KidTalk: Adapting Enhanced Milieu Teaching for Children with ASD CEC 2010

1. KidTalk: Adapting Enhanced Milieu Teaching for Children with ASDCEC 2010

2. Presenters • Ann Kaiser, Ph.D • Jennifer Nietfeld, M.A. • Courtney Wright, M.A., SLP-CCC

3. Agenda • Research and Key EMT Principles • Noticing and responding to child communication; balancing verbal turns • Modeling and expanding play • Modeling and expanding communication • Environmental arrangement strategies • Prompting strategies • Summarizing Adaptations for Children with EMT

4. Goals • Understand core principles and key procedures of EMT • Understand basic principles for adapting EMT for children with ASD

5. What is Enhanced Milieu Teaching? • EMT is an evidence-based intervention with 20 years of research. • EMT is a naturalistic, conversation-based intervention that uses child interests and initiations as opportunities to model and prompt language in everyday contexts. • EMT is an effective interventionchildren with ASD.

6. EMT Studies • Hancock, T.B., & Kaiser, A.P. (in press). Implementing Enhanced Milieu Teaching with • Children Who Have Autism Spectrum Disorders. In P. Prelock & R. McCauley (Eds.), Treatment of autism spectrum disorders: evidence-based intervention strategies for communication & social interaction. Baltimore: Paul Brookes • Hancock, T. B., & Kaiser, A. P. (2002) The effects of trainer-implemented enhanced milieu teaching on the social communication of children with autism. Topics in Early Childhood Special Education, 22, 39-54. • Kaiser, A. P., Hancock, T. B., & Nietfeld, J. P. (2000).The effects of parent-implemented enhanced milieu teachingon social communication of children who have autism. Early Education and Development, 11, 423-446. • McFarland, T. & Kaiser, A. P. (submitted). Naturalistic language intervention for at-risk siblings of children with autism. Journal of Autism and Developmental Disabilities. •  Olive, M.L., de la Cruz, B., Davis, T.N., Chan, J.M., Lang, R.B., O’Reilly, M.F., Dickson, S.M. (2007). The effects of enhanced milieu teaching and a voice output communication aid on the requesting of three children with autism. Journal of Autism and Developmental Disorders, 37, 1505-1513

7. Characteristics of Children with ASD • Restricted interests • Few play skills • Low or no joint attention • Reluctant participant in social communication • May be echolalic • May be prompt resistant

8. Adapting EMT to Children with ASD • Arrange environment to fit child’s interests and needs for support • Teach joint attention skills • Teach play • Prompt only when child requests • Individualize • Example Pre • Example Post

9. 8 EMT Strategies • Play and Engage • Noticing and responding to child communication • Take turns • Mirror and Map • Model and expanding play • Model and Expand communication • Environmental arrangement • Prompting

10. Strategy 1: Play and Engage • The first goal is to set up an interactive context between the adult and child. • Communication develops on a platform of shared joint attention and engagement. • Social interaction between child and adult • Play with objects and partner • Everyday routines where communication is functional

11. How to play and engage? • Be at the child’s level. • Do whatever the child is doing. • Follow the child’s lead. • Avoid directions and let the child lead the play. • Avoid questions and let the child initiate the communication. • Choose toys that are interesting and engaging. • Put away toys that aren’t being used. • Substitute undesired activities with desired activities.

12. Engage using joint attention • Non-verbal communication • Can be a precursor to verbal language • Engages the child with partner • Give • Show

13. Strategy 2: Notice and Respond to All Communication All children are communicating now • How? • Why? • Linguistic • Signs • Pictures • Symbols • Words • Prelinguistic • Point • Show • Give • Vocalizations • Reach • Lifts arms up • Shakes head Requesting Commenting

14. Notice and Respond to Communication • Notice and respond every time the child communicates. • Respond by talking about what the child is doing. • Language is most meaningful when it’s related to what the child is doing OR in response to what the child is communicating. • Example 1 • Example 2

15. Responding to chunk language • Longer than generative target level • Give correct model using generative language • Example 1

16. Strategy 3: Take Turns • Take turns communicating with the child. • Allow time for the child to communicate. • Play a game of “communication catch” • Child communicates • Adult responds (and waits) • Child communicates • Adult responds (and waits) • Only say something after the child communicates. • Video example

17. Strategy 4 :Mirror and Map • Use mirroring and mapping when the child is not communicating. • First imitate the action and then label the action with words. • Child : {feeds baby} • Adult: {feeds baby} we feed the baby some milk. • Example 1

18. What if he’s just stimming on a toy? • Try to bridge action to new action • Add a new toy • Model new action • Replace with equally motivating toy • What not to do

19. Let’s Review: Strategies 1, 2, 3, & 4 • Do what the child does, following his lead. • Make statements (no questions, no directions) • Respond when the child communicates. • Talk about what the child is doing. • Wait for communication. • Only talk after the child talks. • Use mirror/map and give/show to engage child

20. Strategy 5 :Model and Expand Play • Linking words with engaging activities maximizes opportunities for teaching language. • Choosing toys that are interesting keeps the child engaged. • Expanding play activities allows more language modeling and facilitates language learning.

21. Play Goals • Extend the time the child plays with a toy. • Expand the different actions the child does with the same toy. • Expand the types of different toys the child uses.

22. Play with what? • There are 3 levels of play: -Manipulative play • Putting together, taking apart, and combining objects in simple yet purposeful ways. • shape into shape sorter, dump blocks out, putting cars in cups -Pre-Symbolic play • Early themed play with pre-thought • feeding a baby, driving a car -Symbolic play • Complex combinations of play • Pretending there is food when there is not

23. When to model new play? • When the child is doing nothing. • When the child is doing the same action with the same object multiple times. • When the child is doing an undesired action with the toy (e.g., eating play-doh, hitting the baby, mouthing pretend food).

24. How to model and expand new play actions? • Add reality-based toys. Example • Do what the child does and try to add a different action or object. Example • Set a new toy object in sight or model a new action and WAIT and see if the child shows interest. Example • If the child shows interest, model a new play action with the object. Example • As always, follow the child’s lead and if the child is not interested, try again later with a different object or action. Example

25. Strategy 6 : Model and Expand Communication • Children learn language through modeling. • Contingent modeling that is in response to a child’ s communication is the most powerful form of modeling. • Simplifying language to match the child’s language targets helps the child learn language more quickly. • Easier to imitate • Saliency is increased • Video example

26. Language Goals • Increase the rate at which the child communicates • Increase the diversity of communication • Increase the child’s independence • Increase spontaneous communication • Decrease the dependence on adult cues

27. Choosing Communication Targets

28. Modeling Language Targets • 50% of what you say should be one of child’s targets: • 50% should be slightly higher than the child’s current targets • 1-2 words above his/her level • All words should be teaching words (nouns, verbs, modifiers)

29. Expanding communication • When the child communicates, imitate his/her communication and add target words. • Child: {points to ball} • Adult: {points to ball} [target]. • Child: ball • Adult: [target] • Expansions immediately connect the child’s communication to additional new language.

30. Expanding Words/Vocalizations • Words • Child: ball • Adult: roll ball • Vocalizations referring to a specific word • Child: {says “ah” and is pointing to cup} • Adult: {point to cup} [target]. • Vocalizations not referring to a specific word • Child: {says “ah” and is walking cow} • Adult: {walk the cow} [target].

31. Expanding Gestures • Point/reach: • Child: {points to/reaches for baby} • Adult: {points to baby/reaches for baby} [target] • Show • Child: {hold up block} • Adult: {points to block} [target] • Give • Child: {gives adult car to drive} • Adult: {takes the car} [target]

32. Review Strategies 5 & 6 • Do what the child does. • Model new play actions. • Model new target language with these actions. • Expand the child’s communication with target words.

33. Strategy 7: Use Environmental Arrangement • Non-verbal tasks that encourage the child to communicate with you. • Silly situations • Inadequate portions • Assistance • Waiting expectantly during a routine • Choice making • Sabotage

34. Why use EA strategies? • Provide the child with more opportunities to practice communicating. • Increases the child’s rate of communication • Provide you with more opportunities to reinforce and teach new language by • Responding and • Expanding the child’s communication

35. When to use EA strategies? • When the child is not communicating frequently. • Some strategies work better than others for different children.

36. How to use EA strategies? • Set up the opportunity to encourage the child to communicate by using an EA strategy. • Wait until the child communicates (gestures, vocalizes, says a word). • Expand this communication with a target.

37. EA Strategy : Assistance • Creating situations in which the child needs the adult’s help. • Video example

38. EA Strategy : Waiting Expectantly • Setting up a routine in which the child expects certain actions and then waiting before doing the expected action. • Video Example

39. EA Strategy : Choice Making • The adult holds up two objects and waits for the child to communicate about which item he/she wants.

40. Review Strategy 7 • Use EA strategies to set up an opportunity for the to communicate when he/she is not communicating at a high rate. • Silly situations • Inadequate portions • Assistance • Waiting expectantly during a routine • Choice making • Sabotage • Expand this communication to include a target.

41. Strategy 8: Prompting • A signal to the child to do or say something. • There are 4 types of language prompts: • Time delay • Open questions • Choice questions • Model procedure

42. When to Prompt Language? • Only when the child is requesting and not using a target. • Only as one of the many tools (not the only tool) of Enhanced Milieu Teaching • Not more than once per one to two minutes. • Too many demands may cause the child to become frustrated. • Discontinue prompting when the child loses interest.

43. The Prompting Sequence • Always go from least to most support. • Time delay  open  choice  model • You cannot work backwards • Stop prompting after the child says exactly what you wanted him to say. • If the child is not responding, give him/her increasing support. • you must always give the model prompt • Give up to 2 prompts at every level • Depending on when the child says the target and their attention and frustration

44. Review Strategy 8 • Prompt the child’s communication targets when he or she is requesting and not using a target. • Use the prompting strategies that best fit the child. • Use prompting sparingly so the child does not become frustrated. • Discontinue prompting if the child loses interest.

45. Summary Adaptations for ASD • Respond to child communication (now) • Extend the basis for social communication by teaching and expanding play • Teach nonverbal, prelinguistic skills to expand instances of joint attention • Model and expand communication in child’s mode • Communication first • Limit prompting to functional requests • Individualize

46. For More Information • Ann.Kaiser@vanderbilt.edu • Jennifer.Nietfeld@vanderbilt.edu • Courtney.A.Wright@vanderbilt.edu • Kidtalk.org