A Review of the Miller Method and Relationship Development Intervention as Treatments for Autism

1. 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 • Miller Method AND autis* • Miller Method AND developmental dis* • Miller Method AND ASD • YouTube • Miller Method • Miller Method Autism • http://www.millermethod.org/ • http://millermethodcommunity.ning.com/

6. “We maintain that each child – no matter how withdrawn or disorganized – is trying to find a way to cope with the world.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, http://www.millermethod.org/)

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. 490-491)

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 (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. “Children unable to follow directions often began for the first time – when elevated – to respond to manual signs and spoken words.” -Cognitive Designs, Inc. http://www.cognitivedesigns.com/playthings.html

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 • 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 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 - http://www.cognitivedesigns.com/symbol.html • Phase 2: Transition to Phonetic Reading - “Sam and the Boys” • Phase 3: Phonetic Reading and Writing - http://www.cognitivedesigns.com/symbol.html (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” http://millermethodcommunity.ning.com/video/dillon-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,http://www.millermethod.org/)

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, http://www.millermethod.org/)

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, http://www.millermethod.org/)

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, http://www.millermethod.org/)

34. Training in theMiller Method • Parent-Child Training • 12 hours over 3 days • Distance Consultation • Video conferencing • Phone consultation • Internet consultation • http://millermethodcommunity.ning.com/video/video-conferencing (“Distance consultation,” 2009, http://www.millermethod.org/)

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. “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. http://www.cognitivedesigns.com/video.html

41. ABA vs. Miller Method

42. Miller (1996, 2002a)

43. Miller (1996, 2002)

44. Comparing ABA with the Miller Method • http://millermethodcommunity.ning.com/

45. Green (2008)

46. Green (2008)

47. Miller Method References About the Millers. (2009). Retrieved from http://www.millermethod.org/ 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 http://proquest.umi.com.ezproxy.caldwell.edu:2048/pqdweb?sid=1&attempt=1&maxresults=30&maxtopics=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=738058571&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=1289333071&clientId=5222 Cognitive Designs, Inc. (2008a). CDI video library. Retrieved from http://www.cognitivedesigns.com/video.html Cognitive Designs, Inc. (2008b). Sign and spoken language program. Retrieved from http://www.cognitivedesigns.com/sign.html Cognitive Designs, Inc. (2008c). Symbol accentuation reading program. Retrieved from http://www.cognitivedesigns.com/symbol.html

48. Miller Method References Cognitive Designs, Inc. (2000d). Symbolic playthings. Retrieved from http://www.cognitivedesigns.com/playthings.html Discussion forum. (2009). Retrieved from http://www.millermethod.org/ Distance consultation. (2009). Retrieved from http://www.millermethod.org/ For parents/caregivers of children with autism or PDD. (2009). Retrieved from http://www.millermethod.org/ For professionals seeking training in the Miller method. (2009). Retrieved from http://www.millermethod.org/ 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 http://www.millermethod.org/ Miller, A. (1996, Spring/Summer). The Miller umwelt assessment. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A. (1996, Fall). Contrasting the Miller method with behavior modification. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A. (1997, Spring). First independent Miller method outcome study. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A. (1998, Fall/Winter). Angela returns to LCDC/Lynnfield. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A. (1999, Summer). A mother’s thanks. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A. (2000-2001, Winter/Spring). Elevation study under way at LCDC. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/

50. Miller Method References Miller, A. (2002a, Spring/Summer). Contrasting the Miller method with the ABA approach. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A. (2002b, Spring/Summer). The LCDC story. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A. (2002c, Spring/Summer). The Miller diagnostic survey (MDS): Two major issues in the field. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A. (2007, Winter/Spring). Letter from a parent whose child attended LCDC. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ Miller, A., & Eller-Miller, E. (1973). Cognitive-developmental training with elevated boards and sign language. Journal of Autism and Childhood Schizophrenia, 3(1), 65-85. Retrieved from http://www.springerlink.com/content/p11m054675p6l531/fulltext.pdf 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.