A Review of The Miller Method for Autism Treatment

1. A Review of The Miller Method for Autism Treatment Christine Buckley Alexis Hershkowitz Nicole Moinhos Caldwell College Graduate Programs in Applied Behavior Analysis

2. The Miller Method® Philosophy “We maintain that each child--no matter how withdrawn or disorganized--is trying to find a way to cope with the world.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)

3. 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

4. Who are Dr. Arnold Miller & Eileen Eller-Miller? • Married for 45 years, together created The Miller Method® and founded the LCDC • Dr. Arnold Miller • Director of the LCDC of Boston • Affiliate Professor of Psychology at Clark University where he received his doctorate in clinical psychology • Research appointments at Boston University & Harvard Medical School • Was a faculty member of the University of Montana • Directed the Language Development Laboratory at Wrentham State School, Massachusetts • Eileen Eller-Miller • Education Director of the LCDC • M.A. in speech and language pathology from Columbia University • B.A. in psychology from City University of New York • Worked at Flower Fifth Avenue Hospital, Beth Abraham and Hunter College in New York City (www.millermethod.org)

5. 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)

6. 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 • Certified Miller Method specialist or therapist on staff • Ongoing consultative relationship with a senior staff member from LCDC

7. Certification (cont’d) • Appropriate candidates for certification • Clinical/Developmental Psychologists • Psychiatrists • Social Workers • Pediatric nurses • Occupational therapists • Physical therapists • Special educators • Speech and Language Pathologists • Several ways to train • 4-Day Workshops at LCDC • Videoconference Workshops • Qualifications for certification • 4-day training workshops at LCDC • 50 weeks (1 hour per week) of supervised training • Cases covered • Written examination

8. 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)

9. 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.

10. 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

11. Ritual Systems • Based on cognitive-developmental systems theory • MM works with systems • System: any organized behavior with an object or even that the child produces • Are directed, are organized, and lead to some outcome • Viewed as organized “chunks” of behavior, perception, or thought • Rituals are systems • Developed properly, can help a child move from atypical to more typical functioning (Miller, A. & Chretien, K., 2007)

12. 4 Types of Systems • Body systems: Coordinate sensory capacities with motor capacities in the service of a particular function. • Social systems: How two people interact with each other, whether by working together, turn-taking, competing, or bonding • Communication systems: The integration of words and actions around objects in relation to another person • Symbolic systems: The way in which a child organizes the relation between symbols and what they represent (Miller, A. & Chretien, K., 2007)

13. Order and Disorder • Order: Predictable systems • Disorder: Disruption of systems • Two types of Disorder in children with autism • 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. • 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

14. Three Types of Disorder • 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. • Moderate disorder: The interruption of systems in a way in which induces a compensatory reaction on the child’s part to maintain the system • 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)

15. Characteristics of Systems • Once a system has been constructed, each system tends to maintain its reason • Differ from each other • Rigidity: How urgent the child’s need is to maintain a system unchanged • Complexity: Whether the system is simple (a minisystem) or more complex (an integrative system) • Distance reality: Extent to which children substitute symbols for direct physical contact with a person, object, or event (Miller, A. & Chretien, K., 2007)

16. 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 • Miller Diagnostics Survey (MDS) • Miller Umwelt Assessment Scale

17. 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 • Sensory reactivity • Body organization • Problem solving and tool use • Communication • Symbolic functioning

18. MDS: Unique Instrument • 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 • 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 • 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)

19. 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

20. 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)

21. 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)

22. 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)

23. Assessment • Miller Umwelt Assessment Scale • Miller Diagnostic Survey • Parent Survey • Teacher/Instructor Survey

24. 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

25. 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.

26. 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

27. 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

28. 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

29. Contrasting Children with Closed-System and System-Forming Disorders

30. Use of Systems • Each system is a set of behaviors that accomplishes something (whether social or for self) • Interruption of Systems= language opportunity

31. 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

32. 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

33. 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

34. The Elevated Square • 2 ½ feet above ground and a 5 foot by 8 foot structure • Colorful and main focus of the room

35. 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

36. 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

37. Reasons for the Elevated Square • Undefined reality to highly defined • Body awareness • Constraint on child’s actions • “Edge Experience” • Eye contact leveled

38. Purpose for system disorders for the Elevated Square • Systems-Forming disorders • External organization • Closed Systems disorders • Framework taught to expand their systems

39. Andrew on the Elevated Square • www.millermethod.org

40. 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

41. 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 10-12 times

42. 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

43. 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

44. 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

45. 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

46. 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

47. Communication • Extending System principles • Uses Hand over Hand with words and a reinforcer • Come Example

48. Education • Building self/body awareness will lead to education • Uses same creating systems strategy

49. 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 ***

50. 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