MiliWHO??

Posted by Dani, Speech-Language Pathologist MA CCC-SLP

Milieu! Milieu teaching is pretty much the most accurate way I can describe the way I do therapy given my population and their needs.  

I subscribe to the Journal of Speech, Language and Hearing Research and I received an article that caught my eye the other day. Long story short, it led me to a really old article (1993, I was only in 3rd grade!) entitled "Facilitating Prelinguistic Communication Skills in Young Children with Developmental Delay" (Warren, Yoder, Gazdag, Kim &Jones, 1993).

OK don't worry this isn't going to be a boring journal article post but the speechie geek in me got really excited while reading this. Why? Because it literally describes EXACTLY how I do my therapy!! Specifically the article highlights the effectiveness of milieu approach to teaching prelinguistic (before speaking) communication skills. So get ready to learn a new word and feel smart: MILIEU! (To all my professors and speechies, yes this word rang a bell from the days I spent studying, just never stuck with me so meaningfully!)

Here are the important things you should know Milieu teaching approach for prelinguistic communication:

1- Follow the child's lead because children learn best with things that interest them

2- Manipulate the environment so that child has visuals of his favorite toys but not direct access, which means they need to request!

3- Use social games such as peek-a-boo which are fun, motivating and exciting while providing an increase in the incidence of natural reinforcement.

Now you may be reading this and thinking how non-ABA this sounds...and if that's the case, you have a misconceived idea of what ABA truly is and thank goodness you are here reading our blog! Remember my last post where I used the word "prelinguistic?" I am using it here again so listen up! In another post I referenced the fact that my speech sessions sometimes look NOTHING like traditional ABA (and by that I mean what the majority of the world believes to be traditional ABA-- think discrete trial training). Below I will describe to you, through a narrative description, the way I implement ABA and Milieu teaching together in the most natural way.

·         Following the child’s lead does not mean let the child sit and line up his trains because "that's how he likes to play" or letting him spin the wheels close to his face because it "makes him really happy."  From what I know about Floor Time (and please if you are reading this and can correct me, EDUCATE ME!)--- This is encouraged...to go along with the child's inappropriate behaviors and *eventually* shape them. Well what’s with the *eventually* - why not right this minute?  Why would I let a child with Autism, who has limited play skills, continue to engage in a self-stimulatory play when I KNOW this isn't right? That's essentially the same thing as letting a child PRACTICE inappropriate skills.

• How do I follow this child's lead? I follow it by playing with trains, which we know he loves, and then by redirecting his play with the trains. Instead of allowing Joe to have access to the whole box of trains and tracks, and play with it by himself, I create a communicative scenario. Joe can choose to play trains by looking/pointing/vocalizing so, and then we begin. He has thus initiated (or LEAD) this play, therefore I am FOLLOWING him, but remaining the boss of play-- I am also MANIPULATING THE ENVIRONMENT (#2)
• Depending on Joe's current level of communicative functioning, we determine the proper mand (way to request). Let’s say that Joe is pre-verbal, and has no functional means of requesting. At our center, we notoriously start with pointing and we never teach "more" (That is a whole OTHER blog post). We determine that Joe needs some help isolating his finger, but he's VERY motivated to get a train so he tolerates our hand-over-hand shaping and is immediately reinforced with access to the train *(see how I snuck that ABA in here?)
• Okay- now he has the train and without intervention Joe would most likely flip the train over and spin its wheels, lie down with his face sideways on the floor and roll the train back and forth very close to his face, or maybe he hasn't developed these self-stimulatory behaviors yet because the only real reason he wanted the train was to put its cold metal exterior in his mouth or on his cheeks.
• Here is where we come in- Immediately give Joe the opportunity to play functionally by providing him with either another train or a track. Let’s say we give him the track, the "appropriate" play would be for Joe to place the train on the track and push it down the way. If he does this, then we applaud him and praise him (BEFORE it becomes repetitive, i.e. we let him roll it back and forth 1x), and then immediately introduce another train (also reinforcing this "functional" play because he has now gotten TWO trains and he REALLY loves trains). Joe is learning that when I push the train on the track, I'll get another one. (Hmm does this sound like ABA?)
• The next step in this functional play sequence would be for Joe to connect the trains on the track and push them together, have one train chase the other, have them crash into each other or have them talk to each other.  Let’s say Joe takes the second train and puts it in his mouth. What has this told us? That "mouthing" the train is equally if not more motivating to Joe than rolling it on the track or playing FUNCTIONALLY with it by adjoining it to his other train. Do we let him mouth the train? NO WAY JOSE
• We remove the train from his mouth and place it on the track, joining it with the other train while singing a makie-upper song (If you know me, you know that I am constantly singing through therapy- Shout out to Rachel Arnston's CEU course which I highly recommend), or simply producing "choo-choo" with other associated sound effects.
• Joe looks towards our box of trains, so we guess that he may want another one (Do you see how I'm still following his lead, even though I'm ultimately in control?). I hold up a train and when he has solidified my guess by continuing to stare at the train and perhaps trying to grab it from me, I shape his hand into a point and reward this (ABA!) I am immediately on guard for another "mouthing" event so I watch Joe closely and if necessary provide some physical prompts to block the next mouthing episode and place the train with its train friends on the track, all the while excitedly making choo-choo sounds. Maybe Joe gets a little annoyed with me here. I am blocking his *desired* way to play, and making him use this toy in a different, less motivating way- Why am I such a MEANIE!!
• In addition to these possible frustrations, we also are possibly dealing with a child whose attention span is limited at best and therefore may not be THAT into just seeing the trains connect and roll on the track. Okay, we've shown him how to play appropriately and we've blocked the mouthing behavior, so our job is done right? From now on, this child will miraculously play appropriately with the trains? NO!
•  The burden of play falls on OUR shoulders as clinicians. I mean, isn't that why the child is here in the first place? Because he DOESN'T have appropriate play skills. So why would we completely follow his lead and let him indulge in INAPPROPRIATE and self-stimulatory play?? Someone please answer me this!!!! We cannot possibly expect the child to learn after one round of play, so we'll probably introduce this activity every session in increasing increments of time to build his attention span and interest. We also have to be aware that our children are not playing functionally because it’s NOT FUN FOR THEM! It's more fun for them to mouth a train or spin its wheels. We are taking away the "fun ways" for this child to play so we need to make OUR way even MORE fun!  This can ONLY happen if you are continuously involved and exhaust your bag of tricks.
• This is when I tell the students I supervise to become a clown. I have no better way to describe it, as there's no right or wrong thing you can do because every child is different. Something that works with one child for 3 weeks in a row may one day completely bore them. An activity you rely on as your go-to, may not work with the next child. Acting like a clown could more clinically be referenced to as "using social games which are fun, motivating and exciting while providing an increase in the incidence of natural reinforcement"- or Number 3 from Above. Basically  it entails, doing whatever you can to get the child to attend to the toy (or even just you) with pleasure (ideally eye contact). Once this connection is established, I feel the pathway for true communication has begun (Think, yellow brick road...)
  Here are some of my go-to scenarios that kids seem to respond to enthusiastically and that typically create opportunities for natural reinforcement: 
• The Over Dramatic Cry (BOO HOO HOO MY TRAIN FELL DOWN!!! (while fake crying)). I honestly cannot tell you how much success I have had with this type of fake crying. Kids find it absolutely hysterical, and I frequently use this to improve eye contact/increase initiations during play. Although I am not exactly modeling any functional vocabulary, I am establishing a back-and-forth rapport with the child which I find to be a communicative fundamental. I've literally worked with children that looked at me 1-3 times a session, introduced this scenario and the child was visually connecting with me from ACROSS his classroom. 
• The "Hey where did it go?"- putting the train inside the child's shirt, while placing their hand on it, so they are aware, then reacting HUGELY when they eventually pull it out and show you! They love being able to "find" the object, they love the tickles and praise they receive, and then you can ride this wave of happiness by pairing sound with the object. You can also play dumb and see if they initiate continuation of this game (leave the train on the table, and wait for them to grab it and attempt to place it under their own shirts)- With pre-verbal children is important not to forget how meaningful GESTURAL initiations can be as they serve as an opportunity to continue the game, build rapport and pair with language. It gives children a "voice" and can help ease their communicative frustrations.
• Anticipatory Play: This is more of a type of play then an actual individual schema because you can really apply this anticipatory build up to a range of activities, using a range of language structures from vowel combinations to 3-4 word phrases depending on the level of functioning of the child you're working with. Once the child lets you know he likes this game, you can pause and wait for him to initiate with eye contact, gestures (move his hands towards yours, grab your hands) or vocalizing (producing intraverbal previously established). Time delay is a major component of Milieu Teaching, and one that I use very often in order to allow chances for children to initiate (either visually, gesturally or vocally).
•  Building a tower that's shaky and could fall at any second- BOOM! Whoa- whoa whoa it’s going to fall downnnn!! Oh nooo!!!! 
• Tickles that start across the table from the child then reaching the child's fingers and eventually go up to his armpits or neck which are more ticklish. 
• Placing of small objects from high to low (i.e. a ring stack, where the clinician flies the ring while making OOOOOOOO and changing the vowel to EEEEEEE once it lands on the stack). Once the child starts to enjoy this game, you can bring the ring up in the sky with the initial vowel, and then bring the ring to the top of the stack but hold back on producing the  EEEEEE until eye contact is established. This type of play gives the child an idea of what sound is going to come next, and with repeated exposure, gives them the confidence to initiate VOCALLY eventually.
• Peekaboo
• I’m gonna get you!! (Chasing down the hall, across the room, etc).

The list goes on and on and I still come up with the most RANDOM yet SUCCESSFUL activities because I am continuously acting the clown, while always keeping the child's motivation at the top of my mind. I incorporate so many of the characteristics of Milieu teaching while never losing sight of the principles of ABA-- I find this to be a very successful mix! 

I hope through this semi-verbose posting you can understand how natural my sessions look, but how I still adhere to the principles of ABA in order to increase desired behaviors and decrease inappropriate behaviors.