TCSE 22) 1 39=54 (2002)

erry B. HUncocvtand Ann P. Kaise@rVanderbilt University

39

his study examined the effects of Enhanced Milieu Teaching on the social corn-munication skills of preschool children with autism when delivered by trainedinterventionists, A noldified single-subject design across four children was used to

assess the childrenl's acquisition, maintenanice, and ge neralized use of language targetsazd social communication skills as a result of the intervention. Observational data indi-cated that all children showed positive increases foxr speciic target language use at the endof 24 intervention sessions, and these results were maintained through the 6 monthfoilow-up observations. There was also evidence of positive changes in the complexityand diversity of language for children on observational measures. Three of the fourchildren also generalized these positive lan guage effects to interactions with theirmothers at homie, with the greatest changes seen immediately after the interventiol.Parent satisfaction with the intervention procedures and child outcomes were high.

Autism is a pervasive developmental disorder that is de-fined by marked difficulties in social interaction and acqui-sitio:n of adequate socil communication skills. Childrendiagnosed with autism span the range of ognitive abit-ties; about 70% will test in the mentally retarded range(Edwards & Bristol, 1991). Although individuals withoutism vary widely in the extent to wbhicth they manifestthe symptoms associated with autism, nearly all childrenwith autism will require intervention to support the de-velopment of communication skills. Researc'h has demon-strated that systematic intervention cannot only improvethe language and social skills of childrenv with autism, butit can also positively influence the behavioral, so cial, andacademic outcomes for these children (Anderson, Avery,DiPietro, Edwards, & Christian, 1987). Conversely, with-out effective early social communication intervention, thebehavioral symptoms associated with auti sin are likely tobe more severe and disruptive to the individual's devel-opment and daily living (Durand & Carrm 1992).

Studies have demonstrated that children with autismcan benefit from the appiiation of behavioral proceduresto teach specific language skills (Koegel, O'Dell, & Dun-

lap, 1988; Lovaas, 1987; McEachin, Smith, & Lovaas,993). Naturalistic teaching methods have also been,

showtn to be successful in teaching new skills to childrenwith autism (Koegel, Koegel, & Surratt, 1992; KoegelO'Dell, & Koegel, 1987; Laski, Charlop, & Schreibman,1988; McGee, Krantz, & McCLannahan, 1985). Nat-uralistic strategies begin with the learner's intention tocommunicate and the trainer's ability to systematicallyprovide models of appropriate communication formsand meaningful so ial consequen ces for communicationattempts.

It is clear that for language intervention to be effec-tive with children who have autism, it is important that(a) the interventioti begins early; (b) the intervention tar-gets the social use of language, not just the content oflanguage; and (c) the intensity and duration of the inter-vention are sufficient to support the acquisition and gen-eralized use of new skills (Wetherby & Prizant, 1992).Although thiere are a growing number of interventionstudies examining the effects on acquisition of languagefor children with autism, no knownt studies to date spe-cifically explore whether those changes in children's lan-

Address: Ternry B. Hancock, Department of Special Education, Box 328 Peabody College of Vanderbilt University,Nashville, TN 37203; e-mail: terry.hancock@vanderblitedu

39

The Effects of Tra'iner-ImplementedEnhanced Milieu Teach'ing onthe Socl'al Commun'lcat'ion of

Ch'ildren w'lth Aut'ism

*pro-ed

Tb Kc h Eay Chlidhscood SpeId Edu caioin 2:1

gerage generalize to inter actions with th-enr parents. Parentsof children with autiisma frequentlv report tlirci desire tocommunieate with. their children in vways that are funrethona1 foi both parent and child, (Norton & Die cxv, 1 994).In reality, eisiupted pIrnt-cthild comnmunication inter-actions ire frequent in families of ch ildiren with auistsi,and difficuhty in communication ca n exacerbate ehafleng-ing behaviors exhiibited bx, sonme ecaildrcn with aut-tism(Landa, Folstein, & Isaacs, 1 991; LIem-anek Stone, &.Fisceheli 19p93). Genera'hzatio-n of ehiddien's language sk-illsto significant people in their liv es cainnot be assuimed tehappen as Li result of a language intervention becausechildiren w ith autism-i hfave particulai difficultv in generalliizing soeial ci onmunication) skills across settinigs and peo-ple. Given the signiificance of commxunication w:tblin thecontext of thie famrilyx it is extremely imn-ortan-t dinat anvlanguage intervention with- children witnh autusmnialso ex-plore the effects of that intervention. with their families,

ENH ANCE Wu 1V TEA0K14111G

Fuhan ced Adlieu Teach ing (EMaT) is a hyvbridi" approach tonaturalistic, early language intervention. EaMT ci icopo-rates aspeers of both behavioraxl and sociaI interactionistappiroaches t0 laniguage intervention. There aie three comnponents of EHIT.

I . euvironmental arrangemenut t( promotechildi engagement with activities and com-mnunication paritners (Osti osky & Kaiser,1991),

2. respcinsive Tinteractrona technmques to buildsoci ii coniversational inter action and tomiodel. new laniguage foirmxs (NWeiss, 19811;

rndU nmilieu, teac'hing proiceduires to pirompt,

mo,del, and comnseqruate the ase of nesw lair-gerage foirms i-n their functional conrexcts

Militeu teach-ing procedures itielude heiitive model-ing, mands followed by models (Warienx M Quarter 8c&Rogers-Wfflrrei , 1)984), time d'elay (Ilalle, Ba er, & Sprid-lun, 198 .), and inclidental teaching (Hart &-, Rxsley, I97)TPMI has been :howri to he effcctive in teaching new

neiera lized Iang uage skills to c1blidren with developmnen-ta1 disabilities (Hermmeter & Kaiser_1994; Kaiser &_ Hes-ter, 1.994).

Studies of xmilieu teaching w 'tb children with autismI ave show'n that naturalistic lan-guaae teaching can he ef-fective in teaching them new social conomnurice non skills(Gartner &, Scan-ltz, 1990; F-un t Atwell, & Goetz 1988).IResults retortedl in lao-guage interxeTirtioni studiies wlithchildren with antism hxve b een generally positive. CIl-hidreni learned, and in s nme cases, generalized the targetedlanguage responses.T Tpically, sma'll sets of language skills

were taught (c a labels, actions, requiests); only tine study(Sceiere Pz Glsvwang, 1989) targeted earlv seman-tic rela-tions (i.e., t-o-word commen-ting utterances). Increases-n spoutaneous language wer e observx cii at a gcner'alizedeff-ect of tahe Interventioin in some studies (MlcGee et afl,1-9858 Scheiere &c Glswt' g, 1989)

TIhe d fii ition of na ruraitic alanguage teaching varieswidelvx in reported re'sea.rch stunics fiom diiect und Inci-denital teaching proctdures in everyday settings (Ainnersonet aL, 198/1 MN,cGee et aL. 11985) to responsive interac-tio Strategies (expansious, building turn taking, followingthe child's lead; Gartner &, Schultz, 1,909Q Hunt er al.,1988; Scehreibmain, Kanek o, &1, Koegeci 1991).Two studiebiave blenided prompting langerage responses with aspectsof iesponsive interacriion (Koegel et atL. 1987 Sechreib-mnan et,-,I. 1 99 11 None of the studies emxploved the rangeoif responsive iuiteiraction techniquies that ale found ational.to PMT Oi vei 11, the descriptionas of the intervention pro-ceeduses i-n past studies suggests that these procedureswer le iss n teiratistie, n-ore stiructured, and mqore- onl-enxted towaru inistruction than thei- appfctlie nof EMT inthe present study, Mlost important, the majority of re-peretc studies focused only on teachina new languageskills rather than building cornversarioniral interaction orsuppori nag child paiticipation in social corn axunlicativei-nteractionis None of th-e st-udics explored thei effects tif

chan-ges Wn children's language w~ith their parencts.Ini a pei us csvu ( Kaiser Hancock & Nietfeid,

20001 wve examinxed the effects of EMT 1when rimple-menited by soix prents if young childreni with autismx.T he patents learned to use these natuiaabstic language in-tervenlion strategies dtiring 241 mndiv idual training ses-sioixs aixe generalized their use of thxe strategies to haouxerixteractioni xwith their ch-ildren. Positive effects were oh-serven. on, itxe rise of comuicumtiou targets f-or all clxiii-deni and on the co a-plexity ixd divcirsity (if productivelan,guage for ixost chxildrien C hild effects gcieralized anidmaintaineed for four of thie six chlxdren, and tix-ere was ev-idence of charmage cin dev elopmxental a ssessxents of lan-gnag ftoi five of six children.

The Kaiscr et al. (2000) studv provided an imper-taut context for the currenit examnination- of EPMI imtple-nieixteed bW skilled therapists, p articularnv in terms o fexamining thxe effect of the initervenxtion oi rinteractioinswithxin families. Thxe findih gs of Kaiser et al. Hidicatedthat PMTi is an effecative early co mmunic'ation interven,-tion for chldden withii antis anixd tlixat parent-child. in-teractiions ate positively affected by teaching parents to,inxplieixxcnt the PMTI proceduiies. In the current study, wxefocus (in the application if PEMiT by skilled thlerapistsand examine changes in parent.ixild ixtei cetions a-t homerestilting fri n clxildreri's exposure to thxe EMAT ,proce-dures in the clinic, Thus, we investigated the indirect ef-frects of ixaturliastic conmmunication trainling on children's,interactlonxsiix tlxec family.

Traine EMI 4

The purpose of this study was to exam-iie the effects oftrainer-implemented EMT on the language performanceof preschool children with autism. Four questions wereposed:

1. What changes in child language targetsand soeial commIunication skilIs will beohsserved durinn the clinic applications ofEMT by trained interventionmstsr

2. Will changes in chiid language targets andsocial communication skills be maintainedover time?

3. Will changes ndicaiatve of child lan guagedeveloptmeint be observed?

4. VIl changes in chiLd language generalizeto interaction)s vwith parents at h )me.

.Four preschool children with autism and their mothersparticipated in the study (see Table 1). The children werediagneosed as haviKig autism or pervasive developmentaldelay with autistic symTnptorns by an inidependent childevaluation clinic before participating in the stud:y Eachchild mret the followring criteria: (a) The chtild was be-tween 2% aind 5 years of age, (b) the child had at least a

6-Inonth delay in expressive language as measured by theSequen1ced nfvent oy of Conununication Deveiopnment(SI1CD; edrick, IPrather, & Tobin 1983), (c) the child was

everbally imitative, (d) the c-hild had an expressive vocabu-lary of at least 1O spontanneous words, and (e) the child'shearing was within the norm at range as measured by atnaudiometric assessm ent. In addition, the children's parentsmet the follo-ing criteria: Parents consented to (a) bringthe child to the clinic setting twice each week during theintervention phase and ontce each taonith for 6 moitthsduring the follow-up phase, (b) allow project staff tocomplete nine home visits over the course of the study,a td (c) be vdeotaped at home with thler child and allowtheir chitd to be videotaped whth the tra iner at the ctinic.

The children were three boys and one girl (Child B)with a tnean age of 44 months (range 35-54 months). Allchildren hliad expressive and receptive lantguage skills inthe 20- to 28-month range (Expressive Commiunication Age[CA] M = 25 months, Receptive CA M = 21 months) astested by the SICD. The children's average Mean Lengthof Utteranice (MLU) at entry was 1.29 (range 1.03-2.00),and their measured IQ scores ranged from < 50 to 95.

Three indivi duals served as interventiontists f-or tihefour children. One interv entionist who worked with, twoof the four children (Child A and Child D) had a miaster'sdegree in speci:al educationr and had completed 36 hourstoward her doctorate in special education. The interven-tionist for Child B had a hachelr's degree in educationand had completed 24 hours toward her master's degreein special education. The interventionist for Child C had

IABLE 1. a rticipants

Child CA in mo Gender Diagnosis in omnths (SICD) IQ argets

5 0 boy Autism 20EbEa < 50 Agent-actios20-1R Action-object

Attribute-object2-wsord reqtest

L3 38 girl P DD 28-E 9 5 d Agent-action-object24 -R Attribute-obj'e t

Preposition-object3-word request

C 35 boy PDD 24-E < 5OC Agent-action20-R Actlon-object

Attribute-ob ect2-wvord request

I) 54 boy Autism 28-E 52d Agemt-actio i-object20.-K Attribute-object

3-word request

lote. CA c 'hronological age; PD)=) pervasive developmentai disorder. a' - Expressive language age as measured by the Sequenced Inventory ofCommunication I)evelopment (SIC I) Hedrick, Prather, & Tobin, 1983). yR Receptive language age as measured by the SICtD CMental DevelopmnentalIndex score (MIX) as mneasured bv the Bayley Scales of Infant Development-2 (Bayley, 1993). dFpl Scale IQ score as measured by the Wechsier Preschooland Primary Scale of intelligenceeetevsed (Wechsler, 1989).

42 ap� in ad Chiidhoc& Id �c a fare :1

s* master's degr 'e in human deve'lopmnent an d -had com-pinted 30 ho urs toyward her d-octorate in child psyc'hol'ogy. She had 7 years' exiperience working d'rectly vwithchiidren with autism and I, year of experience implement-ing natrnalistic langr uage teach'ng procedures with presc'hool children vwho had disabilities,

All cli ild training sessionis (baselUne, intervenitioni fol-lowup) toiok pla ce in a smal1 playroom at a university-basedclini'c setting. The room wiva: equipped xwith twio adultchairs, a small table with ch'ild-size chairs, two cabiinetsfor storagre of toys and play materials, and a video 'am-era. A varietvy of age-ap propriate toys of interest to thechildren were provided (e.g., blocks, markers and paper,cars an..d tinu'ks, balls and chutes, b.uibbles).

Probhe' to as:ess the generalization of 'hidr'en's lan-gu age skills witi- their parents we're conducted in, thefamiieis' homes. The sessions were videotaped in a. room-of the parents' choice, typicafly in either the family livingroom or lie child'1s b edroom, using thie 'hild's toys.P1arents were ask ed to stay in the same room with their

child during the entire sess ion, with the telev'ision turnedoff. The videotaped sample of parent--child intera ctionwas iS minutes in lengtch,

Four classes of variables vere assessedI in hti:s study:(a) trainer use of t ei intervention strategies, (b) child s ocialcoimmuni'cation during observations, Qc) Ievelo pmentalmeasures of child langua'ge, and (d) par'ent satisfaction'with ti e intervention program.

Trai ner lImpiementation Measu-res. Measores if im-plementation by the interventioniists reflect the initegrityof the intervention delivered to tiie childr'en in this study.The:e measures inc'iuded the key components if the in-tervention, inc'luding 'orrect ose if' all milieu pro'edoires,talk at the ch-ili's target level, expainsions, hala ce ofturns, responsive. feedback , pause errors, and not followin-g t4i child's lead. The trainer measures vwerecoxdedfrtom videot'aupes during 'linic s essio is usinP theCo' ibi'ned MilieuRespo Asve lI 'eractioz Codei (Alpert, Keefer,

&Fisc'her 1992). The Combined Code is a continuousoil ervation system in which each cdult an d 'hild 1behav-ion is 'oded while watc'hing tie vidleotape of the session.

Child Social Communication Skills. Child soci'alcommunication. skills consisted of the frequenc'y of tomn-.-1child utteranc'es, spont'aneouis 'hild uttera oces, to)tai us'eof tazrgets (promp ted plus spontaneous), and frequency oftargets used spontaneousiv, In. addition, the diversity (num'her of different word roots) a-nd the comnplexity (MiLD) of

thi children's language were deterniimed f-rom transc'riptsof children's utter'ances durng each o bserv'ation. MILUand diverstv xwere calculated using the Syste inatF' Anal-

ysis of Language Transcript program (SALT; M ilier andChapman, 1984').

Ch,ild Lan-guage Development. Children's languagedevelo)pnment was assessed befor'e basedine began, at thelend of tr'aining, and at the end of the follow -up period.Expressiv and receptive cmmunication skills were ats=sessed usiinr the SICD, the Peabody Pcture VocabularyTestURd&Sed (PPV T-R' Dunin & Dunn, 1981 ) and Ex-pressiye OneI-Word Picture Vocabulary' Test-Rev ised(EDW' PVT=R; Grdner, 1990). Mea~sures of lingustic 'om-

p lexity (e. g., MILU) and diversity of vocabularyT were oh'ained from verbatim transcripts of the langruage samiple

ses:ions. Thei SALT p rograin was used for the analvsis oftranscrijpts and computatiori of MLU and diver,sfry,

Parent Satisfaction. Pairents were' asked to ecompletesatisfactio -questionnaires at tli e end of the interventionand a~gainr at the end of the follow-up period. The question-naire comisted of fiv-e questions answered using a 5-pointsea-l' and six open-enided questions. The quTestioinnaire

mea~sured parenrs' satisfac'ion with their child's partici-pation in themiterv~ention progtram and with the 'hangesthey observ'ed inx their child's comnmunication sIkills as aresult of th-e intervention.

Interobserver agreement on the Corib ned Milieu!Responsive Interaction Code 'was 'alc'ula't dfor eaich adultand thid behavior. Reserc anssistants 'were trained to acriterion of at least 80% inter'observer agreenment on thedata collectioni system prior to the coding of data in thestudy. Tro determiine interobserver agreement, a1 prim aryobservern and secondary observer independently co)ded th evidceotapes. A comparis'on of the coded data sheets wasmade on apoint'1bvy'point basis. An, agreement was scoredfor abehav'inor that both observers recorded, and a dis-agreement w as scored when only one oibserver scoired abeh avior 'or when the two observers differed on their cat-egor'ization of a b ehavior, When the rat'ngs of the twoohserve's did not matth, a disagreeme it was rec'orded,.aiterobserver agr'eement was calc'ulated using an- exa 't

agreeintu procedure in whichi the total number of agreements w'as divded by the total numnbler of agreementspilos disag'eements and multiplied by 100. Inte'robserveragreement was assessed separately f ir ea'h ca;tegor~yoparent and child b.eha vions. TLai verbatim transcriptioinsof childi otteran'es were verified by second 'od:er usingthe videotapes of the same lanuagae sample or observa =tional session prior to analysis using SALT. A lic'ensedpsychologist verified atil testing data and scoringr,

42 Tdp�cs �,n- Early ChUdhood, Specia-I Educaflorn 22� 1

Trainer EMT

Data for this study were selected from a longitudinalstu dy comparing the effects of three different models ofnaturalistic communication training with children whohave significant language delays (Kaiser, Lambert, Han-coc k, & Hester, 1998). In the targer study, 76 childrenwere assigned randoimly to one of three treatment groups(parent-implemented EMT, n = 20; trainer-implementedEMT, n 20; parent-implemnented Responsive Inter-action, n 20; or a control group, n = 16). The data pre-sented here are for all of the children with autism (n = 4)who were randomly assigned to the trainer-implementedEMT condition.

In each of the treatment conditionis, baseline, inter-vention, and follow up, phases were implemented in theco6ntext of a single-subject, multiple baseline desig i ac-ross children (Tawney & Gast, ±1984). Participants wereassigned randomly and equally to a specific number ofbaselines (five, six, or seven baseline observations). Ad-ditional baseline points were collected if any measure ofadult or child behavior was not stable at the end of theassigned number of baseline sessions. The multiple base-line design was replicated six times across the 20 familiesassigned to the trainer-implemnented EMT condition. Thefour children with autism assigned to this condition hadbaselines consisting of five (Child A), six (Child B), andseven (Child C and Cild D) sessions. The graphic datain this study vwere analyzed using simple visual inspection(Tawney & Cast, 1984).

Prebaseline. All children were pretested on a batteryof standardized language tests at the beginning of thestudy: the SICD, the PPVT-R, and the EOWPVT-R. Two30-minute ianguage samples were collected during playinteractions between the children and a trained researchassistant in a ctinic playroom, Based on standardized as-sessments and the language samples, individu al languagetargets for each child were selected (see Table 1). Targetswere broad classes of early sem antic relationships repre-sen-ted in two-, three-, and four-word utterances (e.g.,agent-action, agent-action-object, agent-action-location).Each child had three or four target classes, and in thiscondition the parents were not informed of their chil-dren's 1anguage targets until the end of tlhe study.

Baseline. Interventionists and children' were video-taped playing together for X5 minutes during each base-line session. From these videotaped sessios, 10 minutesof data were coded. Parents were giveen general informa-tion about their child's participation in each session("Your child really enjoyed playing with the bubbles to-day"), and the nterventionist would answer any ques-tions or concerns posed by the parents. Parents did notobserve their child in the sessions with the ntervention-

ist but generally waited in a comfortable sitting area un-til the session was complete.

Intervention. Following the completion of baseline,intervention sessions were conducted twice each weekwith each child in the clinic playroom. During the sessions,the interventionist and child played with age-appropriatetoys at a small table or on the carpeted floor. The proce-dures used in intervention are summarized in, Table 2.Based on previous implementations of these procedures,criterion levels for each measure were established (seeTable 3). Data were monitored weekly to ensure thera-pists reached criterion levels and to assess child progress.Training sessions were videotaped and lasted approxi-mately 15 minutes. Ten minutes of data on trainer im-pleementation of the intervention procedures and childcommunication measures wvere coded from the video-tapes of the sessions alxways starting with the first fullminute. Parents did not observe their children during thetraining session, but parenits were given a general reportof their child's participation in the initervention sessions.

Follow up. Parents and children returned to theclinic once each month fir 6 months after the end of theintervention to assess maintenan ce of child use of socialcommunication skills. These follow-up sessions were iden-tical to the intervention sessions with interventionists us-ing all of the intervention procedures with the child in thesession. Interventionists and children played together in a15-minute session that vas videotaped with 10 minutesof these sessions coded. Parents did not observe theirchildren duritng the sessions, but a general report of thechild's participation in the session was giveen to the par-ent after every follow-up session.

Generalization. Nine observations were conductedin the home to assess generalization of the children's useof socal communication with their parents. Three ses-sions were conducted at the end of baseline, three at theend of the intervention, and three at the end of the 6-month follow-up period. Parents were instructed to playand interact with their child as they usually did, usingtoys and materials from their home. Parents and childrenwere videotaped for 15 mintutes each time with 10 min-utes of the session transcribed and coded.

Posttesting. Following the last intervention session(average length of time between Pre and Post 1 was5.2 months) and again following the last follow-up ses-sion (average length of time between Pre and Post 2 was11.5 months), assessments identical to the prebaselineprocedures were used to determine changes in the child'sperformance on standardized language tests and in two30-mintute language samples. At both postintervenition andpost-f)ollow-up testing sessions, parents completed the

43

Topici [E&y Childhood SpeKI Educan on 22 1

parent satisfactio tn survey to assess rheir satisfaction withthe inter:vention pricgrami and tiieir children's progress.

Interobserver agreemient on codng using the CowhinedCode was assessed in approximatelvy 20% of che sessionsfor a. total. of 10 tinses ft each fasmily duriig the courseof the study. On-e assessment occurred for eacIK familyduring baseline, fi durfv ing training, one assessnment duritg the follow up, and three durm'g the generalizationassessnsents at Isome, A second coder verified each tran-script of the langage sanmple atnd of cil-d utc terances dur-ing the adult=child interaction sessions a:rid atl test d,atavwere checked Afr scoring accuracy by a -lcensed psychol-ogist,

!Mean interobserver agreement for all trainer behav-iors was 8915% (range 810=100%) for nilieu teaclhiisgepisodes, 95.1% (range 74%/=1i00%) for expansions,95.2% (range 83% 100%) for talk at the target c1eve1,

and 85.1% (range 70%=92%) for all other daolt behav-

iors. The meai interobserver agree nent for child com-mson'cation hehavior vas 84.30/ (rani'ge 68 -98=% )

Interobserver agreenent for total use of targets was8714% (cange 51%=100h%) andl for ail child behaviorswas 94 %5/X (range 86%-=l(0%). Low interobserveragreemetnt perceintages occcurred only when thte rate ofbehavior was very 1 xis'.

Results in T beTainin gSffngn

Ta inr Impltementation. Seven aspects of trainer im-plementation of the interv'ention xere measured: (a) ftr6e

quency and 1percentage of cotrrect use of the four i milieuteaching procedures, (bl frequency of expansions and percentage of chiTd utteranc-es expandeed, (c) frequenc' oftalk at the child's target level, (d) balance of aodut andchild toLrns (turn discrepancy), (e) frequency and percent-age of responsive f tedack, (f) pats.e errors, and Ig) icotfoillowing tih chitd's lead, Table 2 details the speclficcomnponents of the intervention and operating definitionsfior each proceduoe, Criteria levelis were set for aill nter-vention procedures based on data fro6m past studies ofinterventiot efficacy. Table 3 gives the naeans for aL1 im-pteImentation measures as well as the specific criereonfor each procedure. Although there was some variabilityamong the trL-iners on their use of the procedures, tra iners deelivered thme i.ntervention with-i a hligh level of preci-

TABLE 2. EL Cmpon its ftelI M na$ures, a, neC n tDlrnns

EMY conmpo©nerit kieaure Defnton

Milieu teachirg procedures Num-ber and perrcentage of coerrect Corict milieu teaching episodes: (1) begin with childuEse of four procedoures ve baL or nonverbal reqoests; (2) follow a specific se-

queiice of prompts 0-noels, mands, or time delav proce-dures) (3) include corrective prompts as needed, and(4) en-td wIth positive feedback, ex pansion of the child'sutterance, and access to the child's requested object

Expansiot s Percentage of child utterances Adult utterance t-hat follows a child utterance, eimbedsthat were expanded child's utteranice into a more complete form, and main

tainis or extenlds the child's ineaning

Balance of adult and Tuan ratio Tuin ratiRo was calculated by dividing adult turins bychild t.urn-1s child turns, with a nuLmber larger thai 1 indicating

mcore adult turns than child turns and a number less thanI indicating more child turns than adult turns

Not following the Numrber not followinTrg Adult verbal behavior that does not relate directly to thechild's 1ead, child's lead child's topic or ongoing behavior (e.g., recrui:ting child's

attention to another toy, initiatling talk about events oout-side tlie play context)

Pause errors Number of pause errors Three or more consecutive aduLlt utterances withotut atleast a 3-second pause for a child respomnse

Responsive feedback Percentage of child utterances Adult verbalizations that follow a child utterance, arefollowx'ed- by responsin e feedback meaningfui t c hild, and directly rehated to tle child':

Talk at tlhe child's Number of adolt utteranices at Adult utter'ances t rat inclcuded exatriples ftrsm childre-i'starget level target level target classes and were slightly longer (2-3 words)

tha n childs current producti-ve language

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46 Tori �ri En iy h�hood p ml Edu ation 2. :1

sion and were w el1 above the establishedi criteria levfel feorall p rocedures. Figures 1 au-d 2 show session-by-sessiondata for th-e haseline, interve itioi , andI foillow-up ceondi-tions for use of milieu. teaching and expanusions. Thie ititerv~entionists depre'ssed ti-ieir isise of the puro edures dornnathe base ir e phase to resemble levels obs:erved Iin baseliniesession: w ith p arenit: in the other two parwnt-irnplementedinterv'endion g-roups in the large study (K'ise i.et ali1998). Parents may demonostrate some isf th behavioisbieing measured during haseline hot uo at the optiumum

level needed to affect "hid langoage,In an average interveintioin session, i -t trventionmsts

engaged the children. in ei ght milieu e-pisodes to prompttarget Langoage, resp'onded to 98% of thie children's ut-terances with responsive-typ e feedibadk, and expanided86% of the chIldren's utteranIces' Thecy also is ed the chil-dren's targeted languoage forms an average of' 69 tines in

asssieon. Turn trking between the trainer "and child waexpressed as a. ratin of a-dult to c-i ild torus wish a nium-her larger t ai on e reflecting more adult than c'hild torus

and a number less than one reflIctung more child thanad.ult turns. Intervention sessions revealed approiximatelvequal turn taking between the tr-ait ier and children (A4$1.011). During monthly fonlow-up sessions in the clinic,trainers citosely ap proxim .ted t me rates of intensity and

precision of 'impleimentat'on deivered during th-e iater-

venution sessions,

Child Social Communication. After the interventionwas introduced, all four chil-drenm showed inc"reases initheir total ose of targets (promptted plus unpro mpted), a-sshown in Figure 3. The strongest effect :were seeni fIrChil-dren B and C. Children A' a,d D ha.d lower levels ofis ,,rget use throughoot th-e intervention. C 'Iid A in'reasedhis tatget tse in the last 1half of the i literventisi cII xndi

ticon. All four children continoed to. use their targeiss our-ing ise 'c"linic follow-up assessme-nts. Threec of the fourchil-dren (A, B, C) showed clear chang es in spontaneou-suse of targets (see Figore 4). Chili U shoedw small changesin use of spontaneous targets during the interventioni. All

four children maintalined similar rates of spontaneoustarget use during the follow-up period.

Cha-nges in children's commnicalieon uare su-mm-ca-rized in Table 4. All clhildren increa4sed i-i their frequencyof total utterances from baseline to intervention, withChilid C showing the 1argeist gains. Tw,o cildren (A. aiidB) showed further increases in total utterances at followvop. Tw ko child'ten (B and C) increased in dhie' sponta-netous utteranc"es from hasedine ise intervention, withChild C maaking ishe largest ginns. Only Child B showed.an incerase in ftequency of spontaneous utterances ft In'nterve-ntion to follow up; the other three children main-tamned rn twenvtition levels at follow' op. Changes in ML Io courred for three c-i iidren (A, B, C), and changes in di-versity (s umibet of different Itords) vwetc observed for all

four children during the intervention. Ctiiidren B andCsh owed mnodest inicreases in MLU fromn intervention tofeollow u p. TI- ree of t 'ie feour chi ldren (A, B, C) increased,slightly in their diversity at the fol1low up.

Data shoIwing the miean ose of targets, spontaneous ut-terances, M LU, and diversity for the four caildren duringbaseline, treatment, anid the ft 1low-up p hase ina general-ization sessons at home with their mothers are shew i in

Table 5. Generaizatihon to home setting was observed forth ree of the ftour children, wish the greater changes occur-ring iminediately after th-e interv'ention than st the 6-month.fol-low tip. Twvi of the four children (B and C) bhowedlarge increases on their total use of targeiss an-d sp onta-neots usme of targets after interventioni. The other twochildren (A arid D) showed inodest increases hin use oftar'gets analyzed at the 6ntonth follow up . Three of thefour children (B, C, D) increased the frequency of theirtotal otter-ances an-d their spontaneo us utterances atterthe intervention. Children B a nd D Ihad addiltional uincreases in total and sp ontaneous utteranc~es at th-e f ollow-up assessment,

Children also showed geiesratized changres in tvogneral measures of l-anguage co mpiexity: MLUi and num-

bter of different word roots (diversity). MLU mecrea sedf ir two children (B and D) during tli e postintervention-Io~me ga meralization assessmenits, an.-d moeset increansesin this measure were seen at the fo 1 ow-up h-ome gene'r-alization 'assessments for the other two children (A andC). t similuar pattern of effects w as ohserved f or diversitvof wer roots.. Increases in diversity of word roots wereobservedI during Ihome generalization observisions at theend ef t -e inte rvention1 phase for all cii dren, with threof tlie four children (B, C, D) approaximateiy doobllugtheUr diversity from pre- to post'intervention assessmients.Ch-ildren ma'intai led their higher levels of diversitv in thefoIlow-uip ob servations with their m-ot-hers.

Lanuag Dvelpen esure

Six measusres of language development were taken- at theiprebaseline, poistintervention, and post4follow-up periods,The restIlts of these meiasurements are showvn ii. Table 6.Although thetc is evidence indicating developmental

cha 1ge concurrent vwithl th-e intervention period, this eva-

deuice is variable across the four children. Child B showvedchanges oni all measuores at the postintervention assess-nl-ent, dheetas Child A changred positively oni five of t ie sixmea sores. Child D changed on two i-neasures. The post-follov-op as sessmnent reveled a similar poIsitiye develop-mental change for tie children, althougi net quite asstr ing as was measured pre- to postintervention. Child Bsh'ow ed c-ia.nges on all me~asores. T v o children (C and D)

46 fbnpics in, Ear�y ChWhood Spedal Educabon 22� I

Traine EMT

-10

FIGURE I. Frequency and percentage of correct use of the four m1ieu teachNng procedures by interventionists inthe clinic setting.

changed on four of the six measures and maintained thechange made fronl Pre to Post I on the other two mea-sures. Child A made changes on tw o measures and main-tained the change from pre to postintervention on two

other measures. Although the overall pattern is one of pos-itive changes in developmental measures associated withthe intervenition, change on developmental measures isdifficult to interpret in the absence of a control group.

47

I I Ii 47

1 2 3 4 6 8 7 1 2 3 4 G 8 7 8 I 10 11 12 13 U 19 16 17 18 19 28 21 22 n U I 2 3 4 5 6

Swelons

Total Number PercentNumber Cormct Cormct

__&_ 1=

Follow-upr-r-r-1 r IW

InterventionBaseline

At

X.~~ 4I l"

/ '4k

2f-J I

I~T i i G H Ar

S S I~~~~~~~~~~~~~~

X r' N v0 f :>g -

4K

B~~~~~~~~~~ FF^ YG I mrklr LlSWA -4 Al'rt

1 -

a0,ELWI

FIGURE 2. Frequency at expans ans and percentage aot chd utterances that were expanded by intervenflanIsts inthe clinc settlng.

! I I I T I I I ,St I I M I . I .* .i 2 a 4 $ a 7 1 2 IN 4 9) 6 7 aB 9 la i 11 2 f3 14 lai Is 17 SSU 1$ 2S 2 3 4 $

-I- iT'Sm

E panded

X, S 1 .C'

LtI

If

tame E I 49

Pa2renit Satisfaction

Parent ratuiigs of their satisfaction with the training werevery posi.tive. Using a 5-point scale, the mean rating forfive scaled items for the four parents was 4.88. All par-ents rated their satisfaction with improvement in theircthil 1 s communication skills and their overall satisfac-tion with the intervention as 5.0. The onlv question thatparents rated with less than a 5-point response concernedthe time requirement involved in the training with par-ents wanting more sessions for longer time periods.Parents also gave very positive responses to the six open-ended questio ns. All four parents described specific, pos-itive changes in their children's language. One parentSaid, 'Now my child speaks in sentences and can answer

TABLE 4. Child Languag Clinic Sessions

ConditionChild Measure BSL INT rUA Total uttera nces 48.4 68.0 82.3

Spontaneous utterances 41.2 46.2 47.5MLU 1.32 1.65 1.70Diversity 24.4 35.6 46.8

B Total utterances 44.0 52.2 69)7Spontaneous utterances .8 3.8 10.2MLBU 1.94 1.94 3.62Diversity 50.4 31.4 77.5

C, Thtai utterances 16.8 68.8 58.8Spotitaneous utterances 9.2 45.6 43.5MLU 1.54 2.29 2.29Diversity 11.0 38.2 44.2

D Total utterances 35.2 . 0.6 46.2Spontaneous utterances 30.4 27.6 31.0MLU 1.65 1.56 2.06Diversity 20.8 30.6 29,7

Note. BSL = data are the mean of three sessions at the end of baseline;INT = data are the mean of three sessions at the end of intervention; FU =data are the mean of three sessions at the end of follow up; IMLU = meanlength of utterance; Diversity = mean nutnber of differenit word roots ineach session.

questions. The intervention has converted 'babbling' intoreal speech." Another parent reported that the interven-tion had helped her child 'go from one- and two-word ut-terances to having meaninigfui conversation includitng upto nine-word sentences," witi an added benefit that herchild now "gets frustrated less frequently" and is "moreengaged in the environment and the people in it. " Themain suggestion offered for improving the training was

having the trainig last for more sessions and for longerthan 15 to 20 minutes a session. Because of the design ofthis study, we could n ot train the parents in the trainer-inmplemented condition until the last follov-up sessionwas completed. One parent said, "The wait to be trainedas a parent" was what she liked the least about herchild's training, "although I realize it had toI be that waydue to research. I can't wait to learn 'the secret."'

These results extend the application of hybrid naturalisticlanguage intervention procedures to children withautism an d offer further support for the effectiveness ofnaturalistic language interventions implemented withthis population of children. In this study, children demon-strated positive changes in soclal communication as-sessed across settings and measures, and these changesgeneralized to interacetions with their parents. These find-ings are especially important given the social and con-municative difficulties of most children with autism andthe likelihood that they will need continued support toacquire and use functional commtication skills.

)f particular interest in this study is that when a hy-brid naturalistic language intervention is delivered in aprecise, high-quality manner, the actual time it takes toeffect chainges in children's language may not be as longas traditionally thought. In this study, children were en-gaged in intervention for 24 15-minute sessions for a to-tal of 6 hours of direct intervention. In this particularintervention, the emphasis onr responsiveness shifted the

TAB-LE S. Child Language in Home eneralization Sessions

Child A Child B Child C Child DCondition siL NT F BSL IIT FU BSIL INT FU BSL INT FU

Spontaneous targets .7 .7 5.3 2.7 25.0 17.3 0 10.0 9.7 .7 1.0 2.0

Total targets J7 .7 5_3 3.7 27.0 19.0 .3 19.0 14.0 .7 1.0 1.7

Ttai utterances 34.7 32.3 37.3 64.0 94.3 107.0 61.0 105.3 85.3 33.0 62.0 75.3

Spontaneous utterances 26.3 26.0 29.3 44.7 81.0 98.3 30.3 58.7 45.3 22.7 32.7 58.0

MLU 1.34 1.34 1.71 1.94 3.54 3.69 1.33 1.56 1.82 1.49 2.15 2.13

Diversity 159.0 35.0 50.0 52.0 98.3 99.7 26.3 56.3 64.7 21.3 46.0 54.3

Note, BSIL = data are the mean of three sessions at the er d of baseline; INT _ lata are the mean of three sessions at the endi of intervention; FU = data arethe mean of three sessions at the end of follow up; MliU = mean length of utterance; Diversity = sea n number of different word roots in each session.

49TraierA@ EMT

Int erventin

II~~~~~~~~~~~~~~~~~~~~(~~~~~~~~~~~~~~~~~~~~~~~~~~~~~(IsI gt

I1i'',

V V wo s fu ~~~~~~~~~~~~.

C

0 � ( -� eQ

St -��W -(

GURE 3J Frequency of adult and chil communication total target use in the clinic setting.

(I.

~~1~~~~ I I I I ~~~~~ I I V IP

2 3 24 - I 7 4i 7 5 9 fW t 2 IZ 14 fl @ 18 19 X a 2 a X $ 2 a 4 5 6

Sessions

Adult Chitld

Target Taget

= I

FIGURE 4. Frequency of child communcataon, spontaneous target use, and number of different classes of targetsused in the c1in[c settings.

Intervention

&Mc

.0E

z

Number Numberof Targets Different Targets

Base,line Follow-up

Yogi5 in Eo_-Url ChI Bood Special Education 221

TAB~LE 6. CH erom ainc tin DI x Itpra ontai L60gug ktaswer at Pvrehtrvenon, PostO intvven on.adFd~ow UP1

SiCD-R LI __ E0 PVTFRPVT VN ___ M Dter_By

Chd PrePost FU Pr- Post FU Pvost FU p V, os 90 Bo Post FU Pre Post FU

A 2 0 28 28 20 24 24~ Nb Nb 2) Nb 24 2 3 t 58 1.76 2.01 42 10) 93

B 28 36 40 24 36 40 36 34 62 33 40 44 1.79 3.20 4.02 104 -43 173

C 24 28 28 20 3 6 36 Nh 31 34 23 26 30 iN3 1.79 2908 30 64 77

D 28 33 28 20 20 32 Nb Nb 3 0 lb h 3 26 164 1.6t 2.13 67/ 108 94

Note. StCD-Rt = equenciad Inventory of C0 omt 1(7 lion [ei Hopmin (I 1 dIicLun Praithe 'obi i, 1983) 1 cepav conmmunication corc Ii moths

SICDtti = expressive cu inunicttcring sciire Mi inioithxJ EOW Vt 6R 1 Exresivo' On)ordX Piclurt Voc6abulay 'I esAevised (G ar dner 19911) score iRiiMi0tht; PtPVT-R 1 Panbocdv Picluoo Victahma", a~~t-Re'ise (Durino &S Dunn 193 1) Scoon in io-onthsm XIF = oren lenIogth of entterance fromn two 30-miooiite language s umpies, Diversiry =mtean doversity ofval nileatltry fromi nvx 30it-iit lot nguageo s i niples FLi =i folo up; Nb = no bsal established.

focus i'oni proaticve teacboing to tresponsiive teachingoundembeedded prompting into coniver sations and engaigedplay interaccHoris WVhen chLOd-en are enigaged witih aditsin activities at interest to thenqu there ate. marn-Ty opaportiu-niities to teac fLiuncetionad skills without dlisrupip ni teflow of soc ia interaction. It is naossiokb 1b tht for childrenwrith autitsml who may resist a, didactic approach and eveil.dir ect instiructions, the uie of a responsive e-n -ag~ementstrategv m-ay he especialty pinwerU.'tI

Although results ttt this stuely tnd'icate th'is int er,n-tion, was effective, it is iniportant 11oriena bier th vt th-einterventionists whio wsokced with the..e childre we ' elhighly (etueate.d, bad y ears ot expetrtencet woirking withchtldre blletore rhs study, and ree.vew.d intensive. triniangbefote in' rweekly supervisiton duii in the intervetitonpetrtad, Also, the. ehiehreen had to maee llitrninimunirtilertia

to be. tne.nute{ed in the ste.dy, spe.citic ivi the ability to irnii-itate aind prodeiee language oft leac st 10 wsThds. Al ch.ik-dre en wetre selected to he iri tile ran~ge of larngoage abilitiesthat previously has p redticted strang posinive Outconmes ina milieu tdeaning nateivention. (Yodetf Kaiser, Alpert, hFiscbet 1993) Iso we. expected. that alI chTildren wtiuled

bene.fit n rmui the inteervetntioin Resoilts wicth childien -Insinmilar interven-tioins could dlefuintely vary elepending oalie intcivetitionlist' tralininig andi ahilites antd th e il iatc.h

between interv ention eon eent and children5s e ntrv skills.'TIle lev elopmnent af tinteirvention anid tne surernent pro-tocols to fir inidivitduall clhiddren peises a eonsideriblechaillenge fors bohel restaiceiici anmd practitioniers Ibut isneedted to -m ore accnrately characterize the eff ect and ef-fectixveness of nVaturaJistie iananuage intevniOll.o

As Is thie c.ase in nainy studies o)t laniguage intervtenationwitvit childiren withc autismLi the effeets of the inlter'venitiotnwere variable ae.t ass indhvIdualci e.hddren. Cheildieni in tileeurrent studv varied according to age, tested IQ, idt Ian-guage nbidity at the begiinning of the interventaton. In gen-erai, younger ch 1ildlren whoise langua.ge Cievelopnment wasless delayed relative to their age stiowed the. greatest ini-

certases i1n acquisition, mint ienancec, and generalizationat langueaure skluls, hese. resuls ire sinul ai to) ti ose withpaxients wha wxere traintd to -ose EMs/T vwheii interaaeingwithil thetir laiidreii with autism (Kaiser e.t at. 20-00) It ispiossibl e tht die ehildren whLo vere less delaved tn thenrI languae abilities reative to their age reqented less adultsuppar, bath learn, the Interventionist and paient tonalake ptsitiv g ains in their laiguage abilities. Th-e chliledxwho d1il iot tnake the saime gai-ns as the athei thre cs hil-dreni miav have needed mote th-an 24 sessions5 or se.ssionisltonger than 19 miinutes to pirimote pasitive clhanges inhis languaige. The limited numberi of childret inl thisstudy does Itiot allow a forni 1 ianahysi of ehild charac-teristics that might predilct cntled response to) tieatn'enttprtitoco.o IFiiture studies eould expiaore the inatensity antittosageC of lainguage inltervetitions nieedecl to effect pasio

t ve change g iven the differetnt piofile af abhi Ves dientonistrateti hi el-i dureni

It is impor01tant toi niite thi-it although thiere was sortieivariabduiv in laniguage performance amnong the ch.ildren,thaiere wa salso x riability netross ohseirnations for eachchile, 1601 examiple, in ba seline sessions tineire isas a fairt1arge iange in MLU3 'i arss these obseurwatians for all fontchildeiie. (A, tange 1= 1131641 B range 1 39-2.62, C,raiige =1.00-1.86' D, raige 1.23a 2.281) ProfessionalIsneed to he awa=re thait incansisitencx i-n behavior -s tomimoan in clt-ildren with iatisii (L ord, Bristol, o Seheipler1 9931, so itidividnalaize piogramming ten yoong e.hillat rii with autism shouild alwat's inclhide Multiple assess-mne-us and mulitplte Lbservaitiotis to piodote. the. cliearestpicture of chi Its abilities. Inconsistent responding bychildren with autism- also) aftects ttie iesults of the stantO iidize.d test amd devselopmieintal lanignage measures re-potrted in this study. Beecanse there is no way to knrow in.the curient design If developmenit may Laxve contributretito the e.hange.s in child MLSP div'ersity, andi performanceon standaurdized tests, these results must lie interpretedccalttone ly Repllicat'lion with a randotniy assigned control

1'rciner EMT

53

group of children vith autism- w ould be required to con-firm the dev'l(opmrental findlings repoirtec he're.

Children in this stuidy generalfized posirive cha ngesin their iaiiguage skills to interactions with their urn-traimed mi-nohers immediate-lv after the initerventiorn. Al-.1hough these cbanges vere ma intained at the end of thefollow-up period, only on' ch'ild shoiwed evidence ofcontinued accelerarted change ina comm-unication at thefollow' up. If parents had been trained to use simple re-sponsive i iteraction strategies with their children athiome duLring the follow-up period, tl.ey rnig ht hive been,able to) continue to support their children's continuied

language growti.The design used in the current study has limiitations.

In order to imnplement the single subject design, within th--erandomly assignedI treatment groups, we needed no re-strict the nunmbe o f baselinie sessions to contrrof for pre-treatmean expe'rience in the clinic across conditions. Weselected five to sev'en ba selines based on our prevpioussi-glc subject implementations of EMT indicting 'thatchild be~havior is typicu lIar s'table after five sessions. WVeminitiatedI treatment after the pres cribed number of ses-sions; however, in every cse, a clear shift in the inner-vennioInist's im plernenatation aof the Lnterve'ntion occurredimm ediately (see Figures I & 2 ), and modest chang's inchild's total us e of targets (Fig ure 3) were immedianelyohse'rved, The use of combined single so-bject and groupdesigns hias many adIvantag-es but may also constrain theinterp reta tion of the single subject data. Replications ofthe effects of tihe EM T intervention were reen with otherchildren assigned to this trea tment condition six separateth e '-tier'ed mnuitiple baseline ap pl-ications of the treat-ment (Kaiscr en al,, 1,998.). Notably, the effects with chil-

art with autism we're very sirnlIar to those with othe'rchildiren who had arange of different develo~pmental dis-abilities and- nearty identical langTuage stills at entry,

In the Kaiser et al. (2000) study, the children withauisna sho-wed simnilar changes in Iangnag' use in tra in-ing sessions with their parents and slightly sironger gen-eralization to thi-' home setting at the end of intervent-ionand follow up. Child generalization to the' home sendingappeared to be related to p arenits continued use of theFXIT procedures. When parents maintained their u se ofthe pro'edlures, children showed fuLrther ginis in lIn-iguag uens.

For children with ant'sma, it is importanut to consid:erthe range of possib le supports for devieloping commu-nilcation skills. Interventions that employ b oth skilled in-terventionists (e.g., speech-language clinic'ians, earlychildh-ood special 'ducation teache'rs) and parenits miayhelip children a ccelerate their language de'velopment anduse. Investigations of multiple partner interventions tosuapporn comnmunication in everydlay setting: and to pro-mote generafizatrion and maintrenance are needled.

1, T Ihis research was supported in part by Gra nt HDID50OSi andHD27563 fiomT NJCHHD.

2. We thiank the parents anid childreni who participated in this stuldy.We ailso gratefully acknowledge the technical suipport for the con-duict of the stuidy anid analysis of data providied by the MilieuiTeaching Group at Va nderbilt University, especaialy MauireeniKeefer.

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TITLE: The effects of trainer-implemented enhanced milieuteaching on the social communication of children withautism

SOURCE: Topics in Early Childhood Special Education 22 no1 Spr2002

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