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 &
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
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.