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Teaching prelinguistic communication skills to school age children with autism

Dissertation
Author: Jessica Hetlinger Franco
Abstract:
Prelinguistic Milieu Teaching (PMT) is an intervention designed to teach young children to initiate nonverbal communication using vocalizations, gestures, and eye-gaze. Children are taught through social routines in their natural environment. Techniques include contriving an environment in which the children will be motivated to communicate and using a hierarchy of prompting and modeling to evoke the desired communicative behaviors, such as requesting and commenting. PMT has been previously studied in young children (ages 1-5) with developmental delays. In this study, it is implemented with six school-age children with Autism (ages 5-8). A multiple baseline design across participants was used to evaluate the effects of the intervention on the variables of frequency, clarity, and maintenance of the participants' communication. All six participants showed increases in the targeted prelinguistic communication skills during treatment and maintained the increases during follow-up. Analysis of individual behavioral profiles was helpful for disambiguating individual differences in response to intervention across the three variables. Future research should target generalization of learned behaviors across implementers and settings.

Table of Contents List of Tables....................................................................................................xiii List of Figures...................................................................................................xiv List of Figures...................................................................................................xiv CHAPTER 1 1 Introduction.........................................................................................................1 Autistic Disorder........................................................................................1 Development of Meaningful Prelinguistic Communication.........................3 Caregiver Responsiveness..................................................................4 Gestures.............................................................................................4 Vocalizations.....................................................................................5 Eye Contact.......................................................................................6 Rationale for Teaching Prelinguistic Communication.................................6 Interventions for Teaching Prelinguistic Communication Skills..................9 Prelinguistic Milieu Teaching...................................................................12 Populations Previously Studied Using PMT..............................................13 Statement of Purpose................................................................................14 CHAPTER 2 16 Review of the Literature....................................................................................16 Development of Prelingustic Communication...........................................17 Intentional Communication..............................................................17 Pragmatic Functions.........................................................................19 Means of Communication................................................................21 Eye-gaze.................................................................................22 Gesture....................................................................................23 Vocalizations...........................................................................24 Discourse Organization....................................................................25 Development in Children with ASD.................................................26

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Individual Differences......................................................................27 Summary.........................................................................................28 Empirical Study of PMT...........................................................................28 Preliminary Efficacy Studies............................................................28 Comparative Studies........................................................................31 Combination of PMT and RE...........................................................33 Specific Disorder Categories............................................................35 Summary.........................................................................................37 Discussion................................................................................................40 Overall Quality of Evidence.............................................................40 Limitations of the Current Research.................................................41 Conclusions.....................................................................................43 CHAPTER 3 44 Methodology.....................................................................................................44 Participants...............................................................................................45 Inclusion Criteria.............................................................................45 Participant Descriptions...................................................................47 Participant Test Results....................................................................48 Recruitment.....................................................................................49 Setting......................................................................................................50 Target Behaviors......................................................................................50 Procedures................................................................................................52 Assessment (pre-baseline)................................................................53 Parent Interview......................................................................54 Receptive Expressive Emergent Language Scale-3 rd Edition....54 Childhood Autism Rating Scale...............................................55 Communication Sample..........................................................56 Baseline (pre-treatment)...................................................................58 Intervention (treatment)....................................................................58 Enabling Context.....................................................................58

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Teaching Episodes...................................................................59 Follow-up (post-treatment)...............................................................60 Experimental Design................................................................................61 Data Collection and Analysis....................................................................62 Video Review and Coding...............................................................62 Frequency of Child-initiated Communication..........................63 Clarity of Child-initiated Communication................................64 Maintenance of Social Interactions..........................................65 Child Versus Adult Initiation of the Communication...............65 Pragmatic Function of the Communication..............................66 Graphing..........................................................................................67 Methodological Supports..........................................................................68 Interobserver Agreement..................................................................68 Treatment Fidelity............................................................................69 Social Validity.................................................................................70 Post-Hoc Analysis....................................................................................72 CHAPTER 4 74 Frequency of Child-Initiated Communication Acts...................................74 Clarity of Child-Initiated Communication Acts.........................................77 Maintenance of Communication Within Social Interactions......................79 Additional Study Variables.......................................................................81 Child Versus Adult Initiation...........................................................81 Pragmatic Functions.........................................................................82 Individual Differences..............................................................................83 Communication Skills Prior to Treatment.........................................83 Parent Variables...............................................................................84 Post-hoc Analysis of Behavior Profiles............................................84 Methodological Supports..........................................................................85 Interobserver Agreement..................................................................85 Treatment Fidelity............................................................................86

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Social Validity.................................................................................87 CHAPTER 5 89 Discussion.........................................................................................................89 Summary of Results..................................................................................91 Frequency........................................................................................91 Clarity..............................................................................................92 Maintenance.....................................................................................94 Summary.........................................................................................96 Individual Differences..............................................................................99 Chronological Age...........................................................................99 Language Skills..............................................................................100 Autism Severity..............................................................................101 Parent Responsivity.........................................................................101 Behavioral Profiles..........................................................................102 Summary........................................................................................103 Limitations of the Study...........................................................................104 Evidence Based Practice.................................................................105 Independent Confirmation and Converging Evidence......................106 Experimental Control......................................................................107 Subjectivity and Bias......................................................................107 Effect size and Confidence Intervals...............................................108 Relevance and Feasibility................................................................109 Summary........................................................................................111 Conclusions.............................................................................................111

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APPENDIX A: 115 Parent Interview Questions...............................................................................115 APPENDIX B 117 Recruitment Flyer.............................................................................................117 APPENDIX C 118 Examples of Gestures.......................................................................................118 APPENDIX D 119 CARS Categories.............................................................................................119 APPENDIX E 120 Coding Sheet....................................................................................................120 APPENDIX F 121 Coding Guidelines............................................................................................121 APPENDIX G 124 Participant Social Routines...............................................................................124 APPENDIX H 125 Social Validity Rating Sheet.............................................................................125 APPENDIX I 126 Individual Session Results for Initiation...........................................................126 APPENDIX J 129 Individual Session Results for Pragmatic Function...........................................129 APPENDIX K 132 Paired Samples Test and Statistics for Individual Participants...........................132 References........................................................................................................134 VITA 150

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List of Tables Table 1: Communicative functions proposed by Wetherby and Prizant (1989)...19 Table 2: Communicative functions proposed by Sigafoos et al. (2000)...............20 Table 3: Summary of PMT studies..................................................................37 Table 4: Participant descriptions.......................................................................48 Table 5: Pre-study scores on REEL-3 and CARS...............................................48 Table 6: Description of pragmatic functions......................................................51 Table 7: Description of adult intervention techniques........................................60 Table 8: Behavioral profile definitions..............................................................73 Table 9: Comparison of child-initiated versus adult-initiated communication acts during intervention sessions..........................................................81 Table 10: Comparison of communicative functions during intervention sessions 82 Table 11: Participant’s communication skills prior to implementation of study as reported in parent interview..........................................................83 Table 12: Frequency of parent behaviors during 10 minute communication sample .....................................................................................................84 Table 13: Mean percentage of interval occurrence of potential predictive behaviors during baseline.............................................................................85 Table 14: Average percentage of interobserver agreement................................86 Table 15: Average treatment fidelity percentages..............................................86 Table 16: Number of raters, means, and standard deviations for each calculation87 Table 17: Significance and effect size of each calculation..................................87

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List of Figures Figure 1: Frequency of child initiated communication acts per session.............76 Figure 2: Comparison of frequency of child-initiated communication acts using one, two, or three unprompted communicative means...........................78 Figure 3: Average number of child turns per social routine or interaction.........80

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CHAPTER 1 Introduction School-age children with autism who never develop the use of symbolic spoken language may have to rely solely on prelinguistic communication modes. However, these children often demonstrate deficits in prelinguistic communication skills as well (Mundy & Crowson, 1997). As a result, they may have ineffective means to consistently communicate their needs and ideas about the world. Intervention targeting their capacities for acquiring consistent and mature levels of prelinguistic communication skill can improve these children’s overall level of function in social interactions within their environment. This chapter explores the use of Prelinguistic Milieu Teaching (PMT) to facilitate consistency in using recognizable prelinguistic communication means for school age children diagnosed with autism. PMT (Yoder & Warren, 1998) is a teaching protocol aimed at facilitating early communication development. It has been studied with younger, developmentally delayed children. It has not been evaluated for efficacy with older children diagnosed with autism who may potentially persist in use of prelinguistic levels of communication across their lifespan. Research-based evidence is needed before this intervention can be validly applied to this group of children. AUTISTIC DISORDER To provide a framework for this study, autistic disorders must first be defined. The term “autism” is used when a child under 3 years of age begins to display marked

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deficits in several behavioral domains, including communication, social interaction, and adaptive behavior (American Psychological Association, 1994). Within these developmental domains, the severity of behavioral abnormalities varies across children, representing a spectrum of expression for patterns of disorder considered as definitive for an autism diagnosis. Thus, an autistic disorder is often referred to as autism spectrum disorder (ASD). Individual children with ASD differ in intelligence level and in use of symbolic language. However, all ASD children exhibit abnormalities in relating to other persons (Trevarthen, Aitken, Papoudi, & Robarts, 1996). It is estimated that autism affects at least 1 of 500 children worldwide, regardless of culture, race, socioeconomic status, or parental characteristics (National Research Council, 2001). The majority of children diagnosed with autism demonstrate a severe and pervasive level of disorder throughout their lifespan (Harris, 2000). Predictors such as an IQ below 50 and absence of communicative speech by age 5-6 are indicative of poor long-term outcome, including severe restriction of social and adaptive functioning in adulthood (Nordin & Gillberg, 1998). Recent estimates suggest that as many as one half of all children with autism remain nonverbal after age 5 (National Research Council, 2001). These children are also at risk for failure to develop purposeful nonverbal communication skills (Whalen & Schreibman, 2003). Intervention to develop a consistent and intelligible means of functional communication is a priority for educators of children with autism. However, providing communication intervention for children with autism is a challenging task. For older children who remain nonverbal, slower progress is likely and few methods have been

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evaluated carefully for their efficacy in supporting the autistic child’s development of a maximally functional communication system relative to their cognitive and social impairment level (Goldstein, 2002). To make decisions about appropriate interventions for children who have little to no means of functional communication, clinicians must consider the basic nature of communication acts. Such considerations would include: (a) understanding of typical prelinguistic development, (b) the effectiveness of the child’s communication in terms of recognition and interpretation of the communication attempts by communication partners, and (c) presence of research-based evidence to support the use of an intervention technique or program relative to the unique needs of children with autism who are functioning at a prelinguistic communication level. DEVELOPMENT OF MEANINGFUL PRELINGUISTIC COMMUNICATION As a context for understanding the importance of prelinguistic communication to later emergence of language capacities, the nature of language development will be examined. Three broad areas of communication develop during the first several years of life: behavior regulation, social interaction, and joint attention (Bruner, 1981). Behavioral regulation involves requesting objects and actions to get another person to respond to perceived needs. For example, a child may simultaneously give a toy and look at another person in hopes of getting that person to activate the toy. Social interaction involves gaining or sharing another’s attention. A child might engage with another person in a turn-taking game, such as passing a ball back and forth. Finally, joint attention is communication that directs another person’s attention to an item or event. A child may point to a dog across the street and look at an adult to draw their attention to the dog.

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Each of these communicative functions emerges prior to the development of intentional, linguistic communication, which involves use of recognizable words for referring to objects, persons or events (Bruner, 1981). Caregiver Responsiveness Beginning at birth, infants and caregivers engage in face-to-face interactions that create an initial means for development of communication. During the first 6 months of life, a typically developing infant begins to produce sounds, gestures, and facial expressions during these face-to-face episodes (Mundy & Willoughby, 1998). Initially, the infant’s behaviors are non-symbolic or preintentional, indicating that they are not part of a symbolic communication system in which a specific behavior corresponds to an explicit meaning (Siegel-Causey & Guess, 1989). The child does not intend to communicate. Nonetheless, caregivers often recognize these behaviors and respond with attention and interaction. Parent responsiveness has been found to be a critical factor in children’s early language development (Brady, Marquis, Fleming, & McLean, 2004; Calendrella & Wilcox, 2000). Around 6 months, children begin to use these nonverbal communicative behaviors purposefully for behavioral regulation (Mundy & Willoughby, 1998). They may begin purposefully vocalizing, gesturing or making eye-contact with adults to non-verbally request something they desire. Gestures Gestures most generally involve actions produced with the arms, hands, and fingers (Iverson & Thal, 1998). Three basic types of gestures develop between 8-24 months: deictic, representational, and conventional. Deictic gestures involve actions used

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to direct attention to an object or event (Crais, Douglas, & Campbell, 2004; Goldin- Meadow, 2003). Representational gestures are in some way symbolic of the object or event of interest (Acredolo & Goodwyn, 1988, 1996; Capirci, Iverson, Pizzuto, & Volterra, 1996). For example, a child may put his fingers to his mouth to indicate that he wants to eat a cookie. Finally, conventional gestures represent a social action rather than an object. They include actions such as waving bye, blowing a kiss, or placing a quiet finger to the mouth (McNeill, 1998). Vocalizations As children develop motor movements for gestures, they simultaneously develop motor coordination to support production of sounds. Before children produce spoken words, they produce various sounds and sound combinations (see Oller, 2000, for a review of early vocal development). By 6 months of age, children typically produce a variety of consonants and combine consonants with vowels. Early vocalizations may include both repetition of a consonant-vowel syllable sequence, often with sounds such as “buh-buh-buh” and strings of varied sounds and syllables such as “didadidijaja” (Davis & MacNeilage, 1995; Mitchell & Kent, 1990). These vocalization strings will likely contain variable intonation patterns and resemble meaningful words; yet specific vocal means are not yet attached to precise lexical meanings (Nathani, Ertmer, & Stark, 2006). Over the next 6 months, between 12-18 months of age, the children begin to develop specific vocalizations to indicate particular communicative intent (Watt, Wetherby, & Shumway, 2006).

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Eye Contact The use of vocalizations and gestures is frequently coupled with the use of eye- contact, or the connection of the child’s eye-gaze with another person’s. Direct eye- contact and facial expressions such as smiling may be the first behaviors used to indicate that the child wants more interaction with an adult. From birth to about 3 months, eye- gaze is primarily dyadic and involves prolonged gaze between the infant and another (Levelli & Fogel, 2002). Around 3-4 months, infants begin to turn attention and eye gaze away from their mother and toward objects and events in the environment (Lohaus, Keller, Kissmann, Ball, Borke, & Lamm, 2006). Around 9-12 months, infants begin to use eye-gaze to initiate reference of the objects and events to adults (Mundy, Block, Delgado, Parmares, Van Hecke, & Parlade, 2007). The child may look toward an object and then toward an adult. Eye-contact can also be used to initiate a social interaction or routine such as requesting a toy. Social interaction often develops through social games involving the presence and absence of eye-gaze, such as peek-a-boo, where a child and parent are involved in a series of turns. In the case of the peek-a-boo game, for example, these turns may involve a series of non-verbal behaviors such as: 1) making eye-contact, 2) covering the face with hands, (3) removal of the hands from the face to reproduce the eye-contact. RATIONALE FOR TEACHING PRELINGUISTIC COMMUNICATION The use of prelingustic communication means, such as vocalizations, gestures and eye-contact, establishes an important foundation for future development of linguistic communication, or the use of words with consistent referents (Watt, Wetherby, &

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Shumway, 2006; Brady, Steeples, & Fleming, 2005; Calendrella & Wilcox, 2000; Smith, Mirenda, & Zaidman-Zait, 2007; Brady, Marquis, Fleming, & McLean, 2004; McCathren, Yoder, & Warren, 1999; Acredolo & Goodwyn, 1988; Iverson & Goldin- Meadow, 2005). Several studies have suggested that prelinguistic communication might form an important link to development of spoken language skills for many children with typical development as well as those with developmental disabilities. Calandrella and Wilcox (2000) observed 25 toddlers with global developmental delays ages 17-59 months. They found that rate of intentional nonverbal communication, such as use of gesture, was a predictor of spontaneous word productions 12 months later. McCathren, Yoder, & Warren (1999) examined rate of non-word vocalizations in 58 toddlers with developmental delays, ages 17-34 months. They found that rate of vocalizations was positively correlated with expressive vocabulary 12 months later. Similarly, Brady, Marquis, Fleming, and McLean (2004) found that rate of gestures was also correlated with future expressive language outcomes on standardized testing in children ages 3-6 with developmental delays. Initiating joint attention through eye gaze was also found to predict expressive language outcomes in typically developing children (Mundy & Gomes, 1998). These studies suggest that development of prelingustic communication means means a first step in the continuum toward acquisition of symbolic language. Their presence in children determined to have developmental delays appears to be predictive of later level of function. Development of nonverbal communication skills, such as gestures and vocalizations, represents a potentially important step associated with development of meaning-based verbal language.

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Children with autism often experience persistence of severe to profound delay in the onset of language skills (Paul, 2006). These children may not develop the social, motor, cognitive, or perceptual abilities to develop symbolic spoken language. Thus, prelinguistic communication may represent the end state of their communication capacities. As a result, they must continue to rely on prelinguistic means to communicate across their lifespan. Achievement of consistent prelinguistic communication capacities may enable a wider range of overall functional interactions within the child’s social environment. With a consistent set of communication skills that are readable by individuals in the environment, children who operate at a prelinguistic communication skill level will have a means to communicate consistently in absence of symbolically based linguistic ability. Importantly, establishing a broad range of communicative means may allow an individual to increase the clarity of communicative intentions. For example, the combination of a vocalization with a gesture and eye-contact may create a more consistent and recognizable means of communication for getting an adult to support communication about need for using the toilet. The more consistently the child communicates, the more easily caregivers will be able to interpret and respond to those communication attempts (Keen, Sigafoos, & Woodyatt, 2001). When children begin to communicate to achieve important functions in the environment, caregivers can, in turn, begin to attend and respond to the child’s communication attempts. Thus, caregiver responsivity plays a crucial role in further development of communication skills. In the case of an older, nonverbal child who is not likely to develop spoken words, an increase in “communication skills” might be

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quantified by the frequency of initiated communication acts with an adult caregiver. Over time, the child’s increase in clear and readable means of communication and the parent or caregiver’s increasing responsiveness interact to mutually create more complex and consistent interactions (Skinner, 1957; Sameroff, 1975; Tomasello, 2003). INTERVENTIONS FOR TEACHING PRELINGUISTIC COMMUNICATION SKILLS Several contemporary intervention approaches focus on teaching nonlinguistic communication acts will be discussed to understand the range of contemporary interventions targeting prelinguistic communication skills. These include Hanen Parent Training Program (Hanen; Girolametto, 1988), Picture Exchange Communication Systems (PECS; Bondy & Frost, 1994), and Prelinguistic Milieu Therapy (PMT, Yoder & Warren, 1998). All of these interventions are focused on populations of young children with developmental delays who are not yet demonstrating verbal or symbolic language based communication skills. For older children and adults with severe disabilities, communication intervention more frequently focuses on communication repair (Brady, McLean, McLean, & Lee, 1995; Halle, Brady, & Drasgow, 2004) or functional communication training (FCT; Carr & Durand, 1985). The goal of the Hanen parent training program (Girolametto, 1988) is to train parents to respond to their child’s communication acts. Parents are taught techniques such as following the child’s lead, imitating the child, and simplifying language models (Girolametto, Pearce, & Weitzman, 1996). Picture Exchange Communication Systems (PECS; Bondy & Frost, 1994) focuses on teaching the use of pictures or symbols to support emergence of the pragmatic

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intention of “requesting” or “commenting”. The child is taught to select pictures for initiating a request in a highly structured sequence of levels and stages. PECS has been supported empirically in a number of studies (see Lancioni, O’Reilly, Cuvo, Singh, Sigafoos, & Didden, 2006, for a review of PECS literature). Available studies have been conducted primarily on children with autism spectrum disorders (ASD) and have targeted only a small range of prelinguistic skills (e.g., requesting). The goal of communication repair (Brady, McLean, McLean, & Lee, 1995) is to teach strategies to repair failed communication attempts (i.e., “breakdowns”) by teaching the individual to modify a request (Halle, Brady, & Drasgow, 2004). A communication breakdown occurs when an individual makes a request, but caregivers fail to recognize or respond to the communication act consistently (Brady & Halle, 2002). With communication repair, the individual is taught two or more means of the same communication response to enable a variety of means to communicate. Communication repair is a relatively new intervention in the beginning stages of developing empirical support. The goal of Functional Communication Training (FCT; Carr & Durand, 1985) is to teach appropriate communicative responses to use in lieu of challenging behaviors such as aggression or screaming, which are thought to be functioning as communication acts (Durand, 1990). Responses are chosen based on the results of a functional analysis (Iwata, Dorsey, Slifer, Bauman, & Richman, 1994), where a specific behavioral consequence maintaining the challenging behavior is identified. While FCT may include the use of prelinguistic means, most FCT studies have been conducted on verbal

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individuals or individuals using augmentative communication (see Mancil, 2006, for a review of FCT intervention with children with autism). Finally, the goal of Prelinguistic Milieu Teaching (PMT; Yoder & Warren, 1998) is to establish intentional communication (e.g., requests and comments), as well as build turn-taking within social routines. Vocalization, eye-gaze, and gestures are included as target behaviors in PMT intervention routines (Warren, Bredin-Oja, Fairchild, Finestack, Fey, & Brady, 2006). Intervention procedures are embedded in social and play activities occurring within the child’s natural environment (Fey et al., 2006). A series of studies have been conducted to evaluate PMT with young children diagnosed with developmental language delay (e. g. Yoder & Warren, 1998, 1999, 2001, 2002; Fey et al., 2006; Yoder & Stone, 2006a, 2006b). Studies evaluating PMT have been conducted by the originators of the approach. These prelinguistic interventions offer diverse methods for teaching differing aspects of prelinguistic skills. Each carries the implication that teaching prelinguistic skills means a necessary pre-requisite for later symbolic language acquisition. Approaches vary in the level of empirical support, commercial availability, and methods employed. They are also diverse in the comprehensiveness of communication behaviors targeted for intervention relative to the spectrum of pre-linguistic communication skills described in theoretical approaches focused on understanding the nature and factors underlying pre-linguistic communication development.

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PRELINGUISTIC MILIEU TEACHING Of the various interventions available, PMT (Yoder & Warren, 1998) has the targets the broadest span of prelinguistic communicative behaviors described as underlying communication development. Further, PMT intervention has a clearly established history of research validation. However, PMT has only been tested on young children under the age of 5 described clinically as “developmentally delayed”. The key component of PMT intervention is to create an “enabling context” for use of prelinguistic behaviors by arranging the environment and using social routines. Social routines implemented are repetitive and intended to model predictable interactions between the child and the adult (Warren et al., 2006). PMT techniques include a hierarchy of prompts, models, and natural consequences. Prompts may include physical, verbal, or gestural cues that it is the child’s turn to communicate. For example, the adult may ask the child, “What do you want?” Models of appropriate gestures and vocalizations at the child’s communication level are given during the intervention, such as saying “ba” while giving the child a ball. However, the child is not prompted to directly imitate these behaviors. When the child engages in a target behavior, natural consequences such as responding to the request or smiling and nodding are used. Additionally, the adult may use verbal recasting to put the child’s nonverbal communication into words. If the child points to an item, for example, the adult may model the spoken word for the item. No materials or guidebook are available. Procedures for PMT have been described in a series of studies completed by the researchers who developed the intervention. The researchers describe PMT in terms of the transactional approach to language acquisition (Sameroff, 1975), where child variables such as

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communication initiation and environmental variables such as parent responsivity influence each other over time. POPULATIONS PREVIOUSLY STUDIED USING PMT Prelinguistic Milieu Teaching as it is presently supported in available research appears to be appropriate for Anglo and African-American children ages 2-5 who are nonverbal and functioning at the 9-15 month level of communication development (Yoder & Warren, 1998, 1999, 2001, 2002; Fey et al., 2006; Yoder & Stone, 2006a, 2006b). While present research on PMT indicates that it is a promising intervention for teaching prelinguistic skills to young children with disabilities, no evidence of this approach is available to help guide clinicians in terms of implementation of PMT in the population of older children who have more severe disabilities. These broader considerations could have an impact on populations with high vulnerability to persistence of function at the pre-linguistic level of communication development. In addition, autistic children being raised within culturally and linguistically diverse groups have not been studied to understand the potential effects of cultural diversity on outcomes of PMT intervention. Evaluation of the efficacy of PMT with differing types of developmental disabilities, different chronological and developmental ages, from different cultural environments is needed to establish the general validity of PMT with children who may persist in use of prelinguistic levels of interaction to meet their basic communication needs in the environment. School-age children with autism who demonstrate persistence of communicative behaviors at a prelinguistic level represent one such sub-population.

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Of the various disability categories where prelinguistic communication may be an intervention target, children with autism are consistently described as being at risk for failure to develop functional prelinguistic communication skills (Whalen & Schreibman, 2003). These early skills form relevant intervention goals for these children who may not yet acquire spoken or linguistically-based communication. Prelinguistic communication skills may develop at a later age or fail to emerge at all (Brady, Marquis, Fleming, & McLeon, 2004). Furthermore, such children will likely persist in functioning at a prelinguistic level of communication for a long period. In some cases, prelinguistic function may represent a developmental endpoint for communication (Paul, 2008). STATEMENT OF PURPOSE The goal of this study was to evaluate the effectiveness of PMT (Yoder & Warren, 1998) as an intervention for school-age children diagnosed with autism spectrum disorders who exhibit severe and persisting levels of communication disability. PMT intervention techniques were implemented to evaluate efficacy related to increasing overall intentional communication during and following treatment. The children were taught to use gestures, eye-contact, and vocalizations as a means to take turns in functional communicative interchanges and to accomplish the pragmatic intentions of “request”, “comment”, “negate/protest”. The following questions quided the study: 1) What is the effect of PMT on the frequency of the child’s communication measured by the rate of child-initiated communication acts? 2) What is the effect of PMT on the clarity of child’s communication measured by consistency of use of combined means of communication?

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3) What is the effect of PMT on the maintenance of child-adult interactions within an activity measured by the number of child communication turns? The predicted hypothesis is that implementation of PMT will result in increases in frequency, clarity, and maintenance of communication exchanges.

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CHAPTER 2 Review of the Literature Prelinguistic Milieu Teaching (PMT) is an intervention designed to support teaching communication skills to children operating in the prelinguistic period of communication development (Warren, Bredin-Oja, Fairchild, Finestack, Fey, & Brady, 2006). With PMT, a child is taught specific nonverbal communication skills, such as gestures and eye gaze, through procedures embedded into social interaction within the child’s natural environment. Therapists use natural prompts and responses to encourage the child to make requests and comments through nonverbal means (e.g., pointing). Prelinguistic communication skills form relevant intervention goals for children with a variety of developmental disabilities who have not yet acquired spoken language communication capacities. To make decisions about appropriate interventions, clinicians and teachers must evaluate research-based evidence supporting the use of an intervention technique or program (IDEA, 1997). While PMT is a promising intervention for teaching prelinguistic skills to children with disabilities, no meta-analysis of this approach is available to guide clinicians regarding empirical evidence for PMT. The goal of this synthesis is to critically examine empirical support for the PMT approach to teaching prelinguistic communication skills as well as to consider applications with chronologically older children diagnosed with autism where persistence of prelinguistic level of function across the life span may be expected.

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This chapter will provide a review of the development of prelinguistic communication skills in typically developing children, considerations for prelinguistic development in children with autism, and a critique of the current literature on Prelinguistic Milieu Teaching (PMT). DEVELOPMENT OF PRELINGUSTIC COMMUNICATION Early communication skills targeted with PMT intervention include skills that typically develop between 9-15 months (Warren, Bredin-Oja, Farichild, Finestack, Fey & Brady, 2006). The focus is the development of intentional communication across multiple pragmatic functions, including requesting and commenting. At this level, intentional communication is typically in the form of vocalizations, gestures, and eye gaze as they are combined to convey meanings to an adult caregiver. Play and daily routines provide the context for learning to use intentional communication, through the development of turn-taking and imitation skills (Bakeman & Adamson, 1984). This section will provide a structure for understanding how these capacities develop during the developmental period of prelinguistic communication in typically developing children. Intentional Communication Intentionality is when a child deliberately engages in a behavior meant to communicate with another, knowing that a listener will receive the message and act on it (Westling & Fox, 2004). At some point in the first 12 months, a child’s behaviors become purposeful and meaningful. This important transition in language acquisition was first

Full document contains 166 pages
Abstract: Prelinguistic Milieu Teaching (PMT) is an intervention designed to teach young children to initiate nonverbal communication using vocalizations, gestures, and eye-gaze. Children are taught through social routines in their natural environment. Techniques include contriving an environment in which the children will be motivated to communicate and using a hierarchy of prompting and modeling to evoke the desired communicative behaviors, such as requesting and commenting. PMT has been previously studied in young children (ages 1-5) with developmental delays. In this study, it is implemented with six school-age children with Autism (ages 5-8). A multiple baseline design across participants was used to evaluate the effects of the intervention on the variables of frequency, clarity, and maintenance of the participants' communication. All six participants showed increases in the targeted prelinguistic communication skills during treatment and maintained the increases during follow-up. Analysis of individual behavioral profiles was helpful for disambiguating individual differences in response to intervention across the three variables. Future research should target generalization of learned behaviors across implementers and settings.