Milieu Therapy as a Communication Intervention: A Review of the Literature Related to Children with Autism Spectrum Disorder

Several researchers have employed milieu therapy to address the communication needs of children with autism spectrum disorder (ASD). Thus, the purpose of this review is to examine milieu therapy, particularly, the environments and individuals involved in the training and the effectiveness of milieu therapy with children who have a diagnosis of ASD and to provide suggestions for practitioners and researchers. Milieu therapy consistently increases communication and generalizes to other settings, while maintaining over time; however, milieu therapy does not analyze connections to challenging behaviors and few studies have focused on teachers in the classroom or peers. Future research teams should continue to train parents and teachers while addressing the connection to challenging behavior and including peers in the interventions. ASD is a developmental disorder affecting the lives of thousands of children. ASD was first described by Leo Kanner in 1943 through the case histories of 11 children. Kanner observed that the characteristics of these children differed significantly from other children; therefore, he suggested a separate diagnosis entity was needed to describe their unique characteristics. Since Kanner’s first description of autism, the disorder has evolved into a spectrum disorder (i.e., ASD) with the number and percentage of diagnoses increasing each year (Autism Society of America, 2007). According to the Autism Society of America (2007) and the Centers for Disease Control and Prevention (CDC), 1 in 150 children born today will eventually be diagnosed with ASD (Autism Society of America). The Autism Society of America (ASA) also notes that 1.5 million Americans including children and adults have ASD, while another 15 million Americans (e.g., family, educators, and health care workers) are affected by this disorder. In sum, the incidence and prevalence rates of ASD appear to be growing at high rates. The essential features of ASD include significant impairments in social interaction and communication skills and a highly restricted area of activities and interests (American Psychiatric Association, 2000). Social interaction problems may be exhibited through an impairment in nonverbal behaviors (e.g., eye to eye gaze, body postures, facial expressions) and/or failure to create developmentally appropriate peer relationships. For example, a child with ASD is less likely to initiate peerrelated social interactions or respond to social bids from peers. In addition to social interaction problems, children with ASD have communication skill deficits. Often, these deficits include a delay in or absence of spoken language (e.g., 40% never obtain speech). Children that do develop speech may have difficulty initiating or sustaining conversations with others. Further, these children may develop stereotyped and repetitive use of language or idiosyncratic language (e.g., repeating nonfunctional phrases over and over). Coinciding with impairments in social interaction and communication, children with ASD may exhibit restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. They often demonstrate a preoccuCorrespondence concerning this article should be addressed to G. Richmond Mancil, Kelly Autism Program, College of Education and Behavioral Sciences, Western Kentucky University, Tate Page Hall 347, 1906 College Height Blvd. #71030, Bowling Green, KY 42101–1030. Email: rich.mancil@ wku.edu Education and Training in Developmental Disabilities, 2009, 44(1), 105–117 © Division on Developmental Disabilities Milieu Therapy / 105 pation with idiosyncratic interests to a level considered abnormal in intensity and focus (American Psychiatric Association, 2000). For example, a child may know every fact about the makes and models of cars and sustain conversations related to this topic for hours, but remain unable to hold conversations about any other topic. They also may engage in inflexible, nonfunctional rituals and routines such as turning a doorknob over and over in each direction before leaving their home. Although these rituals and routines initially may appear to decrease anxiety, the routines typically impede an individual’s ability to socialize and function properly within society (Heflin & Alaimo, 2006). Further, many children with ASD have stereotyped and repetitive motor mannerisms (e.g., hand flapping). For example, a child may engage in repeated hand flapping, for no apparent purpose. Concurrent with the aforementioned features, many children with ASD exhibit high levels of challenging behaviors toward others or themselves that interfere with their learning, such as screaming, hitting, and biting (Sigafoos, 2000). For instance, some children may repeatedly bite themselves or they may aggress toward other children or adults (e.g., scratch others). Challenging behaviors such as biting create substantial obstacles for individuals responsible with their education and care (Durand & Merges, 2001). Many parents experience stress when their children engage in aggression or tantrums. Unlike other parents, parents of children with ASD may have difficulty determining the reason for the tantrum because of the child’s deficits in communication. It is difficult for an individual who does not have any communication skills to explain what may be the cause of the tantrum. These characteristics (i.e., social interaction impairments, communication deficits, repetitive behaviors, and challenging behaviors) and their negative effects on the children and families combined with the increase in the prevalence of ASD present a critical demand for the field of special education to respond and provide effective practices to meet these children’s needs at home and in educational settings. One area of important research is investigating methods aimed at increasing communication skills, decreasing challenging behavior, and determining the relation between communication abilities and challenging behaviors. A number of researchers have responded by examining the relation between challenging behaviors and communication abilities of children with ASD (e.g., see Bott, Farmer, & Rhode, 1997; Chung, Jenner, Chamberlain, & Corbett, 1995; Sigafoos, 2000; Schroeder, Schroeder, Smith, & Dalldorf, 1978). Chung et al. found an inverse relation between communication ability and the display of challenging behaviors such as self-injury and aggression in children with ASD. Similarly, Bott et al. (1997) determined that individuals with more developed speech skills exhibited a lower rate of challenging behaviors than those with impaired speech skills. Further, Sigafoos hypothesized in a more recent study that impaired communication development in children with ASD and other developmental disabilities may actually cause challenging behaviors. He suggested that when children lack the appropriate skills to communicate, they might actually use challenging behaviors for communication purposes. To address the communication needs of children with ASD, several researchers employed milieu therapy. Milieu therapy is supported by a plethora of studies demonstrating that it has been effectively used to teach communication skills to children with developmental disabilities and/or communication disorders (e.g., Hester, Kaiser, Alpert, & Whiteman, 1995; Yoder & Warren, 2002) and to a lesser extent, children with ASD (e.g., Hancock & Kaiser, 2002; Ross & Greer, 2003). In milieu therapy, the focus is teaching children new skills and behaviors within their natural environments (Kaiser, 1993). The natural environment may refer to any setting that the child would naturally spend time regardless of his or her disability, including the home, school, or an inclusive educational setting (Schwartz, 2003). As demonstrated in the literature, teaching communication skills in natural environments has many advantages including: (a) increases in vocabulary (Yoder et al., 1995), (b) generalization (Hancock & Kaiser), (c) maintenance (Spradlin & Siegel, 1982), and (d) unprompted use of language (Yoder & Warren). Milieu therapy includes the following basic procedures: (a) providing a model of desired 106 / Education and Training in Developmental Disabilities-March 2009 responses and correcting child responses, (b) providing a mand and then modeling/correcting if needed, (c) using a time delay, and (d) employing incidental teaching strategies (Hancock & Kaiser, 2002). One of the strategies used in milieu therapy to promote communication in natural environments is modeling correct responses and correcting the target child’s responses. This involves modeling a target behavior and then providing correction to the child as necessary (Alpert & Kaiser, 1992). For example, while outside on the playground, a child may tap on the adult’s arm and look at the toy dump truck. The adult gains the child’s attention and provides a verbal prompt that matches the child’s communication skill level, such as Want truck? If the child says, Want truck, the adult provides praise, repeats the child’s phrase (e.g., says, yes, want truck) and provides the child the toy dump truck. Otherwise, the adult provides a corrective model repeatedly, Want truck until the target child correctly models the response. However, if the child does not respond in a reasonable time frame (e.g., two to three seconds), as predetermined by the researcher, parent, and/or teacher, the adult provides a model and gives the object to the child. The purpose of modeling and correcting responses is to provide the target child the necessary prompts and instructions in natural situations to assist in skill development. Another component of milieu therapy is the mand-model technique. The mand-model technique involves giving a direct instruction (commonly referred to in the literature as a mand) within a naturally occurring activity and context (Charlop & Walsh, 1986). The mand is a vocal operant that is maintained by a reinforcer (e.g., obtaining a preferred item such as a toy car) and is evoked by the discriminative stimuli for that reinforcer (Skinner, 1957). For example, if a child says, Water please and receives the water, it is likely that this is a mand. Also, it is important to recognize that responses are deemed mands based on their controlling variables and not on their topography. Sign language and picture cards can function as mands the same as vocal responses function as mands. When necessary, this mand would be followed by a model and a correction similar to the description above. The mand-model is performed by first gaining the child’s attention and then providing a prompt for a target behavior. After the prompt, a guided model (i.e., assisting the child in performing the target behavior) is provided when necessary. For instance, a child is given apple juice for snack and reaches to pick it up with his hands. The adult provides a response block (e.g., blocks his hands), obtains the child’s attention, and says, Tell me what you want (mand), places the communication card with the picture of juice on it in the child’s hand, and physically guides his hand to the adult who has the apple juice (corrective model). If the child continues to ask for juice by using the picture card, the adult provides the juice paired with positive praise (e.g., Good job asking). If the child attempts to grab the juice again without using the communication card, the adult repeats the process. The purpose of the mand/model strategy is to develop independent skills by providing the child with a prompt and an example of performing the communicative response correctly. The adult continues with this procedure until a performance criterion is met (e.g., child perform the task correctly for two days). Time delay is another procedure often used in milieu therapy that involves the adult providing a stimulus and then waiting approximately 5 to 30 seconds, based on the child’s developmental and mental age, for a childinitiated response (Kaiser, 1993). Time delay typically is combined with other techniques such as the mand-model. If the child does not respond, the adult provides a mand-model. For example, a child may want his coat, but need help getting it from the shelf. While attending to the child, the adult waits for a period of 5 to 30 seconds (depending on the child’s developmental level) for the child to request help. If the child requests by using a communicative response such as a picture card or vocalization, the adult provides immediate praise and a correct model, you want your coat? If the child does not independently request help within the time delay, the adult provides a mand-model. The amount of time delay chosen depends on the child’s level. The longer the wait period, the greater the chance of losing the child’s interest; therefore, care is needed in choosing the appropriate time delay. The purpose of time delay is to decrease the child’s dependence on adult Milieu Therapy / 107 prompting, instructions, and models; thus, promoting independent and spontaneous (i.e., unprompted) communication. Incidental teaching is another strategy often employed within the framework of milieu therapy. Incidental teaching is a process where communication skills are learned in naturally occurring interactions or interactions arranged in natural contexts, which may be the reason the terms incidental teaching and milieu therapy have been used interchangeably at times. Hart and Risley (1968; 1975) described incidental teaching as an interaction between an adult (e.g., parent) and a child during unstructured situations such as free play where the child controls the incidences in which teaching occurs by signaling interest in the environment. For example, while playing with toy cars, a child may point to a car and say, ca. The adult reinforces this behavior by providing positive praise and giving the child the toy car. Incidental teaching typically is combined with the other procedures and is applied during situations when children are requesting either vocally or non-vocally. Prompts are provided if necessary. Further, access to desired objects is contingent upon correct responses, which are followed by behavior specific praise. For example, an adult may create a situation by “accidentally” forgetting to give a child her milk during snack (i.e., sabotaging the environment). The adult then would use the aforementioned techniques to enhance communication by giving a prompt when needed, praising the child for correct responses, and giving the child the milk (contingent access) for correct responses. The purpose of incidental teaching is to promote fluency and expand skills of children with delayed language skills, which may include children with ASD (e.g., see Hart & Risley, 1975; MacDuff, Krantz, MacDuff, & McClannahan, 1988). In sum, milieu therapy is one practice that researchers have used to successfully demonstrate an increase in communication skills of children with ASD. The focus in milieu therapy research has been teaching children new skills and behaviors within their natural environments (e.g., home and school). The research has been done using various combinations of the four procedures described above, which has resulted in skills generalizing to other settings and people. The majority of the research, however, has been conducted with children with language delays, not solely identified as having ASD, thus, making it difficult to generalize findings to children with ASD. Further, research has not focused on involving peers, which is crucial to increasing the social network of individuals and improving overall quality of life (Wagner, 1999). Thus, the purpose of this review is to examine milieu therapy, particularly, the environments and individuals involved in the training and the effectiveness of milieu therapy with children with ASD. First, analysis of the characteristics of the participants, environment, research designs, behaviors, interventions, major findings, reliability, and treatment fidelity across studies are provided. Second, a critique of the findings to address limitations and implications for future researchers and practitioners are provided.