Presentation on theme: "CHRISTINE BUCKLEY ALEXIS HERSHKOWITZ NICOLE MOINHOS CALDWELL COLLEGE GRADUATE PROGRAMS IN APPLIED BEHAVIOR ANALYSIS A Review of The Miller Method for Autism."— Presentation transcript:
CHRISTINE BUCKLEY ALEXIS HERSHKOWITZ NICOLE MOINHOS CALDWELL COLLEGE GRADUATE PROGRAMS IN APPLIED BEHAVIOR ANALYSIS A Review of The Miller Method for Autism Treatment
The Miller Method® Philosophy “We maintain that each child--no matter how withdrawn or disorganized--is trying to find a way to cope with the world. Our task is to help that child use every capacity or fragment of capacity to achieve this.” (www.millermethod.org)
History of The Miller Method® Founded by Arnold Miller and wife Eileen Eller-Miller in 1965 Language and Cognitive Development Center (LCDC) in Boston With the help of research and demonstration grants from the U.S. Department of Education, the Millers have created a wide variety of strategies to help developmentally challenged children Currently, center is being headed by Dr. Arnold Miller and his senior staff Affiliate in Los Angeles, California called the Los Angeles Miller Method Resource Center (LAMMRC), directed by Rebecca Sperber (a parent) LCDC is internationally known
Who are Dr. Arnold Miller & Eileen Eller-Miller? Married for 45 years, together created The Miller Method® and founded the LCDC Dr. Arnold Miller 1. Director of the LCDC of Boston 2. Affiliate Professor of Psychology at Clark University where he received his doctorate in clinical psychology 3. Research appointments at Boston University & Harvard Medical School 4. Was a faculty member of the University of Montana 5. Directed the Language Development Laboratory at Wrentham State School, Massachusetts Eileen Eller-Miller 1. Education Director of the LCDC 2. M.A. in speech and language pathology from Columbia University 3. B.A. in psychology from City University of New York 4. Worked at Flower Fifth Avenue Hospital, Beth Abraham and Hunter College in New York City (www.millermethod.org)
The Millers (cont’d) Eileen Eller-Miller passed away on June 18, 2004 from colon cancer Her obituary read: “Eileen Eller-Miller, wife and colleague of Arnold Miller for 45 years, died on June 18, 2004 after a long and courageous battle with colon cancer. She died at home as she wished. Throughout her devastating illness she maintained her optimism and wish to help children with autism achieve a meaningful life. Just weeks before she died -- with barely enough strength to sit up -- she participated in a videoconference with Dr. Miller to help an autistic child and his family. Over the years she partnered with Arnold Miller in founding the Language and Cognitive Development Center and in developing the Miller Method. Before she died, she urged that her husband continue the mission of the Center. “ (www.millermethod.org)
Cost, Time, Location & Certification Length of treatment varies Fee: $150 per one hour session. 50% scholarships are available Takes place in private and public schools in Massachusetts, New York, New Jersey, Ohio, Pennsylvania, California, Canada, Israel, and secondarily in the homes of families equipped for videoconferencing Authorized Miller Method® School Program a. Certified Miller Method specialist or therapist on staff b. Ongoing consultative relationship with a senior staff member from LCDC
Certification (cont’d) Appropriate candidates for certification 1. Clinical/Developmental Psychologists 2. Psychiatrists 3. Social Workers 4. Pediatric nurses 5. Occupational therapists 6. Physical therapists 7. Special educators 8. Speech and Language Pathologists Several ways to train 1. 4-Day Workshops at LCDC 2. Videoconference Workshops Qualifications for certification 1. 4-day training workshops at LCDC weeks (1 hour per week) of supervised training 3. Cases covered 4. Written examination
Goals of The Miller Method® Assess the adaptive significance of the children's disordered behavior Transform disordered behavior into functional activity Expand and guide the children from closed ways of being into social and communicative exchanges Teach professionals and parents how to guide the children toward reading, writing, number concepts, symbolic play and meaningful inclusion within typical classrooms (www.millermethod.org)
Problems with ABA according to The Miller Method® ABA makes no assumptions about the sources of autism or the inner life of the child Addresses the atypical behavior using the tools of the learning theory Reinforcing with rewards for desired behaviors (Ex. Food or praise) Extinguish “unacceptable” behaviors with “time-out,” “turning away,” or aversive procedures Emphasis on compliance Children seem to be acting appropriately but without any clue as to what they are doing. Assume that if they can get a disordered child to behave like a typical child, then the child will be typical.
ABA vs. The Miller Method® ABA Child remains seated to learn Turning away from acting out children Divert or extinguish unacceptable behavior Establish compliance with the help of rewards The Miller Method® Learn best through action Turning towards and engaging the acting out child Transform unacceptable behavior into functional, interactive exchanges Establishes repetitive rituals (systems) to elicit spontaneous initiatives from the children
Ritual Systems Based on cognitive-developmental systems theory MM works with systems a. System: any organized behavior with an object or even that the child produces b. Are directed, are organized, and lead to some outcome c. Viewed as organized “chunks” of behavior, perception, or thought d. Rituals are systems a. Developed properly, can help a child move from atypical to more typical functioning (Miller, A. & Chretien, K., 2007)
4 Types of Systems 1. Body systems: Coordinate sensory capacities with motor capacities in the service of a particular function. 2. Social systems: How two people interact with each other, whether by working together, turn-taking, competing, or bonding 3. Communication systems: The integration of words and actions around objects in relation to another person 4. Symbolic systems: The way in which a child organizes the relation between symbols and what they represent (Miller, A. & Chretien, K., 2007)
Order and Disorder Order: Predictable systems Disorder: Disruption of systems Two types of Disorder in children with autism 1. System-forming disorder: Children with autism who are quite scattered and have trouble ordering (systematizing) and making sense of their immediate surroundings and the people in it. 2. Closed system disorders: Children with autism who become over-preoccupied with routines (systems) and objects to the exclusion of people Develop daily routines (ritual systems) in therapy and in school sessions By developing ritual systems, the child can cope with disorder and change and is open to explore environment
Three Types of Disorder 1. Mild disorder: Evident when the teacher or therapist expands a system by changing the location of the object, the person involved in the system, the objects used in the system, or the position with which the child deals with the object. 2. Moderate disorder: The interruption of systems in a way in which induces a compensatory reaction on the child’s part to maintain the system 3. Dramatic disruptions: A strategy used in which the teacher messes up or dramatically changes something in a child daily routine (Miller, A. & Chretien, K., 2007)
Characteristics of Systems Once a system has been constructed, each system tends to maintain its reason Differ from each other 1. Rigidity: How urgent the child’s need is to maintain a system unchanged 2. Complexity: Whether the system is simple (a minisystem) or more complex (an integrative system) 3. Distance reality: Extent to which children substitute symbols for direct physical contact with a person, object, or event (Miller, A. & Chretien, K., 2007)
Capacity A search for the kinds of systems a child brings to a situation Need to know to what extent a child is dominated by his/her systems Need to know about the relative rigidity of these systems, their complexity, and the extent to which they can be altered Assess the child’s relative emphasis on whether the child is engaged exclusively with action-object systems, with people systems, or with both Assessment Test/Questionnaires 1. Miller Diagnostics Survey (MDS) 2. Miller Umwelt Assessment Scale
Miller Diagnostics Survey (MDS) Questionnaire filled out by parents Assesses the child’s atypical functioning Establishes a ratio between a child’s overall performance and his/her atypical functioning Produces a coping score which reflects the extent to which a child’s performance is adversely affected by atypical functioning Area covered by the MDS questionnaire 1. Sensory reactivity 2. Body organization 3. Problem solving and tool use 4. Communication 5. Symbolic functioning
MDS: Unique Instrument 1. Organized developmentally in that each category includes specific questions about behaviors from both earlier and later stages of development, ranging from 18 months to about 7 yrs of age 2. Parents’ responses to MDS questions provide an estimate of the child’s functional capacities as well as an estimate of how atypical the child’s behavior is 3. Presents 107 questions which cover a broad range of functioning. To be completed by parents at the beginning and end of the academic year (gap between responses of 10 to 12 months)
MDS: Unique Instrument (cont’d) 4. Parents or caregivers who live with the child are continuously more fully aware of the child’s capacities and challenges 5. When gains which are first generated in school or clinic become apparent at home, this demonstrates that new learning has been generalized by the child beyond the confines of school and clinic 6. Probing questions which are part of the MDS may have positive effect of helping parents look more closely at exactly what the child can or cannot do
More about the MDS Once a parent transmits her/his responses to the questions, a senior staff member at the LCDC will review them, construct a profile of your child, and send a report with recommendations. Fee: $100 (www.millermethod.org)
Miller Umwelt Assessment Scale Assessment of the child in which the child’s behavior is examined in unstructured, interactive, and structured situations “Umwelt” coined by Uexküll (1957) - “world around the child” or world perceived through the child’s eyes During the assessment, therapist is interested in determining how close a child is to achieving the next step in development which is determined by the additional cues a child might require for success Seek to determine the child’s emotional resourcefulness in initiating and maintaining ongoing interactive systems with adults in the manner described by Greenspan. (Miller, A. & Chretien, K., 2007)
Miller Umwelt Assessment Scale (cont’d) At the end of the 2-hour session, the parent receives an oral summary of findings and a videotaped copy of the assessment. A detailed report with recommendations is sent within 2-3 weeks. Fee: $1,000 (www.millermethod.org)
Assessment Miller Umwelt Assessment Scale Miller Diagnostic Survey Parent Survey Teacher/Instructor Survey
Umwelt Assessment Coined by von Uexkull (1957) meaning “world around the child” Components Parent Examiner Step slide Climbing equipment A soccer ball Large plastic container Large red ball suspended on a rope from the ceiling to the child’s eye level Box of wooden blocks under the slide
Umwelt Assessment (cont’d) Test measures 16 different tasks Looking for child’s capacity in: Interation with people and objects Adapting to change Learn from experience “Testing the limits” to see their “zone of proximal development.” Child’s emotional resourcefulness initiating and maintaining ongoing interactive systems with adults.
Umwelt Assessment (cont’d) First unstructured section to see what the child will interact with on his/her own Normal development: play with everything Autistic: run in circles, back and forth, etc. 16 tasks are all targeted for different components and to assess for closed or system forming disorders
Major Components Suspended Ball Task Type A- child-object-adult Type B- child object = closed systems Type C- No object = system forming Goal: Interaction with person and object Cups and bowls activity Stacking cups and bowls in different ways Goal: Adapting to change
Major Components (cont’d) “Swiss Cheese” Board Avoidance of holes on Elevated Board 2.5 feet in air Goal: Awareness of space and body and ability to learn from experience “Croupier” Task Rake- Obstacle Goal: Problem solving ability and to learn from experience
Contrasting Children with Closed-System and System-Forming Disorders DisorderType AType B Closed System Minimal executive functioning and few systems Poor shifting/scanning People excluded from systems Executive functioning with many object systems Ability to shift from one to another system People excluded from systems System Forming Minimal executive functioning Poor sensory-motor coordination limits system forming Little executive functioning Salient properties of many sources induce repeated orienting, but not engagement
Use of Systems Each system is a set of behaviors that accomplishes something (whether social or for self) Interruption of Systems= language opportunity
3 Steps to Restore Typical Developmental Progressions First Set of Interventions Systematic Body Work Second Set of Interventions Transformation of aberrent systems Third Set of Interventions Systematic and repetitive introduction of developmentally relevant activities
Strategies for Applying The Miller Method Elevated Square Transforming Systems Take pre-existing abberent systems and transform to more functional systems Creating Systems Fill in developmental gaps Inclusion Principle Extension Principle
Orienting, Engaging, and System Formation Having child look at stimuli Children may have aberrant behaviors that distract from orienting Child then must have contact--physical or emotional--with the person or object to create systems Repetitive engagements are needed to create systems Then, interruption of the newly acquired system creates language opportunities
The Elevated Square 2 ½ feet above ground and a 5 foot by 8 foot structure Colorful and main focus of the room
Purpose of Elevated Squares “Word Deafness” Spoken words not relevant to what is engaging them at the moment Solution: Enhanced reality by elevating children on the Elevated Square so they can hear the words and focus on the manual gestures
Components Square Work stations in each corner Removable piece to make U-shaped structure and be able to have instructor in the middle Obstacles Slide that can be removable
Reasons for the Elevated Square Undefined reality to highly defined Body awareness Constraint on child’s actions “Edge Experience” Eye contact leveled
Purpose for system disorders for the Elevated Square Systems-Forming disorders External organization Closed Systems disorders Framework taught to expand their systems
Andrew on the Elevated Square
Transforming Systems Find ways to channel energy used by children with autism to maintain their rituals into systems that are flexible and interactive Autistic Systems e.g. Rocking, flapping, dropping things 1. Assess the casual dynamic that captures the child 2. Find a way to cast that dynamic as part of an interactive and flexible system
But How? Rocking Have child sit facing you Imitate rocking with child and maintain eye contact When child starts to anticipate, STOP! When child tries to communicate that they want to rock again using direct eye contact and some rocking, begin again Repeat game times
But How? (cont’d) Flapping Give child symbols for a more functional system Extend the system using other objects like sand blocks Repetitive Dropping or Throwing things Have child throw things in different directions and into different containers to “finish the experiment” Extend the system with different objects or containers Goals: Get into what the child is doing Make it interactive Then, extend to a better functional skill
Creating Systems Filling in developmental gaps or lags Acceptable to use Hand over Hand (H.O.H.) to first teach skill Spheres or Spheric Activity Block examples Closed System Disorder System-Forming Disorder Repetition and a gradual “taking over” or conversation of sphere into a system by child
The Inclusion Principle Introducing new parts to the system Object/ Person Word Gesture Assimilating new parts to the system Verbal prompt= child searches for other aspects
Extension Principle Child learns a new property or aspect of a system Incorporates the newly extended system into the original system Plays an important role in the language system of spoken words to written words in the Symbol Accentuation Reading Program
Extending to Social Capacity Play Games e.g. I’m going to get you, Peek a Boo, and Hide and Seek Mother-Child Bond Grand Central Station 4 interaction skills Turn-taking Cooperating Competing Shifting to the other’s perspective
Communication Extending System principles Uses Hand over Hand with words and a reinforcer Come Example
Education Building self/body awareness will lead to education Uses same creating systems strategy
Support Systems Parent/Instructor relationship to child Four different kinds: High Support/Low Demand High Demand/Low Support Low Demand/Low Support High Support/High Demand ***
Angela One of a few known “successful” cases Beautiful, blonde 5 year old from Toronto Umwelt Informal Assessment 2 parts of systematic behavior done while she was in Toronto Putting discs in a slit and was able to adapt to change Balloon blowing up and she made a social interaction by pursing lips and moving forward Parents decided to enroll Angela in Boston
Angela (cont’d) Umwelt Assessment Ball Task- Level B Step-Slide Task (Step-Slide System) Climb up the steps, sit down, hitch forward, go down, and return to steps Created system quickly but would stomp feet at the top and threw blocks down the slide Spontaneous expansion!! “Croupier” Task Did an excellent job of adapting Cup-Bowl Task Reverted halfway through putting cup into bowls Angela put her head down and turned toward the wall But she showed social intention when Dr. Miller turned her head (she had an “impish” smile which showed she had a lot of promise!)
Angela (cont’d) Umwelt Assessment (cont’d) Symbolic doll task Imitate the instructor by feeding a baby doll a bottle then putting to bed Angela added taking off all the doll’s clothes and inspecting the doll, then imitating the instructor Mother-Child Bond Mother leaves room by saying, “Bye, Bye” and examiner observes child’s reaction Angela ran over to mom when as she was leaving and pulled her back into the room exhibiting a great mother daughter bond – High demand/High Support
Angela’s Progress according to Mother First Week- screamed and tantrumed Second Week- first sign After this, signs and communication efforts were progressing quickly. Angela signed come, go, plate, give, and cup. 1 month- spoke come, give, plate, and cup 3 months and 3 weeks- requested and made simple sentences 1 year later- returned to learn how to read Able to sustain herself in a typical classroom…able to read and write better than typical 6 year olds!
Research Relevant to the Miller Method Cook, C.E. (1998) The Miller Method: A case study illustrating use of the approach with children with autism in an interdisciplinary setting. Journal of Developmental and Learning Disorders, 2, 2, Messier, L.P. (1970) Effects of Reading Instruction by Symbol Accentuation on Disadvantaged Children. Unpublished doctoral dissertation, Boston University. Miller, A. (1968) Symbol Accentuation: Outgrowth of Theory and Experiment. In Proceedings of the First International Congress for the Scientific Study of Mental Deficiency, Montpelier, France, , Surrey, England: Michael Jackson. Miller, A. (1991) Cognitive-developmental systems theory in pervasive developmental disorder. Psychiatric Clinics of North America, 14, 1, Miller, A. & Miller, E.E. (1968) Symbol Accentuation: The perceptual transfer of meaning from spoken to written words. American Journal of Mental Deficiency, 73, 1,
More Research Miller, A. & Miller, E. E. (1971) Symbol Accentuation, single-track functioning, and early reading. American Journal of Mental Deficiency, 76, 1, Miller, A. & Miller, E. E. (1973) Cognitive-developmental training with elevated boards and sign language. Journal of Autism and Childhood Schizophrenia, 3, 1, Warr-Leeper, G., Henry, S., Versteegh, T. Outcome Study: (1997) The Effect of the Miller Method on Five Severely Disordered Children with Pervasive Developmental or Communication Disorders. Unpublished Honors Study, University of Western Ontario.
Problems with References Some references are unpublished dissertations/honors studies Much of the “research” is dated (i.e. most is from the 1960s-1970s) Not readily accessible to the public (i.e. consumers of treatments for autism) Few references are empirical in nature
Why Study Cognitive-Developmental Systems? The Miller Method is based on a “cognitive- developmental systems” approach Helps us better understand typical versus atypical patterns of growth, change, and stability across the life spans of people with and without autism (www.millermethod.org)
More about Cognitive-Developmental Systems Assumes that typical development depends on formation of systems Becoming aware of the distinction between themselves and their surroundings, systems (previously triggered only by salient properties of environment) gradually come under their control Systems are then combined in new ways leading to problem solving, social exchanges, and communication with themselves and others about the world (www.millermethod.org)
Cognitive-Developmental Systems Theory in Pervasive Developmental Disorders (Abstract) The concept of reality systems is introduced in context of cognitive-developmental systems theory. Examination of the parallels between the reality systems of normal infants and those of children with pervasive developmental disorders supports the view that the latter are stalled at an early stage of development. Evaluation of pervasively disordered children with closed-system and system-forming disorders indicates the aberrant manner in which such children orient toward and engage objects and events, a manner that precludes flexible adaptation to people or surroundings. Attention is given the role of interruption as it triggers a compensatory reaction to maintain systems and the contribution of such reactions in developing the intentional behavior so lacking in children with pervasive developmental disorders. Finally, the author discusses theory-driven strategies to correct deficits in the body schema, coping with surroundings, social development, and communication and representation.
Cognitive-Developmental Systems Theory in Pervasive Developmental Disorders This is an information-only article; no experiment was performed Author’s terms are subjective Restates previously stated information
Cognitive-Developmental Training with Elevated Boards and Sign Language “To test the relevance of this approach, elevated board-sign language procedures were applied with 19 intransigent, nonverbal, autistic children in several institutions at which we were consulting. Children who previously could not follow spoken language directions could do so when signs were paired with spoken words, and particularly when these signs and words were taught in the context of elevated board structures.” (Miller, A. & Chretien, K., 2007)
Cognitive-Developmental Training with Elevated Boards and Sign Language Is experimental in nature But, article is difficult to obtain… Replication?
Significance of Elevated Boards Miller observed a “dramatic change in behavior” when children stepped on planks between tables “Edge experience:” Heightened awareness and increase in attention Words paired with obstacles, generalization to other settings
However, Miller also says… Range of concepts to be taught was limited Children seemed to turn vital involvement into rituals (stereotypy) Continued to perform tasks, but automatically and without alertness Was it worth it, then?
Symbol Accentuation Miller developed this technique as a reading program and has written 2 articles on it Teaches symbolic function of printed words via object-word pairing Eventually helps children understand that words can be meaningful without resembling their objects (www.millermethod.org)
Symbol Accentuation (cont’d) Helps children learn how to sight-read sentences in both large and small type (generalization) Helps children shift from sight-reading to phonetic reading Helps children develop letter-sounds relationships and blending and sequencing of letter sounds into meaningful words Encourages active participation by both students and teachers (www.millermethod.org)
Symbol Accentuation, Single-Track Functioning, and Early Reading (Abstract) “Accentuated conditions, during which animated motion pictures of objects blended into their customary printed words, was found more effective than the conventional look-say presentation of objects and words in teaching retarded persons to read.” Looks (and sounds) a lot like stimulus shaping!
More on Symbol Accenuation “In a series of experiments, it was demonstrated that transfers could be made with children and adults who were able to speak but could not identify printed words. If pictures and printed words were fused on one side of a flash card, and that flash card was flipped to the other side revealing the word in its conventional form, children could transfer picture properties to printed words. Then, subsequently, they could identify the printed words without needing further transfers.” (Miller, A. & Chretien, K., 2007)
Miller’s Research More publications on symbol accentuation and signing than elevated boards (unique to Miller Method) Earlier publications about other topics Field of interest is a bit broad for an “expert”
Conclusions Dr. Miller is a clinical psychologist who did some post doctoral work in language development, but does that make him qualified? Assessments are very subjective and no empirical data are used Further research is needed: Elevated Square Methodology
Conclusions (cont’d) The Miller Method is pseudoscience! Lots of subjectivity (no objectives defined) Poor research techniques Correlation does not equal causation! Did experimenters control for variables in empirical studies? Claims to be effective for a wide variety of disorders Area of expertise?
Lastly… “The ‘innovative’ Miller Method has been around for 35 years, yet according to this report, it is not well-known outside their local area. Given that there are so few effective treatments for autism, one would think that this Miller Method would be quite well-known outside of their community if it demonstrates effectiveness. Effective treatments for autism don't stay hidden for very long, let alone 35 years. Also, according to this report, Miller assets that the Miller Method is not a behavioral-oriented program. But by the description given, it can only be just that. Like Stanley Greenspan's DIR Model and Barry Kaufman's Options Therapy, the Miller Method, while denying it, appears to indeed use behavioral principles, but intuitively (rather than consciously and scientifically as in Applied Behavior Analysis). Science and intuition have their respective places in evaluating program consistency and effectiveness. Choose carefully.” (www.best-pals.org/a_med_miller1.html)
References Cook, C.E. (1998) The Miller Method: A case study illustrating use of the approach with children with autism in an interdisciplinary setting. Journal of Developmental and Learning Disorders, 2, 2, Kyle Westphal Foundation (2005). The miller method. Retrieved June 2, 2008, from Kyle’s Treehouse Website: Messier, L.P. (1970) Effects of Reading Instruction by Symbol Accentuation on Disadvantaged Children. Unpublished doctoral dissertation, Boston University. Miller, A. (1968) Symbol Accentuation: Outgrowth of Theory and Experiment. In Proceedings of the First International Congress for the Scientific Study of Mental Deficiency, Montpelier, France, , Surrey, England: Michael Jackson. Miller, A. (1991) Cognitive-developmental systems theory in pervasive developmental disorder. Psychiatric Clinics of North America, 14, 1, Miller, A. (1996). The miller method. Retrieved June 2, 2008, from The Language and Cognitive Development Center (LCDC). Website: Miller, A., & Chretien, K., (2007). The Miller Method: Developing the capacities of children on the autism spectrum. Philadelphia, Pa: Jessica Kingsley Publishers. Miller, A. & Miller, E.E. (1968) Symbol Accentuation: The perceptual transfer of meaning from spoken to written words. American Journal of Mental Deficiency, 73, 1, Miller, A. & Miller, E. E. (1971) Symbol Accentuation, single-track functioning, and early reading. American Journal of Mental Deficiency, 76, 1,
References Miller, A. & Miller, E. E. (1973) Cognitive-developmental training with elevated boards and sign language. Journal of Autism and Childhood Schizophrenia, 3, 1, Miller, A., & Eller-Miller, E. (1989). From Ritual to Repertoire: A cognitive-developmental systems approach with behavior-disordered children. New York: Wiley and Sons. Pediatric Services (2008). A Look at the Miller Method: A Cognitive-Developmental Systems Approach to Therapy for Children on the Autism Spectrum. Retrieved June 7, 2008, from B.E.S.T. P.A.L.S. website: Warr-Leeper, G., Henry, S., Versteegh, T. Outcome Study: (1997) The Effect of the Miller Method on Five Severely Disordered Children with Pervasive Developmental or Communication Disorders. Unpublished Honors Study, University of Western Ontario.