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Milieu Therapy 

The foundations of Milieu therapy were derived from psychoanalytic theory by Europeans working with children in residential treatment where most of the therapy occurred in daily life situations (Soth, 1997).  Milieu therapy is characterized as a type of treatment where the child's social environment is manipulated for his or her benefit (Gunderson, 1978).  Therapy involving milieu treatments often involves the child living a highly structured life.  This type of therapy is based on five components including structure, support, containment, involvement, and validation (Gunderson, 1978).  This approach has been modified for pre-linguistic children based on the same principles of traditional milieu therapy. The development of pre-linguistic skills is an important building block in a childs progression to expressive and receptive communication skills needed to function and thrive in society (Warren, 2002).

The Prelinguistic Milieu Teaching (PMT) technique (Yoder and Warren, 1998) was developed by Yoder and Warren at the Vanderbilt University.  This technique uses a setting (preferably the home) and situation in which the children are naturally disposed to employ proto-declaratives (Yoder & Warren, 2002).   

Prelinguistic Milieu Teaching (PMT) is an early intervention method that has been studied to increase language development in young children with language delays. In a study by Yoder and Warren (2002), 39 pre-linguistic children with intellectual disabilities and their parents were paired up and each randomly assigned to a Responsivity Prelinguistic Milieu Teaching (RPMT) group or a control group. Language was assessed before the study, and then at six, nine, and twelve months post-RPMT through the Communication Development Inventory-Infant Scale (CDI-I) and coding and transcription of the parent-child interaction sessions.  The parents were trained in 12 sessions RPMT before beginning the curriculum with their child.  PMT involves direct services for children along with a program of parent education. The outcomes showed that some children in the experimental group improved in communication skills and some declined in skills. The study found that children with Down Syndrome did not show improvement.  The research in this area is very limited, thus the findings do not show that RPMT is a consistently effective program.  In light of the varied findings, continued research is needed to determine which children are best served by this type of  intervention. 

The underlying basis of PMT is that it does not focus on making the child talk, but rather helps build the first stage of communication. PMT builds the child's motivation and awareness of a communication partner (Yoder & Warren, 2001). Though little research has been done in this area, clinical insights reveal children to be much less frustrated when they learn to communicate.

PMT is based on the same underlying principles as the Hanen Program. PMT focuses on three main factors in increasing language.  The first is to follow the child's lead because children learn best with things that interest them (McCathren, Yoder, & Warren, 1995).  The PMT therapist or the primary care provider first observes the child and waits to communicate until assured of what the child is focused on.  Intervention occurs face-to-face with the child while the therapist or parent talks to the child about what he or she is doing or playing with. 

The second principle of PMT is to increase communication attempts by placing a favorite toy or food in sight but out of the reach so the child will have to attempt to ask for it.   If a child loves to eat bananas, the parent would place the banana just out of reach of the child so to create an environment where the child has to attempt to communicate to request it.

The last PMT principle is to use social games.  The game should be fun, provide greater incidence of natural reinforcement, and enhance the motivation of the child and caregiver to be more consistent and effective in their communicative efforts (McCathren, Yoder, & Warren, 1995).  Games can vary in complexity from playing peek-a-boo to duck-duck-goose.

The research for Responsivity education and Prelinguistic Milieu Teaching (RPMT)  has shown to be effective in some children with intellectual disabilities whose parents have high responsivity to their childs communication (Yoder & Warren, 2001) but ineffective with others.  Yoder and Warrens findings have expanded the research focused on the importance of direct parental involvement in the childs development of proto-declaratives. 

RPMT is also reported to increase the responsivity of the parent and create greater opportunities for interaction between the parent and the child (Yoder & Warren, 2001). Each time this training is done, the repetitiveness of the framework may provide an expectedness that the parent can prepare for and work on using the Hanen Method.  Yoder and Warren (2001) believe motivation in doing the home-based therapy may also increase due to more interactions.

Children with intellectual deficits are more likely to benefit from language forms in their zone of proximal development rather than being taught word production (Yoder & Warren, 2002).   RPMT supports parents by teaching them language facilitation techniques to increase their childs communicative acts.  The key to the effectiveness of treatment is the parents ability to interactively communicate with their child (Yoder & Warren, 2002). 

While piloting the Parent-Child Session, a technique used several times throughout Yoder and Warrens (2002) research study to determine each parents responsivity, it was established that parent-child interactions without structure resulted very few opportunities for parents to be able to respond.  Introducing greater structure with the PMT technique would help increase opportunities for parents to respond.

Yoder and Warren (1998) studied the relationship between the effectiveness of PMT and maternal responsivity. Fifty-eight children with developmental disabilities (40% delay in one domain, 25% delay in two domains)  participated. The children were all in the pre-linguistic communication stage and were randomly assigned to PMT or RSG. The PMT was evaluated against an alternative treatment called Responsive Small Group therapy (RSG).  In the Responsive Small Group approach, clinicians were told to respond but not motivate the child to interact.  The study found that PMT was very successful when childrens mothers scored high on the responsivity test, unlike the RSG approach.  Maternal responsivity is the ability of the mother to respond and motivate the child to communicate. This test was given to mothers before the study was performed.  Mothers who  showed higher responsivity were found to be predictive of the childs likelihood of success when taught with PMT.  Mothers who scored low on responsivity did not perform as well as their counterparts.  These findings provide evidence that successful use of PMT was related to the participating mothers high responsivity.

Progress in the first three years may affect how well a child uses communication skills throughout life. These early years can have dramatic effect on the childs ability to achieve vocabulary, reading comprehension, and increased social interaction (Calandrella & Wilcox, 2000). Early intervention is considered best practice for children with developmental delays (Calandrella & Wilcox, 2000).  Building support for childrens development in the early stages of life may help alleviate learning and behavioral problems as the child gets older (Calandrella & Wilcox, 2000).