1. ToniAnne Giunta Caldwell College
A Review of the Miller Method and Relationship Development Intervention as Treatments for Autism
ToniAnne Giunta
Caldwell College

2. The Miller Method

3. Miller Method Overview
What is it? – Definition, history, central concepts
What does the Miller Method claim to do…and HOW is this done?
What research support does it have?
ABA vs. Miller Method

4. Search Criteria PsycINFO YouTube http://www.millermethod.org/
Miller Method AND autis*
Miller Method AND developmental dis*
Miller Method AND ASD
YouTube
Miller Method
Miller Method Autism

6. -Philosophy of the Miller Method (“What is Miller Method?,” 2009)
“We maintain that each child – no matter how withdrawn or disorganized – is trying to find a way to cope with the world.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.”
-Philosophy of the Miller Method
(“What is Miller Method?,” 2009)

7. What is the Miller Method?
An integrated approach that addresses problems of body organization, social interaction, and communication in school, clinic, and home settings as presented by children on the autism spectrum
Cognitive-developmental systems theory
(Miller & Eller-Miller, 2000)

8. Founders Arnold Miller, Ph.D.
Director of Language and Cognitive Development Center (LCDC)
Affiliate Professor of Psychology, Clark University
Received his doctorate in clinical psychology from Clark University.
(“About the Millers,” 2009)

9. Founders Eileen Eller-Miller, M.A., C.C.C.-S.L.P
Education Director of LCDC until her death in 2004
M.A. in speech and language pathology from Columbia University
(“About the Millers,” 2009)

10. History Heinz Werner (mentor from 1954-1964)
For the next 45 years, the husband-wife team built on Werner’s developmental “theory”
Founded Language and Cognitive Development Center (LCDC) in Boston, MA in 1965
Rewarded research and demonstration grants from the U.S. Department of Education to help “developmentally challenged children achieve their fullest potential”
(“About the Millers/What and where is the LCDC” 2009,

11. Central Concepts: Systems
“Organized, coherent ‘chunks’ of behavior that are, initially, quite repetitive”
Mini-systems
Integrative systems
Broken systems
“Unlike typical children, those on the autistic spectrum show system aberrations that interfere with performance and development…this means that before such children can progress, careful attention must be given to their system problems.”
(Miller & Eller-Miller, 2000, p )

12. Central Concepts: Executive Function
“Emerging capacity”
Initially, systems are driven by external events
Gradually, the child deliberately forms systems based on an inner plan
Choosing one system over another
Altering systems
Combine previously developed systems
The failure for this shift to occur  Developmental Delays
(Miller & Eller-Miller, 2000)

13. Central Concepts: System Disorders
Type A
Type B
Closed-system
Dominated by only a few systems; unable to respond to any stimuli not related to their current system
Minimal executive functioning
Have multiple systems; move from one system to another; prohibit others from entering their systems
Executive functioning with many objects/systems
System-forming
Unable to form systems due to poor sensory-motor coordination
Unable to form systems because “too sensorily driven” by various stimuli
Little executive functioning
(Miller & Eller-Miller, 2000)

14. What does the Miller Method claim to do?
Help children achieve executive control over their systems
Help children enrich their limited systems
Helps children with disabilities restore to typical developmental progressions
This can only be done through body awareness
Rough and tumble activities
Mutual face touching
Deep pressure
Swinging
Elevation
(Miller & Eller-Miller, 2000)

15. -Cognitive Designs, Inc.
“Children unable to follow directions often began for the first time – when elevated – to respond to manual signs and spoken words.”
-Cognitive Designs, Inc.

16. The Elevated Square 5 ft x 8 ft 2.5 ft high Middle Steps Slide
Stations at each corner
(Miller & Eller-Miller, 2000)

17. The Elevated Square Up
Limits the child’s options for movement, which improves
Eye contact
Direction following
Sign-word relationships
Body awareness
Motor-planning
Social-emotional contact
Focus
Ability to cope with obstacles
Attention to surroundings
Problem solving
(Cognitive Designs, Inc., 2008d; Miller & Eller-Miller, 2000)
Around
Sit down
Down

18. The Elevated Square Closed-system disorders System-forming disorders
Expand systems
Move from one system to another
Including others in the system
System-forming disorders
External organization so the child can function
(Miller & Eller-Miller, 2000)

19. The Elevated Square Walking short and long sides Turning corners
Responding to directions
Turning corners
Changing circumstances
Coping
Understanding detours
Noticing gaps
Navigating
(Miller & Eller-Miller, 2000)

20. “We chose sign language to link action to spoken language after preliminary research indicated that body gestures could facilitate spoken language.”
-Arnold Miller and Eileen Eller-Miller
(Miller & Eller-Miller, 1973, p. 74)

21. Sign and Spoken Language Program
Relates objects and events to signs and spoken words
Manual signs adapted from American Sign Language
4 segments
Actions
Food
Familiar Objects/Events
Two-word Combinations
(Cognitive Designs, Inc., 2008b)

22. Symbol Accentuation Reading Program
Children who can speak or sign 2-3 word phrases but cannot read or write
Phase 1: Establishing sight words -
Phase 2: Transition to Phonetic Reading - “Sam and the Boys”
Phase 3: Phonetic Reading and Writing -
(Cognitive Designs, Inc., 2008c)

23. Sam and the Boys
(Cognitive Designs, Inc., 2008c)

24. Multispheres
Sphere – “Any activity that we introduce repetitively with the expectation that the child will ‘take it over’ and transform it into an internalized system”
“Out of sight out of mind”
Child engaged in a sphere
Interrupt the activity at maximal tension
Tension state: Introduce second sphere
Repeat
(Miller & Eller-Miller, 2000)

25. Receptive Language
Helps children who are “word deaf” – not possible to guide his behaviors by using solely words
Repeating the appropriate word while the child is performing the action
Narrating what the child is doing as he is performing an action
“Vygotsky test” passes-the-vygotsky
Differentiating objects at a distance by pointing, touching it with a long stick, or squirting it with water
(Miller & Eller-Miller, 2000)

26. Expressive Language Interrupting situations to elicit signs or words
E.g., on elevated square, “scavenger hunts,” videotapes in action
The use of signs “pulls” spoken language and contributes to language development
Using your hands
Using tools to extend the reach of hands
Using gestures that simulate actions
Spoken words
(Miller, 2002b; Miller & Eller-Miller, 2000)

27. Success Depends On… The child’s age Neurological status
The child’s relationship with his parents
System characteristics
Support demand stance
(Miller & Eller-Miller, 2000)

28. Miller & Eller-Miller (1989) The Umwelt Assessment
Determines present system functioning through 16 tasks – “provides information as to the relative emphasis the child places on things as opposed to people” (Miller, 1996, Spring/Summer)
2-3 hours
Oral summary of findings + video
Recommendations sent within 2-3 weeks
$1000
“Parents or caregivers are directly involved in the assessment and often contribute information which allows the examiner to gain access to the child’s functioning” (“For parents/caregivers of children with autism or PDD, 2009, )

29. The Umwelt Assessment Capacity to interact with a person and an object
Capacity to adapt to change
Problem solving and learning from experience
(Miller & Eller-Miller, 1989)

30. Miller Diagnostic Survey
Survey that gathers information about the child so a program can be created for the child
107 Likert-type questions about behaviors from earlier and current stages of development
Completed by parents before and after a school year at LCDC
Computer program organizes the responses – “A statistical analysis comparing the two developmental profiles will determine which changes in scored categories are statistically significant” (Miller, 2002)
LCDC staff member writes a report of recommendations
$100
(Miller, 2002c, Spring/Summer, “Miller diagnostic survey,” 2009,

31. Miller Diagnostic Survey
Disclaimer. While the MDS has been shown scientifically to be both a valid and reliable instrument, it is not a substitute for direct, face-to-face evaluation of a child by a qualified professional. The formulations derived from parents responses to MDS questions, should be viewed as useful preliminary formulations that need to be confirmed by face-to-face assessments.
(“Miller diagnostic survey,” 2009,

32. Training in the Miller Method
Workshops
LCDC
4 days
Provide “dramatic alternatives to behavioral approaches [and] ‘compliance training,’ which assumes that children must first sit at a table before they can learn”
(“For professionals seeking training in the Miller method,” 2009,

33. Training in the Miller Method
Certification: Miller Method Specialist
Professional discipline in one of the following areas: clinical or developmental psychology, pediatric nursing, occupational therapy, physical therapy, psychiatry, social work, special education, speech and language pathology
Workshop participation
Supervision – 50 weeks, 1 hour per week
3 case studies
Written examination of “searching questions”
(“For professionals seeking training in the Miller method,” 2009,

34. Training in the Miller Method
Parent-Child Training
12 hours over 3 days
Distance Consultation
Video conferencing
Phone consultation
Internet consultation
/video-conferencing
(“Distance consultation,” 2009,

35. PsycINFO Yielded 3 results… 1 textbook 2 doctoral dissertations
Cook, C. E. (1998)
Qualitative study
Data collection procedures: videotapes, staff interviews & journals, parent interviews
Shore, S. M. (2008)
Study design: written survey, recorded interviews

36. Miller & Eller-Miller (1973)
Literature review (preliminary research)
Participants – 19 children with autism, average 11 years old
Body awareness – “This was apparent in the sudden cessation of autistic mannerisms, the steadiness of eye contact” (p. 70)
50 functional signs
Procedure – 1 hour per day on school days
Generalization – High levels, low levels, ground, different rooms, outside

37. Miller & Eller-Miller (1973)
Results
One-sign words – “All children could respond appropriately” (p. 77)
Two-sign words – “The children seemed somewhat less able to understand and respond appropriately” (p. 78)
Intercorrelations
Length of time in program
Age

38. Miller & Eller-Miller (1973)
3 case studies
E.g., “Philip’s parents report that most of his bizarre mannerisms have disappeared” (p. 81)
Conclusions
“Even severely autistic children can benefit from the present approach” (p. 82)
However… “We cannot answer these questions decisively because we have not conducted a controlled study in which all factors but the use of the boards are held constant. Our clinical observations, however, support the importance of elevated boards” (p. 82)

39. Testimonials
“She would scream a lot and tantrum…but in the second week of the program she made her first sign…from that time everyday she would come up with a new sign.” –Angela Bogus’ mother
“Approximately four months after Johnny started the school year, he started to speak…in my heart, I know that if I did not bring Johnny to LCDC he may have never learned to talk.” –Janet Abramson, mother
“I discovered the Miller Method on the Internet, then arranged to come to Boston for an Umwelt Assessment…my son now does chores willingly, he is productive and helps around the house…there is not enough I can say about these wonderful people who have virtually saved my son’s life.” –Shirley Simmons, mother
(Miller, 1998, Fall/Winter; Miller, 1999, Summer; Miller, 2007, Spring/Summer)

40. -Cognitive Designs, Inc. http://www.cognitivedesigns.com/video.html
“If we view such aberrant behaviors [stereotypy] as asocial or ‘bad’ then we follow the path of behaviorists who try to make the children look as normal as possible by having them sit quietly in their seats like typical children.”
-Cognitive Designs, Inc.

41. ABA vs. Miller Method

42. Miller (1996, 2002a) ABA Miller Method Built on the foundations of…
B.F. Skinner and animal research
Developmental psychologists Werner, Vygotsky, & Piaget
How children with autism are taught
Prerequisite of sitting quietly at a desk they can be taught
Their entire bodies should be used actively and repetitively while narrating/signing what they are doing – “like a sports announcer”
Attitude toward learning
“Compliance training” –rewarded for sitting at the table; undesirable behavior punished through ignoring or aversive measures
Importance of using the entire body (e.g., by climbing on elevated structures) to improve attention and focus

43. Miller (1996, 2002) ABA Miller Method Definition of Stereotypy
Negative, abnormal-looking behaviors that must be extinguished immediately; serve no immediately apparent function
Valuable sources of organized, integrated behavior that must be expanded so they can become more functional; the very best behaviors that children can manage
Treatment of Disruptive Behavior
Ignore it or place the child in time out until the child is “ready” to rejoin the group – “this merely intensifies the child’s autistic isolation”
Breakdown of child’s ability to cope; providing nurturing “special time,” introduce a repetitive and calming ritual

44. Comparing ABA with the Miller Method

45. Green (2008) Evidence-Based Practice
Relies on scientific methods to separate opinions and speculations from demonstrated facts
Direct testing of interventions
Controlled (experimental) analyses comparing the intervention to no intervention
Objective and reliable measurement of the intervention and its effects
Replications by multiple investigators, not just one person or group – especially if they are the developers/principle promoters of the intervention
Publication in peer-reviewed journals

46. Green (2008) Non-Evidence-Based Practice
Indirect, subjective evaluations
Uncontrolled, descriptive studies
No comparison of control and treatment conditions
Reports in self-published books or journals
Self-reports, anecdotes, and testimonials in books, workshop handouts, media reports, and websites
Theories based on speculations

47. Miller Method References
About the Millers. (2009). Retrieved from
Cook, C. E. (1998). Implementation of the Miller method in an early intervention program for children with pervasive developmental disorder (PDD): A case study. (Doctoral dissertation, Kent State University). Retreived from xtopics=56&maxpubs=32&sq=STYPE%28dissertation%29+AND+AU%28Cook%2C+Christine+Elizabeth %29&RQT=309&xsq=STYPE%28dissertation%29+AND+AU%28Cook%2C+Christine+Elizabeth%29&did= &skip=1&rqt=309&vinst=PROD&mfgquery=STYPE%28dissertation%29+AND+AU%28Cook% 2C+Christine+Elizabeth%29&fmt=6&ssm=S&startpage=- 1&vname=PQD&sortby=N&vtype=PQD&TS= &clientId=5222
Cognitive Designs, Inc. (2008a). CDI video library. Retrieved from
Cognitive Designs, Inc. (2008b). Sign and spoken language program. Retrieved from
Cognitive Designs, Inc. (2008c). Symbol accentuation reading program. Retrieved from

48. Miller Method References
Cognitive Designs, Inc. (2000d). Symbolic playthings. Retrieved from Discussion forum. (2009). Retrieved from Distance consultation. (2009). Retrieved from For parents/caregivers of children with autism or PDD. (2009). Retrieved from For professionals seeking training in the Miller method. (2009). Retrieved from Green, G. (2008). Evidence-based practice: Improvement or illusion? Association for Behavior Analysts International Autism Conference, Atlanta, GA.

49. Miller Method References
Key publications. (2009). Retrieved from Miller, A. (1996, Spring/Summer). The Miller umwelt assessment. The Miller Method Newsletter. Retrieved from Miller, A. (1996, Fall). Contrasting the Miller method with behavior modification. The Miller Method Newsletter. Retrieved from Miller, A. (1997, Spring). First independent Miller method outcome study. The Miller Method Newsletter. Retrieved from Miller, A. (1998, Fall/Winter). Angela returns to LCDC/Lynnfield. The Miller Method Newsletter. Retrieved from Miller, A. (1999, Summer). A mother’s thanks. The Miller Method Newsletter. Retrieved from Miller, A. ( , Winter/Spring). Elevation study under way at LCDC. The Miller Method Newsletter. Retrieved from

50. Miller Method References
Miller, A. (2002a, Spring/Summer). Contrasting the Miller method with the ABA approach. The Miller Method Newsletter. Retrieved from Miller, A. (2002b, Spring/Summer). The LCDC story. The Miller Method Newsletter. Retrieved from Miller, A. (2002c, Spring/Summer). The Miller diagnostic survey (MDS): Two major issues in the field. The Miller Method Newsletter. Retrieved from Miller, A. (2007, Winter/Spring). Letter from a parent whose child attended LCDC. The Miller Method Newsletter. Retrieved from Miller, A., & Eller-Miller, E. (1973). Cognitive-developmental training with elevated boards and sign language. Journal of Autism and Childhood Schizophrenia, 3(1), Retrieved from Miller, A., & Eller-Miller, E. (1989). From ritual to repertoire: A cognitive-developmental systems approach with behavior-disordered children. New York: John Wiley & Sons, Inc.

51. Miller Method References
Miller, A., & Eller-Miller, E. (2000). The Miller method: A cognitive-developmental systems approach for children with body organization, social, and communication issues. The interdisciplinary council on developmental and learning disorders: Clinical practice guidelines: Redefining the standards of care for infants, children, and families with special needs. (pp ). Retrieved from
Miller diagnostic survey. (2009). Retrieved from
Shore, S. M. (2008). Examining five promising approaches for treating children with autism spectrum disorders. (Doctoral Dissertation, Boston University). Retrieved from axtopics=56&maxpubs=32&sq=STYPE%28dissertation%29+AND+AU%28Shore%2C+Stephen+Mark%2 9&RQT=309&xsq=STYPE%28dissertation%29+AND+AU%28Shore%2C+Stephen+Mark%29&did= &skip=1&rqt=309&vinst=PROD&mfgquery=STYPE%28dissertation%29+AND+AU%28Shore%2C +Stephen+Mark%29&fmt=6&ssm=S&startpage=- 1&vname=PQD&sortby=N&vtype=PQD&TS= &clientId=5222
What and where is the LCDC?. (2009). Retrieved from
What is Miller method?. (2009). Retrieved from

52. Relationship Development Intervention (RDI)

53. RDI Overview What is it? – Definition, history, central concepts
What does RDI claim to do…and HOW is this done?
What research support does it have?
Is it a worthwhile intervention?

54. Search Criteria PsycINFO YouTube http://www.rdiconnect.com/
Relationship Development Intervention AND autis*
Relationship Development Intervention AND developmental dis*
Relationship Development Intervention AND ASD
RDI AND autis*
RDI AND developmental dis*
RDI AND ASD
YouTube
Relationship Development Intervention
RDI

55. Books

56. -Steven E. Gutstein (Gutstein, 2000)
“…regardless of his or her abilities and limits, there was something more I wanted to give them [children with autism]. I wanted my patients to smile when I walked into the waiting room, because they were happy to see me, not because they received an M&M as a reward.”
-Steven E. Gutstein
(Gutstein, 2000)

57. Founder & History Steven E. Gutstein
Ph.D. in clinical psychology from Case Western Reserve University
20 years studying relationships as a child, marital, and family therapist
Rationale for creating this intervention:
First book on RDI published in 2001
As of 2009: families in 16 countries are practicing RDI
(Gutstein, 2002; Gutstein, 2009)

58. What is RDI?
Teaches children with autism the value of interpersonal relationships
Shared experiences
Parent-directed, NOT a direct intervention for children
(Freeman, 2007; RDI Program Standards and Code of Ethics, 2008)

59. What is RDI?
Parents learn the techniques through videotapes, consultants, and books
Parents conduct 9 hours of therapy per week
Simple shared interactions
Distraction-free environments, move to more typical settings
(Freeman, 2007)

60. RDI in Action Emotion sharing with Mommy Building blocks with Dad
4&feature=related
Building blocks with Dad
o&feature=related

61. Parent Roles Slow down communication
Avoid over-talking, frequent questioning, and prompting
Simplify physical environments
Slow down the pace of daily activities
Provide opportunities for experience-sharing
Journaling and reflection on a regular basis
(Gutstein, 2005; RDI Program Standards and Code of Ethics, 2008)

62. What does RDI claim to do?
Help develop emotional feedback systems
Increase guided participation
Fix dynamic intelligence, the core deficit of autism
Establish neural pathways in the area of the brain that regulates emotion and motivation
(Freeman, 2007; Gutstein, 2009; Gustein, 2005)

63. RDI claims that children with autism will…
Make true friends who genuinely appreciate them
Communicate more creatively (communication will become less scripted)
Receive more invitations and have more desire to accept them
Become good collaborators and valued team members
Make meaningful contributions to others’ lives
Become more fun to teach
View their parents as real people versus as objects
Allow feelings versus scripts to guide their actions
(Gutstein, 2002b)

64. RDI claims that children with autism will…
Act in more flexible manners and be more accepting of change and transitions
Become more curious about discovering new features of their worlds
Consider several alternative solutions to problems
Think in terms of “gray” areas (versus “right or wrong, black or white”)
Seek out and value others’ perspectives and opinions
Be more aware of their unique identities
(Gutstein, 2002b)

65. What research support does RDI claim to have?
ONE peer-reviewed journal article
Between-subject design
17 children with ASD in treatment group
Received RDI therapy
14 children with ASD in control group
Unspecified behavioral intervention or social skill group
Children in treatment group scored higher on the Autism Diagnostic Observation Scale
Children in the treatment group were more likely to transition from special to general education
(Freeman, 2007)

66. HOWEVER… Small treatment group sample
No random assignments, no subject matching
Children in the treatment group…
“High functioning,” no significant cognitive impairments
One year younger
Higher IQ’s (an average of 12 points higher!)
More children with Asperger’s Syndrome
Did all children benefit?
(Freeman, 2007)

67. Is RDI a worthwhile treatment?
Freeman, 2007:
“Based on the scientific research to date, there is not enough evidence that RDI is an effective treatment for decreasing the symptoms associated with autism” (p. 156)

68. Is RDI a worthwhile treatment?
Association for Science in Autism Treatment, 2010
“Preliminary data that may support this intervention are cited on the developers’ website and in one published but uncontrolled study (Gutstein, Burgess, & Montfort, 2007). However, the intervention has not been evaluated in peer-reviewed studies with strong experimental designs.”
“Researchers may wish to conduct studies with strong scientific designs to evaluate Relationship Development Intervention. Professionals should present this intervention as untested and encourage families who are considering this intervention to evaluate it carefully.”

69. RDI References
Freeman, S. K. (2007). The complete guide to autism treatments: A parent’s handbook: Make sure your child gets what works! Lynden, WA: SKF Books USA, Inc. Gutstein, S. E. (2000). Autism Aspergers: Solving the relationship puzzle. Arlington, TX: Future Horizons, Inc. Gutstein, S. E. (2005). Relationship development intervention: Developing a treatment program to address the unique social and emotional deficits in autism spectrum disorders. Autsim Spectrum Quarterly, Gutstein, S. E. (2007). Evaluation of the relationship development intervention program. Autism, 11 (5), Gutstein, S. E. (2009). Empowering families through Relationship Development Intervention: An important part of the biopsychosocial management of autism spectrum disorders. Annuals of Clinical Psychiatry, 21 (3), Gutstein, S. E., & Sheeley, R. K. (2002a). Relationship development intervention with children, adolescents, and adults. New York: Jessica Kingsley Publishers Gutstein, S. E., & Sheeley, R. K. (2002b). Relationship development intervention with young children. New York: Jessica Kingsley Publishers RDI Program Standards and Code of Ethics (2008).

70. Question Period