were a little hesitant about the time commitment involved in the project, but it was worth every minute of time spent."
Out of the mouths of mothers
Also...
Case Study
Video Example
Commentary from an
SLP/Researcher
Questions/Concerns?
Video example
Language modeling:
Extensions
Expansions
Descriptive talk
Full transcript