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.
5 comments:
Hi Dani, great article! I will share it on my Facebook page. I love how you emphasize using humor and dramatic reactions to engage and motivate children. I recently presented at a conference on that exact topic! You and I have very similar styles of working with children with special needs. If you want to see me at my zaniest while working on speech goals, check out this video blog post of mine.
http://www.therhythmtree.com/video-blog/entry/using-humor-to-help-a-client-with-speech-goals
Thanks again for your insightful post.
Ryan Judd, MA, MT-BC
Thank you so much Ryan! I just checked out your website and it looks great. I think music is an amazing tool for increasing and expanding communication and is often overlooked and dismissed because it may not be as academic/structured as other techniques. Also, alot of people may feel silly doing using it :) I sing ALL day and use lots of musical toys (even just tapping a table). Thank you SO much for reading our blog and sharing it on your facebook page!! My boyfriend just moved home from New Hampshire, its a beautiful state :)
Enjoyed your post, Dani, thanks for sharing! I also love utilizing music. If you need fresh song ideas, check out Listen, Sing, Speak! Children's Songs for Speech, Language & Hearing Goals at http://www.thespeechstop.com/sub.php?page=music. I also have a YouTube post with a song activity at http://youtu.be/fFhB3ODu5Pk. As you share these techniques with parents, check out these FREE tip sheets for parents based on the premise of milieu teaching, or teaching language through natural settings, activities, and routines. I call it Purposeful Ongoing Play - the POP sheets are available at http://www.thespeechstop.com/sub.php?page=planguage.
Hi Dani,
Nice post! I agree with you on how to appropriately follow the child's lead. I write about how to use play routines and songs to facilitate language development in toddlers in my book - My Toddler Talks: Strategies and Activities to Promote Your Child's Language Development. If you would ever like to write/share a guest post about ABA on my website - www.scanlonspeech.com please let me know :)
Kim Scanlon
Hi Kim! I just realized the connection between your comment and the scanlon speech I follow on Facebook! I grew up in Ramsey! Two of my grad school friends also like your page- did you go to Montclair??
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