Milieu Teaching

Question 1

Building Blocks of communication (5)

- In the first year intentional communication results from the culmination of:

Answer 1

— Accelerated auditory development

— Emergence of complex babbling

— Emergence of social responsiveness

— Development of receptive skills

— Coordination of attention

Question 2

Early communication

Answer 2

• Frequent and clear prelinguistic communications by 12-18 months
• Designed for kids functioning between 9 and 15 months- mama and daddy, yes/no, turn taking with vocalizations
• Different technique for 6 year olds and above

Question 3

1. Pre-linguistic Intentional Communication
2. Proto-imperative
3. Proto-declarative

Answer 3

1. Acts composed of gestures and or vocalizations directed toward a communication partner (they send a message)
2. Request- child trying to get someone to do something (children with downs syndrome have trouble with this)
3. Commenting- more social in nature, typically requires joint attention (children with autism have trouble with this)

Question 4

1. Canonical Vocalization

2. Coordinated eye-gaze

Answer 4

1. A production of syllables containing both a true consonant and vowel
2. Alternate attention between an object of interest/event and communication partner

Question 5

1. Pre-linguistic Milieu Teaching
2. Responsivity Education
3. Premise

Answer 5

1. Delivered from SLP to child, used to increase frequency and complexity of intentional non-verbal communicative acts (gestures, coordinated eye gaze, and vocalizations)
2. SLP to caregiver- designed so the SLP can teach the caregiver to get optimal communication
3. when prelinguistic communication is delayed the 1st step is encouraging intentional communication

***Biggest problem is that it is often used with the wrong kids

Question 6

RESPONSIVITY EDUCATION AND PRELINGUISTIC MILIEU TEACHING (RE/PMT)- Not for everyone

Answer 6

• Appropriate for children who need to increase their frequency of gestures and vocalization
• Not appropriate for children who use more than 10 words or signs productively (or understand more than 75 words)(people will use it with this population and that is not appropriate)
• Not appropriate for children who produce more than 1-2 spontaneous intentional communication acts per minute

Question 7

RE/PMT – FOUNDATION

Answer 7

• Transactional Model of Social Communication Development
• Assumes pre linguistic skills form
  later language skills
• Based on principles of “Enabling Contexts”

Question 8

1. Communication

2. Linguistic Mapping

Answer 8

1. Communication comes from a bidirectional plan. Communication is built on. Child’s increased attempts to communicate increases the parents communication attempts.
   - Learning in children birth to 3 is through interaction
2. Linguistic mapping- adult verbal responses reflecting the core meaning of what the child has communicated. If the child holds up a truck, the adult should say you have a truck, they give meaning to the child’s actions.

Question 9

4 enabling contexts for PMT

Answer 9

1. Arrange environment to increase opportunities for communication- children are most likely to initiate communication when they find something they are interested in (what they want and need)
2. Follow child’s intentional lead- young children are going to be far more likely to attend to objects they are interested in
3. Specific forms- Contingent motor imitation- SLP imitates the child’s motor act (creates turn taking and allows the child to regulate how much stimulation they get and there is more likelihood the child will understand the interaction)
   Contingent vocal imitation- adult imitates vocalization
4. Building social routines in which child and adult have some sort of predictable role- peekaboo, patty cake (repetitive and can be built in throughout the day)

Question 10

1. Goal of PMT

2. Intermediate goals (5)

Answer 10

1. Overall Goal – To help children establish and/or increase the frequency, clarity, and complexity of their non verbal communicative acts
2. a. Establish routines to serve as the context for communicative acts
   b. Increase the frequency of nonverbal vocalizations
   c. Increase the frequency and spontaneity of coordinated eye gaze
   d. Increase the frequency, spontaneity, and range of conventional and non conventional gestures
   e. Combine components of intentional communication acts

Question 11

Intermediate Goal I

I. Establish routines to serve as the context for communicative acts

Answer 11

A. Imitate child’s motor acts

B. Imitate child’s vocal acts

C. Interrupt child’s established pattern with an adult turn, then wait for child to take a turn

D. Perform action that child finds
interesting /funny, pause, repeat

E. When the child produces one part of the routine, “oblige” by performing the action needed to complete it

Question 12

Intermediate Goal II

II. Increase the frequency of nonverbal vocalizations

Answer 12

A. Recast the child’s nonverbal vocalization with word if the child is focused on clear referent (recast with the actual word)

B. During vocal play, model vocals with sounds and word shapes known to be outside child’s repertoire

C. Model sound w/I child’s sound/word shape repertoire when vocals are not part of communicative act

D. Imitate child’s spontaneous vocals with sounds and syllable shapes know to be w/I the child’s repertoire when the vocals are not part of a communicative act

E. Imitate the child’s spontaneous vocals as precisely

Question 13

Intermediate Goal III

III. Increase the frequency and spontaneity of coordinated eye gaze

Answer 13

“Create a need for communication w/I a routine in which the child looks at the object, then”:

A. Provide child with desired object or action contingent on looking

B. Verbally prompt eye gaze

C. Move the desire object to adult’s face to encourage more explicit look

D. Intersect the child’s gaze by moving the adult’s face into the child’s line of regard

E. Once child complies, acknowledge with pleased effect

F. If, after using methods above, child fails to produce act, provide child with desired object or action

• Often parents give up

Question 14

Intermediate Goal IV

IV. Increase the frequency, spontaneity, and range of conventional and non conventional gestures

Answer 14

“Create a need for communication w/I a routine, then”:

A. Provide child with desired object or action contingent on use of gesture

B. Pretend not to understand by looking and gesturing and saying “what?” or “what do you want?”

C. Ask or tell child to be more specific “Show me which one”

D. Tell the child, explicitly, to produce a particular gesture “show me”

E. Model an appropriate gesture

F. Once child complies, verbally acknowledge child’s gesture

G. If, after using the above methods, child fails to produce target then give desired object or action

Question 15

1. Conventional Gestures

2. Unconventional gestures

Answer 15

1. intentional communication acts (waving hi/bye, pointing, shaking head, putting hand out)
2. contextually driven ( touch the object to show they want, giving an object to an adult or taking it away) Involves the object

Question 16

Intermediate Goal V 1

V. Combine components of intentional communication acts

Answer 16

• If child produces 1-2 components of a communication act, wait to prompt next component.
• If child produces 1 or 2 components but fails to produce the next after a time delay:

A. Ask “what do you want?” or another general prompt, wait

B. Intersect the child’s gaze or call child’s name

C. Model/help child to produce gesture

D. If child produces a communicative act that is focused on a referent, slp should recast by producing a word

Question 17

Intermediate Goal V 2

Answer 17

E. If child produces components yielding a communicative act, slp should not produce a nonverbal model

F. Immediately after child produces target component, provide appropriate consequence and verbal feedback

G. If all above fails to yield target then provide child with desired object or action

-Used to establish very basic intentional communication

3 components:
- Eye contact with partner

• Vocalization
• Gesture (at this point you want a combination of all three)

Question 18

PMT – Types of Acts

Answer 18

Requests- seeking some object or action (proto-imperatives)

Comments- more social in nature (proto-declaratives)

Question 19

PMT – Procedures for achieving goals

- Prompts

Answer 19

Prompts- elicit intentional communication attempts (get vocalizations, eye gaze, and gestures)

1. Time delay prompts- tickling and you stop, turn taking routines
2. Nonverbal prompt- hold your hand out to get obj. or get in their line of sight
3. Verbal prompts- show me, tell me

Question 20

PMT – Procedures for achieving goals

- Models

Answer 20

• Models- enhance and support vocalizations and gestures the child uses
  1. Vocal models- SLP gives a vocal in return (child banging, SLP says bababa)
  2. Gestural model- use and imitate gestures (pointing is communicating, model gestures to show this
• Natural consequences- if the child uses intent, they get the desired object

Question 21

Using PMT to teach Proto-imperatives (requesting)

Answer 21

Establish routines that involve turn-taking

• At least 2 turns then
• Interruptions and
• May provide encouragement for response

Question 22

Using PMT to teach proto-declaratives (commenting)

Answer 22

• Establish a positive relationship with child
• Use of modeling
• Providing situations likely to stimulate

Question 23

The Responsivity Education Piece…

Answer 23

• Critical for success- needs to be reinforced by parents or it will not work
• Hanen program (ex.)
• Modifications of programs such as Hanen (one of the 1st big programs to help parents)
• Responsive interaction also referred to as interactive modeling

Question 24

Milieu

Answer 24

Foundations-
Need to understand the difference between 3 levels (enhanced and pre-linguistic spin off of milieu)

Milieu- core hybrid approach- conversation based model of early language intervention. Uses kids interests and initiations as opportunities to prompt and model language

Question 25

4 Foundational Aspects of Milieu

Answer 25

4 Foundational Aspects- 1. Arranging environment 2. Selecting specific targets for child’s skill level 3. Responding to child’s initiation with prompts for elaborated language 4. Functionality (reinforcing communication attempts by providing access to what they want) SLP/researchers created other 2

Question 26

Enhanced Milieu Teaching- Distinguishing Features

Answer 26

- Naturalistic - Conversation-based- because 10 words or more - Promotes child’s functional use of productive language skills - Hybrid approach 3 components of EMT 1. Environmental arrangement 2. Responsive interaction 3. Milieu teaching Hybrid approach*** COMPS

Question 27

Target population of EMT

Answer 27

- Children in the early stages of language development --- Intellectual Disability --- Autism Spectrum Disorder --- Specific Language Impairment Most successful with kids who can verbally imitate, have 10 productive words, and have MLUs between 1.0-3.5

Question 28

Theoretical Foundations of EMT

Answer 28

1. Behavioral Perspective - Behavioral- some sort of stimulation that is set up to elicit language - Child response is related to some stimuli - Consequences that follow the child’s responses are impt. to the use of strategies ---Modeling, imitation, and prompting 2. Social Interactionist Perspective - Driven by interaction, adults play a critical role because they read child’s intentions and give more meaning

Question 29

EMT Focus

Answer 29

- Strong emphasis on parents as language facilitators - Generalization is promoted when stimuli and consequences occur in a natural environment - Parents are the best educators – if they are taught how to do it - Important to do in the naturalistic environment

Question 30

KEY COMPONENTS OF MT PROCEDURES THAT ARE PART OF THE EMT APPROACH

Answer 30

- Modeling - Mand-model - Time-delay - Incidental Teaching - The 4 Milieu approaches + RI (Responsive Interaction) = Enhanced Milieu Teaching - Came out of Milieu- will not have us differentiate between milieu and enhanced (we will have to differentiate between enhanced and pre-linguistic)

Question 31

Modeling

Answer 31

- MOST fundamental strategy of MT - --Establish joint attention ---Present verbal model ---If child does not respond correctly or at all, provide another model ---If child responds correctly, acknowledge response with expansion and material ---If child does not respond correctly or at all, state correct response and give child the material

Question 32

Mand-Model 1

Answer 32

- Similar to modeling but includes a verbal prompt in form of ?, choice, or request 1. Establish joint attention 2. Present verbal mand/question 3. If correct response, acknowledge response with expansion and material You are framing it by asking a question

Question 33

Mand- Model 2

Answer 33

4. If incorrect or absent response provide another mand or model depending on level of support needed 5. If correct on 2nd try acknowledge response with expansion and material 6. If child does not respond to mand at target level or to model, state correct response and give child the material

Question 34

Time-Delay Procedure

Answer 34

- Used to establish environmental stimuli for child initiation instead of presenting models or mands 1. Establish joint attention 2. Wait for child to initiate request or comment 3. If child initiates request at target level give mand or model 4. If responds correctly then acknowledge with expansion and material 5. If no response to mand or model exactly, state correct response and give child material Hardest part is the time delay as you wait for the initiation- you need to tempt them

Question 35

Incidental Teaching

Answer 35

- Developed for teaching more elaborate language and to improve conversation skills for particular topic - Used when child makes a request 1. Arrange environment so child will request assistance or materials 2. Wait for child to initiate a request or comment 3. If child initiates verbal/nonverbal request, respond by using 1 of the other 3 procedures depending on support needed

Question 36

Responsive Interaction (4)

Answer 36

- Responding to child’s communication - Noticing and responding to child’s communication - Taking and balancing verbal turns - Mirror child’s actions and mapping language onto the actions

Question 37

Parents and EMT (4)

Answer 37

- Parents are an integral component of a successful EMT program. They must: - Commit time/energy - Learn and practice recommended strategies - Be able to take direction/accept feedback - Be able to implement strategies in the home

Question 38

EMT Requirements for Professionals

Answer 38

Professionals - Must have knowledge and experience prior to teaching parents - Minimum experience – intervention with 3 different children (before you teach a parent) Skills Include: - Ability to model procedures to children - Make necessary adaptations - Establish SLP’s skill with parent and EMT procedures

Question 39

EMT Requirements for Parents

Answer 39

20-36 sessions - Continuous monitoring of parent and child data during training as basis for feedback to parents Sessions last – 45- minutes to 1 hour - First 15 minutes – review progress/new info/and answer questions - Child joins session for 15-20 minutes to allow for practice of EMT/SLP provides feedback - Final 10-15 minutes – Parent may reflect/evaluation session

Question 40

EMT – STRATEGIES THAT WORK WHEN TRAINING PARENTS (6)

Answer 40

- Giving positive examples - Providing coaching and feedback - SLP being able to problem solve “problems” with interaction between parent and child - Modeling - Use of videos of other parents performing EMT techniques - Role playing

Question 41

EMT – STRATEGIES THAT WORK WHEN TRAINING PARENTS Cont. (3)

Answer 41

Sequential - Environment arrangement (parents need help in this area) - RI –reponsivity - MT – techniques Each step must be mastered by parents prior to advancing - Criterion – parent will perform strategy for 2 consecutive sessions

Question 42

Strategies

Answer 42

- Environmental Arrangement

Question 43

Key Environmental Components | How can the parent help facilitate communication?

Answer 43

- Increases child’s engagement with the physical setting --- Provides more frequent opportunities for communication and modeling - Parents taught to select toys of interest that will give the child a reason to talk - Parents taught to manage the toys so the child maintains play, stays engaged, and has a reason to communicate - Have the child do things that they need your help doing

Question 44

ONGOING ASSESSMENT AND DECISION MAKING 1

Answer 44

Child’s outcomes of EMT are assessed by: - Pre and post standardized measure - Observational measure (session-by-session) Standardize measures include: - Expressive and receptive skills - Expressive and receptive vocabulary - MLU - Language Sample

Question 45

ONGOING ASSESSMENT AND DECISION MAKING CONTINUED 2

Answer 45

Observational data may include: - Frequency measures of child’s total utterances - Spontaneous utterances - Total target language - Elicited target language - Spontaneous target language - MLU - Language sample would be helpful

Question 46

ONGOING ASSESSMENT AND DECISION MAKING- parent behaviors

Answer 46

Assessment of parent use of strategies is crucial for determining when next step may be introduced - Parent behaviors that are assessed include: -- Frequency of pause errors -- Frequency and % of responsive feedback -- Frequency and % of responsive expansions -- Frequency and % of language at child’s targeted level -- Frequency and correctness of MT episodes

Question 47

ONGOING ASSESSMENT AND DECISION MAKING- informal assessment

Answer 47

Informal assessment of parent and child takes place at the beginning and end of every session - Initiation – How is the process of implementing EMT going at home? - At the end – How does the parent feel about the new strategy that was learned in the session? EMT Checklist – - Environmental arrangement - Parent style and affect - Parental responsiveness

Question 48

Cultural Considerations for using EMT 1

Answer 48

Consider – - Specific EMT strategies - Specific EMT behavioral outcomes - The venue for EMT intervention (includes toys/materials Strategies – - Important to consider norms for responsiveness in the culture - Observe child-parent interaction if unfamiliar with the culture - Need to consider each one. - May need to modify toys

Question 49

Cultural Considerations for using EMT 2

Answer 49

- Determine if culture involves the language forms targeted for EMT - Successful language outcomes of the child often depend on the adult model Venue - EMT occurs in play context - SLP must select culturally appropriate toys/materials