The Miller Method: A Cognitive-Developmental Systems Approach for Children with Body Organization, Social, and Communication Issues1

 
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                         489

                                                    19

                   The Miller Method®:
      A Cognitive-Developmental Systems Approach
          for Children with Body Organization,
           Social, and Communication Issues1
            Arnold Miller, Ph.D., and Eileen Eller-Miller, M.A., C.C.C.-S.L.P.

  WHAT IS THE MILLER METHOD®?                            developmentally organized interventions
                                                         introduced by teachers and therapists.
    The Miller Method is an integrated                       The Miller Method is guided by a cogni-
approach that addresses problems of body                 tive-developmental systems theory with links
organization, social interaction, and communi-           to the work of Piaget (1948, 1954, 1962), von
cation in school, clinic, and home settings as           Bertallanfy (1968), Vygotsky (1962), Werner
presented by children on the autistic spectrum           (1948), and Werner and Kaplan (1963) and is
as well as those with significant challenges in          adapted to the needs of children with severe
learning or communication. Integrated means              developmental challenges. It was developed
that, in this approach, each person working              by the authors during the last 40 years
with the child—while focusing on one aspect              (Miller, 1963, 1968, 1991; Miller & Eller-
of the child’s functioning—also addresses                Miller, 1989; and Miller & Miller, 1968,
                                                         1971, 1973). Current outcome research
other areas of concern. It is also a coordinat-
                                                         includes studies by Cook (1998), Messier
ed program in that each person working with
                                                         (1971), Miller and Miller (1973), and Warr-
the child is in close touch with and con-
                                                         Leeper, Henry, and Lomas (1999).
tributes to others working with that child. It is
                                                             The approach is cognitive because it
an action-oriented program, which assumes                deals with the manner in which children
that children learn best when they move and              organize their behavior, develop concepts of
make direct physical contact with things and             time and space, problem solve, and form
people. It also assumes that children learn
best when they are taught or treated by those
                                                         1
who understand that they require a combina-               The Miller Method is currently in practice at schools
                                                         and clinics within six States as well as in Canada and
tion of both support and demand. Greenspan               other countries, under videoconferencing consultation
and Wieder (2000) refer to the present                   arrangements with the Language and Cognitive
approach as “semistructured,” in that the peo-           Development Center in Boston, Massachusetts. For
                                                         additional information, contact the Language and
ple working with a child are guided both by              Cognitive Development Center at (800) 218-5232 or
the initiatives of the child and by certain              through its website: www.millermethod.org.
490                                                                    ICDL Clinical Practice Guidelines

relationships with people. It is developmental      an object with their hands or with a stick can
because it deals with the ability of children to    be taught to do so in a way that helps fill in a
shift from action stages of functioning to          developmental gap by establishing, often for
communication and representation of reality         the first time, their ability to act on and influ-
through various symbolic forms. It also is a        ence objects and events in their surroundings.
systems approach because it views the                    Another important strategy is having the
formation and use of systems as indispensa-         therapist narrate, with signs and spoken words,
ble to the entire array of human performance.       what the children are doing while they are doing
    The goals of the Miller Method are to:          it. We find that such narration helps the children
• Assess the child’s capacity to interact           relate the words and signs to their own actions.
    with people and objects, adapt to change,       As this happens, they seem to become more
    and learn from experience.                      aware of themselves and to begin to develop the
• Build the child’s awareness of her own            inner speech so important in communicating
    body as it relates to objects and people.       both with themselves and with others.
• Guide children from closed, disconnected,              This process is facilitated by elevating the
    or scattered ways of being into functional,     children 21/2 feet above the ground on an
    social, and communicative exchanges.            Elevated Square or similar structure. Ele-
• Provide the necessary transitions from            vating the children seems to enhance not only
    concrete to more abstract symbolic              word-sign guidance of behavior but also to
    functioning.                                    induce an awareness of body/self and others,
                                                    more focused and organized planning of
Unique Aspects of the Miller Method®                behavior sequences, and better social-emo-
                                                    tional contact. It also provides a framework in
    Among the novel features of the Miller          which the children can more readily be taught
Method are its pragmatic use of two major           to transition without distress from one engag-
strategies. The first is the exploitation for       ing object or event to another. In addition to
developmental gains of the aberrant systems,        work on the Elevated Square and other such
or “part systems,” the children bring. The          structures, special programs are introduced
assumption behind this strategy is that all         during the day to help children develop both
organized behaviors—even those that are             spoken and written language. These pro-
aberrant—have within them the potential for         grams are described later in this chapter.
developmental gain. For example, atypical
behavior systems of children with disorders            DEFINING CENTRAL CONCEPTS
(e.g., lining up things, flicking light switches,
or flushing toilets) can often be transformed           Before discussing assessment and inter-
into functional, interactive behaviors.             vention, it is desirable to define and discuss
    The second major strategy is the system-        the concept of systems and the various roles
atic introduction of developmentally relevant       that systems play in the economy of both typ-
spheres (repetitive activities concerned with       ical children and those with disorders.
objects and people) to repair developmental
lags and restore developmental progressions.                           Systems
For example, children who have never expe-
rienced picking up and dropping objects or              Systems are organized, coherent “chunks”
who have not learned that they can push over        of behavior that are, initially, quite repetitive.
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                    491

They involve the child acting with the body on          her arm to restore the interrupted system. As
or with some object, event, or person in a pre-         discussed later, the careful interruption of
dictable manner. A 10-month-old baby repeti-            systems is an important technique for helping
tively involved in picking up and dropping              children initiate actions or words to help
everything on the food tray is involved in a            repair their “broken” systems.
system, as is the 15-month-old toddler repeat-               Interrupting systems is also used to moti-
edly filling and emptying a sand bucket.                vate a child. For example, one child who at
There are also interactive systems, such as             first refused to use a rake to get a disc that
when the12-month-old plays peek-a-boo with              was out of reach did so when the therapist
her mother, an 18-month-old child realizes              proceeded as follows. First, the therapist
that after the ball is rolled to her she is to roll     helped the child establish a disc-in-bottle sys-
it back, or when the small child holds up his           tem by having the child repeatedly put discs
arms to communicate a desire to be picked up.           in the slit on top of a bottle until the child did
Systems also are involved in symbolic play,             this completely on his own. Then, the thera-
such as when children begin to feed their dolls         pist interrupted this system by placing the
in the manner in which they themselves are              disc out of the child’s reach while placing the
fed. When children are able to indicate objects         rake between the child and the disc. At this
by pointing, gestures, or words, these ges-             point, the child immediately used the rake to
ture/word relations to various objects, events,         bring the disk closer so that he could restore
or people are systems that may be regularly             the interrupted system by continuing to place
reactivated by the sight of particular referents.       the disks in the slit on top of the bottle.
    Systems vary in their complexity from                    Unlike typical children, those on the autis-
the simplest one-component systems such as              tic spectrum as well as those with other devel-
pick up/drop, which are referred to as mini-            opmental issues show system aberrations that
systems, to more complex, multistep systems             interfere with their performance and develop-
leading to a particular goal. The latter are            ment: They may, for example, tend to become
referred to as integrative systems as, for              so overinvolved with things and events that
example, when a child learns to climb up                they are unable to detach from them, as does
steps to go down a slide or to open a cup-              the child who perseveratively flicks on and off
board door to get something inside. Children            light switches or television sets. Alternatively,
who are able to address previously developed            these children may be so uninvolved or dis-
(internalized) systems in new ways (sponta-             connected from things and people around
neous expansions) have a basis for problem              them, that there is little basis for building or
solving and creative thought and play.                  sustaining relations with either things or peo-
    The hallmark of all systems is the invest-          ple. This means that before such children can
ment the child has in maintaining or continu-           progress, careful attention must be given to
ing them. This investment becomes apparent              their system problems.
when a particular system is interrupted. For
example, a 15-month-old child involved in a                   Steps in the Early Formation,
system of putting on and taking off a series of                    Maintenance, and
bracelets on her arm became very distressed                      Expansion of Systems
when a bracelet was taken—crying, pointing
at the desired bracelet and even trying to say              For children with disorders to develop, it
the word—in an effort to have it replaced on            is important that many different kinds of
492                                                                  ICDL Clinical Practice Guidelines

systems form, expand, and, increasingly,           framework for not only making functional
come under their control. There is a progres-      and emotional contact with things and people
sion in the manner in which systems are            but for maintaining and expanding that
formed. At first, system formation is driven       contact. However, engagement by itself does
by the external properties of objects, events,     not ensure the development of a system.
and people, with the child reactive to the
process. Later, the formation, expansion, and      From Engagement to System
combination of systems come increasingly           Formation
under the child’s active control as the child          Engagement is to system formation as a
uses previously developed systems in the           casual encounter between one person asking
service of various ends. The following sec-        another for the current time is to a life-long
tions outline the progressive steps of form-       friendship between the two people. The initial
ing, maintaining, and expanding systems.           brief encounter (engagement) is a necessary
                                                   prerequisite for a relationship (system) to
Orienting                                          develop between people or objects, but such
    Systems begin to form as a salient sound,      a relationship may or may not develop from
motion, or a particular property of an object,     the initial encounter. The system develops
event, or person induces the child to “‘turn       only through a more prolonged and repetitive
toward,” or orient, toward the source of the       engagement with an object, event, or person.
stimuli (Goldstein, 1940; Pavlov, 1927;                For example, a 16-month-old girl who
Sokolov, 1963). Orienting has been shown to        stumbles over a bucket half filled with sand is
make the stimulus that the child is turning        momentarily engaged with that bucket.
toward more salient for the reacting child.        However, she has not formed a system with
However, even at this initial phase of system      that bucket until she repetitively addresses it
formation, aberrations are evident among           in any of a variety of ways: Having stumbled
many developmentally challenged children.          over it, she may form a system by repeatedly
For example, some children with disorders          kicking the bucket across the sand or by
are so driven that they orient to any stimuli      repeatedly filling and emptying the bucket,
that they see, hear, or feel in a way that keeps   and so forth. Once her behavior with the
them helplessly reacting to so many stimuli        bucket follows a predictable pattern she has
that they have difficulty with the next step in    transformed her initial engagement with the
system formation—engagement.                       bucket into a system. At that point, her
                                                   behavior is internalized as a way of being
Engagement                                         with that object.
    Once a child orients toward a salient              The decisive indication that an internal-
stimulus, the next step in system formation        ized system has developed occurs when, fol-
entails the child moving toward and becom-         lowing interruption of the child’s system by
ing physically and emotionally involved or         removing her bucket or preventing her from
engaged with the stimulus properties of the        acting on or with it, the child becomes com-
object, event, or person in his immediate sur-     pensatorily driven to maintain or restore
roundings. In cognitive-developmental sys-         action with that object by reaching for the
tems theory, orienting plus engagement             bucket, yelling, pointing, and otherwise indi-
provides the precondition for the formation        cating her urgent need to continue that sys-
of systems which, in turn, provides the            tem. When interruption of an activity does
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                 493

not induce a child to continue or restore that              The following outline summarizes the
activity, a system has not yet developed.               steps involved in system formation and
    However, if systems are to move beyond              expansion via the inclusion principle:
mere rituals, there must be both a means of
recalling or reactivating them when they have           1. Orienting
not been used for a time and a means of                    Child orients (turns toward) the introduc-
extending their influence to other aspects of a            tion of a large object (a wagon) within her
child’s surroundings. Two principles—inclu-                visual field.
sion and extension—suggest how this occurs.
                                                        2. Engagement to system forming
The Inclusion Principle                                    Child approaches and pushes the wagon,
     This principle states, “Whenever the child,           which moves and then stops in a way that
engaged by a stimulating object or event, is               induces him to push it again and again
concurrently stimulated by a background                    until a pushing-wagon system forms.
aspect of the situation, that background aspect
                                                        3. Inclusion process
soon becomes part of the total, engaging sys-
                                                           a. Introducing new parts to the system.
tem which emerges. Subsequently, when only
                                                              Therapist uses words and gestures to
the background aspect appears (partial inter-
                                                              introduce the word “push” while the
ruption), the child compensatorily behaves as
                                                              child is repeatedly pushing the wagon.
he/she had toward the originally engaging
                                                              At first, the child orients toward the
object” (Miller & Eller-Miller, 1989).
                                                              sounds and gestures (indicating that
     For example, if while an infant is nursing at
                                                              she still experiences them as separate
the breast (nursing system), the mother simul-
                                                              from her pushing-wagon system).
taneously croons and strokes the infant’s cheek,
                                                           b. Assimilating new parts to the system.
then subsequently, in the absence of the breast,              As the spoken word and gesture con-
the mother’s crooning or cheek-stroking, by                   tinue to accompany the pushing-
itself, will elicit vigorous sucking by the infant.           wagon system, the child no longer
In a similar fashion, a small child who has not               orients toward them as if they were
previously responded to the term “Push!” or to                separate entities but experiences them
a pushing gesture will do so if, while the child              as part of the pushing-wagon system.
is pushing a wagon (pushing-wagon system),                    In other words, the child now experi-
the child repeatedly hears the therapist saying,              enced it as a pushing-wagon + “push”
“Push ... push ... push!” accompanied by push-                (word) + (gesture) system.
ing gestures. As this occurs, both word and ges-
ture soon become included within the child’s            4. Partial interruption
pushing-wagon system so that when the thera-               Later, when only the spoken word or ges-
pist later introduces either word or push-ges-             ture part of the system is introduced (par-
ture in the presence of the wagon (partial                 tially interrupted system), the child
interruption), the child feels compelled to push           compensatorily searches for a wagon or
the wagon to complete the system.                          other moveable objects to push.
494                                                                   ICDL Clinical Practice Guidelines

The Extension Principle                            system” had been extended for this child to
    The extension principle comes into play        include not only the bird but the forked
when the child has already developed some          branch on which the bird had been pecking.
gestures, utterances (natural signs), or spoken    However, the bird valence of the forked
words that are closely related to a particular     branch only became evident when the bird
referent located in the child’s immediate sur-     disappeared behind it (interruption) and left
roundings. This principle explains how the         only the forked branch part of the system,
familiar meanings attached to these expres-        which the child continued to designate as
sive systems become extended to an initially       “bird.” This extension principle, as illustrated
neutral entity, which then becomes part of the     later in this chapter, plays an important role
child’s expressive system. This occurs by the      in the transfer of meaning from spoken words
child’s expressive system acting upon the          to the arbitrary forms of printed words in the
neutral property.                                  Symbol Accentuation Reading Program
    The principle states, “Whenever a system       (Miller & Eller-Miller, 1989).
with which the child is engaged acts upon a
new property of an object or event, that prop-     Executive Function
erty becomes an extended part of the original          The system expansions discussed so far
system. The child then maintains the integri-      have largely depended on external events
ty of the newly extended system when it is         driving the system. Early in a child’s life,
interrupted just as with the original system”      such externally driven expansions are the pri-
(Miller & Eller-Miller, 1989).                     mary mode by which systems are expanded.
    Two examples illustrate the operation of       They entail minimal intention or initiative on
the extension principle. In one, the child has     the part of the child. Gradually, however, this
established the natural sign “ch ch” to refer to   reactive mode of expanding systems is
his small train. Subsequently, the parent          accompanied by a new mode whereby the
introduces the term “train.” The child             child deliberately forms systems as well as
responds by saying, “ch ch train,” clearly         new combinations of systems based on an
extending the rhythmic “ch ch” cadence to          inner plan. This emerging capacity is referred
include the new term. In the second example,       to as the development of executive function.
a 2-year-old child sees a bird land on the fork        Early examples of executive function may
of a branch and begin pecking on it. The child     be noted as a child decides that he no longer
points and exclaims, “Bird!” (word “bird”          wishes to go down the slide in the sitting posi-
plus bird-pecking-on-forked-branch system).        tion but prefers, instead, to slide down on side,
Abruptly, the bird disappears (interruption)       back, stomach, etc. These spontaneous expan-
behind the fork in the branch. Nevertheless,       sions of the slide system are possible because
the child continues to point at the forked         of the newly emerging executive function. It
branch (where the bird had been pecking) and       appears that executive function is only possi-
to exclaim, “Bird!” On subsequent occasions        ble when children have developed sufficient
when the child passes that forked branch, the      awareness of their bodies to self consciously
child points at the branch and says “Bird!”        direct them in different ways. When this
even though no bird is present.                    occurs, they find that they have the ability to
    Because the bird had acted upon the            choose one system over another, to alter sys-
forked branch, it had assumed bird signifi-        tems, or to combine previously developed
cance for the child. In other words, the “bird     systems in new ways. Perhaps the best known
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                   495

indication that executive function is well                  blocks, immediately began to build a con-
established occurs when the typical 2-year-                 nected structure. But, unlike Jack’s con-
old responds to her mother’s request to do                  struction, his structure consisted only of a
something with a defiant “No!”—a statement                  row of rectangular blocks carefully
that marks both awareness of self and other                 placed so that each block abutted the pre-
as well as the notion of choice.                            vious one. Curved or triangular blocks
    The failure of this shift to fully occur                were not attended, and he did not make
among developmentally challenged children                   the sounds that other children made as
accounts for many of the dramatic differ-                   they played.
ences in behavior between typical and com-                      Damon worked with rapid intensity,
promised development. The following                         regularly scrambling from the end of the
examples of children’s activities with blocks               row of blocks to get another block so that
during an unstructured period contrasts the                 he could continue extending the struc-
functioning of a 3-year-old who has devel-                  ture. At no time did Damon acknowledge
oped executive function with the functioning                the existence of the adult seated nearby.
of two children on the autistic spectrum who                When the adult tried to hand him a block,
demonstrate little or none of this capacity.                Damon rapidly turned his body so that his
                                                            back was between the adult and the
Children With and Without the                               blocks. When the adult removed one
Capacity for Executive Functioning                          block from the row, Damon screamed,
• Jack, a typical 3-year-old with capacity                  then frantically sought another block to
   for executive function. As soon as Jack                  close the gap in the structure. Damon
   received the pile of assorted blocks, he                 continued to extend the row of blocks
   began to build a connected structure of                  until it reached the wall. Confronted by
   ramps and towers. He picked up each                      the wall, he made a right angle with the
   block, examined it, selected a place for it              next block and continued placing blocks
   in the block structure, and inserted it care-            along the wall until there were no more
   fully. Needing a block of a particular size,             blocks. Then he began rocking back and
   he scanned the blocks and spotted an                     forth while twiddling his fingers in front
   appropriate one near the foot of the                     of his eyes. Except for his scream when
   observing adult about 6 feet away. He                    the adult altered his block structure, he
   looked at the adult, pointed at the block,               uttered no sound.
   and exclaimed, “Block, please!” After
   receiving the block, he smiled at the adult,         •   Brian, a 3-year-old boy on the autistic
   added the block to his structure, and took               spectrum who demonstrates little or no
   another block. Next, while making “rmm”                  executive function. Presented the blocks,
   car sounds, he “drove” his block up the                  Brian was momentarily drawn to the clat-
   ramp and around the block towers.                        tering sound they made when they were
   Finished with car-block play, he got up                  placed in front of him. What Brian saw
   and set off for something else to do.                    and heard, however, seemed quite discon-
                                                            nected from what his hands were doing.
•   Damon, a 3-year-old boy on the autistic                 Even though he picked up a block, it soon
    spectrum with minimal capacity for exec-                slid from his hands, forgotten, as he was
    utive function. Damon, seeing the pile of               “caught” by the movement and sound the
496                                                                 ICDL Clinical Practice Guidelines

   adult made as she seated herself in a near-    required such a change. This change, howev-
   by chair. When the adult offered him           er, came about not through any executive
   another block, he seemed not to notice it      decision on Damon’s part, but because the
   because he was now turned toward the           wall required the change. Finally, there was no
   sound of a bus starting up outside the         decision to stop connecting blocks; Damon
   building. At no time did Brian sponta-         stopped when he ran out of blocks. When this
   neously explore his surroundings or            occurred, he had no means of directing him-
   examine the manner in which blocks             self to a new activity. Apparently, the only
   stacked or things worked. Instead, time        means he had of filling the void left by the
   and again, he turned toward or began to        end of the block-connecting system was rock-
   move toward a stimulating object or event      ing and hand twiddling.
   only to be diverted by another new stim-           For Brian, the observing adult seemed to
   ulus, which “drove” his behavior.              exist only momentarily as the adult moved
                                                  and made sounds. Brian’s constant tendency
An Analysis of the Children’s                     to be driven by transient stimuli (sudden
Executive Functioning and                         sound or motion) interfered with the prospect
System-Forming Ability                            of a deeper relationship with either people or
    Although both Jack and Damon produced         objects. Brian oriented but seemed unable to
systems, their systems differed dramatically.     become physically engaged with the stimuli.
Jack, the typical child, had a complex, inte-     Because of his “drivenness,” Brian formed
grative system composed of towers, ramps,         only fleeting contact with objects and events
and cars. As Jack played with the blocks, it      as he was driven from one source of stimula-
became evident that he experienced himself        tion to another—never lighting long enough
as the executive or master-builder with an        to physically engage the stimulating source.
inner plan to which both the blocks and the       The unfortunate outcome is that he failed to
adult contributed. This allowed him to form a     develop either coherent systems or the exec-
complex, integrative system with the blocks       utive capacity required to explore their prop-
(towers and ramps) that he could exploit in       erties. In short, like Damon, Brian lacked the
different ways. He could, for example, turn a     executive functioning to guide his own
block into a car and move it, car-like, up and    behavior, but unlike Damon, he also lacked
down the ramps. He could also turn from the       coherent, compelling systems.
main block structure to request a block from          The different ways the children related to
an adult and turn back to his structure with-     the observing adult illuminates the extent to
out losing touch with his goal. In carrying       which they dominated or were dominated by
through his plan, Jack demonstrated that he       their systems. Jack, needing a block to com-
could integrate several smaller systems into a    plete his block structure and seeing a block
larger one.                                       near the adult, was able to turn toward the
    In sharp contrast, Damon, the autistic        adult and ask her for the block. In doing this,
child with a closed-system disorder, had a sin-   Jack creatively brought together the world of
gle, minisystem composed of lining up             relationships with people with his world of
blocks. Damon’s system was not driven by          objects. The situation was very different for
any inner plan but by the way each block          Damon: for him, the observing adult did not
abutted the next one. He changed the structure    exist except as a momentary threat (when
only when the physical barrier of the wall        removing a block from his lined-up blocks) to
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                  497

the integrity of the structure being built.             important, children with Type A closed-sys-
Clearly, he lacked the executive function               tem disorders tend to prohibit parents or oth-
required to draw upon relationships with                ers from entering and participating within
people. Stated differently, his closed-system           their object or event systems. In other words,
tendency precluded people from being part of            having only minimal executive function,
his system.                                             these children are quite dominated by their
    After children make the shift to executive          few systems. Clearly, children with such
function, their relation to the systems they            closed systems are restricted in their social
have formed changes radically. Systems previ-           interactions and ability to communicate with
ously triggered only by properties of the envi-         others about things and events in the immedi-
ronment are now at the disposal of the                  ate environment.
executive capacity of the child. The distinction            Children with Type B closed-system dis-
between systems that dominate the behavior of           orders share some but not all dispositions
children and those which children dominate is           with Type A closed-system children. Similarly,
evident in the comparison of Jack, who has              they resist having people enter their systems.
made the shift to executive function, with              However, unlike Type A children, Type B chil-
Damon and Brian, who have not.                          dren are able to demonstrate executive func-
                                                        tioning in a circumscribed domain composed
          Closed-System and                             of action-object systems. In contrast to Type A
       System-Forming Disorders                         children who tend to remain engaged with one
                                                        or two objects from which they cannot extri-
    There are two broad system dispositions             cate themselves, Type B children have suffi-
among children having autistic spectrum as              cient executive function to scan their
well as those with other developmental disor-           surroundings and to move without difficulty
ders: closed-system disorders (Miller, 1991;            from one object or event system to another.
Miller & Eller-Miller, 1989) and system-                However, their executive functioning does not
forming disorders. Both kinds of system dis-            yet permit them to allow people to participate
orders are divided into Type A and B forms to           in their systems. In other words, they have
indicate the nature and limitations of their            child-object systems but not child-object-per-
systems and the extent to which executive               son systems. Should a person attempt to enter
function plays a role.                                  one of their systems, the children show the
    Type A of the closed-system disorders               same kind of resistant behavior (although to a
refers to those children, like Damon, who               lesser degree) found with Type A children
become so involved with one or two action-              with closed-system disorders.
object systems that they are unable to notice               Children with system-forming disorders
or respond to any stimuli unrelated to the sys-         are very different from those with closed-sys-
tem with which they are engaged. These are              tem disorders. Children with system-forming
the children who are so unresponsive to being           disorders have great difficulty forming any
called that parents often have the children’s           systems. Brian (described earlier), with his
hearing checked. They are also unable to scan           tendency to be “driven” by every salient stim-
their environment, tending to “live” quite              ulus, falls into a Type B system-forming dis-
close to their bodies. Not surprisingly, these          order. Children such as Brian are repeatedly
children have great difficulty shifting from            driven to orient toward stimuli from objects
one object or event to another. Equally                 and events but fail to engage them physically.
498                                                                     ICDL Clinical Practice Guidelines

However, there is another group of children,          systems, which these children achieve
designated Type A system-forming disorder,            through repetition, is very different from the
whose difficulty forming systems stems                creative and complex integrative systems
largely from their poor sensory-motor coor-           achieved by the typical child, such as Jack.
dination. Such a child may orient toward a            Because Jack had achieved executive func-
particular salient object or event but have dif-      tioning, he could creatively combine systems
ficulty relating his body to that object or           following his inner plan. In contrast, children
event in a way that forms either mini- or mul-        with Type A system-forming disorders, who
tistep integrative systems.                           lack executive function, can form integrative
     It is interesting to note that children with     systems only in a rigid, unvarying manner by
Type A system-forming disorders can, with             virtue of having been repeatedly led by a
proper intervention, learn to form integrative        therapist through the system until it “takes.”
systems, such as climbing up steps to slide               While children with both Type A and Type
down a slide. The problem is that the child’s         B system-forming disorders have difficulty
sensory-motor coordination is often so slug-          forming coherent systems with objects and
gish that by the time the child has climbed the       events in their surroundings, their challenges
stairs and slid down, she has completely lost         come from different sources. Type B children
contact with the location of the stairs and so,       are “too sensorily driven” by various stimuli
having slid down, continues straight ahead.           to readily form systems, whereas Type A chil-
Failing to return to the stairs, the child at first   dren have physical coordination problems that
cannot repeat and “own” that system without           interfere with the sequencing and motor plan-
continuing physical support. However, with            ning they need to form their systems. (See
many repetitions and rapid pacing, the child          Table 1).
will begin to anticipate the various parts of             Finally, there is a developmental sequence
the step-slide system. Nevertheless, the rigid,       in the formation of systems. Least developed
circumscribed quality of the integrative              are children such as Brian, whose drivenness

      Table 1. Contrasting Children with Closed-System and System-Forming Disorders
       Disorder                                           Children
                                            Type A                               Type B

  Closed system                Minimal executive                     Executive functioning with
                               functioning and few systems.          many object systems.
                               Poor shifting/scanning.               Ability to shift from one to
                               People excluded from                  another system.
                               systems.                              People excluded from
                                                                     systems.

  System-forming               Minimal executive                     Little executive functioning.
                               functioning.                          Salient properties of many
                               Poor sensory-motor                    sources induce repeated
                               coordination limits system            orienting, but not
                               forming.                              engagement.
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                      499

results in aborted system formation and an              Umwelt (Uexküll, 1934) refers to the “world
almost total lack of executive function. More           around one.” Consequently, in performing an
developed, but still compromised, are those             Umwelt assessment for a particular child, we
closed-system, Type B children whose modest             try to determine the nature of the systems the
executive function enables them to shift from           child brings to a new situation by first exam-
one closed system to another but who still              ining his behavior in unstructured situations
exclude people from their systems. Most                 where he has access to both people and a
developed are children such as Jack, who                variety of objects, but where the adults are
have the executive capacity to creatively               passive. We also examine the child’s ability to
assemble a variety of minisystems into an               become engaged in new systems that the
integrative system (involving people) that              examiner introduces. Recently, influenced by
they can modify as they choose in accord                the work of Greenspan and Wieder (1998),
with their inner plans. Table 1 captures the            we have been paying more attention to affec-
major distinctions between the two types of             tively driven systems between the child and
disorder and their subcategories.                       others. Now, just as we examine the child’s
                                                        resourcefulness in coping with objects via
               ASSESSMENT                               detours or by using tools, we seek to deter-
                                                        mine the child’s emotional resourcefulness in
    Before therapists can intervene effective-          initiating and maintaining ongoing interac-
ly, they need to assess the nature of each              tive systems supported by the adult.
child’s system functioning. The following sec-               This means that we now examine three
tions explore different assessment strategies.          kinds of interaction with a particular child: (1)
                                                        the child’s response to unstructured situations
         Assessing the Children                         (adults passive); (2) the child’s ability to main-
                                                        tain an interactive system with the examiner
    One of the goals of the Miller Method is            when the examiner actively builds on the
to assess each child’s capacity to interact with        child’s initiatives, and so forth; and (3) the
people and objects, adapt to change, and                child’s ability to accept and participate in
learn from experience. An Umwelt assess-                examiner-initiated systems. Table 2 captures
ment was developed to determine how best to             the three different ways of examining the child.
intervene with children on the autistic spec-                Each of the adult stances is important in
trum (Miller & Eller-Miller, 1989). An                  determining how well a child can cope with

  Table 2. General Strategies Used During the Umwelt Assessment

  Assessment Strategies            Adult Stance                           Child’s Task
  Unstructured                     Passive               Child to initiate without support.

  Child-initiated                  Interactive           Child initiates and cyclically builds on
                                                         adult’s response to his or her initiatives.

  Adult-initiated                  Active                Child to accept adult-initiated interaction
                                                         and expansions.
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people and things in her immediate surround-         each child with disorders experiences reality
ings. The child who, during the unstructured         as well as her adaptive potential. The follow-
period, can—without support—initiate actions         ing example indicates how one of the
toward people and things in unfamiliar sur-          Umwelt tasks throws light on a child’s abili-
roundings demonstrates a repertoire of organ-        ty to interact with both a person and an
ized behaviors (systems) that enable her to          object in a simple game.
engage with people or objects. In this condi-
tion, the relative emphasis on people or             Assessing the Capacity to Interact
objects, and the quality of interaction or           with a Person and an Object: The
exploration (if it exists at all) tells much about   Swinging Ball Task
the coping resources available to that child.             Figure 1 illustrates the manner in which
On the other hand, child-driven interactions         the examiner assesses the child’s ability to
tell more about the emotional capacity of the        form an interactive system involving an
child to initiate and to sustain more prolonged      object and another person.
interactive systems with the examiner                     Figure 1a represents a child enjoying a
(Greenspan & Wieder, 1998). How well the             repetitive pushing-game (a child-object-adult
child can sustain shared attention and involve-      system) in which adult and child push a swing-
ment with the adult is an important indication       ing ball back and forth. The dotted lines to both
of the relationship potential of the child.          ball and adult indicate that the child’s system
     However, since many circumstances,              includes awareness of both the ball and the
such as school, entail teaching the child from       adult. Figure 1b, reflects a more limited child-
the adult’s and not the child’s agenda, it is        object system that includes the ball, (which the
also important to determine how well the             child pushes whenever it arrives) but does not
child can accept adult-driven interactions.          include the adult. Figure 1c shows an even
How the child responds to an adult setting up,       more circumscribed system. Here, the child
expanding, and directing shifts from one sys-        fails to react even when the ball bumps into
tem to another provides important clues              him, which infers that the child lacks that
about how well the child will learn in school-       object system.
related or similar situations. Further, the               Typical children as young as 2 years of
importance of therapist- or teacher-initiated        age will behave interactively with ball and
systems (called spheres) lies in their potential     person as illustrated in Figure 1a. Children
for remedying serious developmental lags.            with closed-system disorders will interact
     Different tasks from the Umwelt assess-         with the ball but not with the person, as
ment help clarify the unique way in which            shown in Figure 1b. Children with system-

      Figure 1a, b, c. Assessing a Child’s Ability to Form an Interactive System:
      a. Child-object-adult            b. Child-object                 c. No object system
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                  501

forming disorders may respond as shown in
Figure 1c because they have difficulty coor-
dinating with the ball’s trajectory.

Assessing the Capacity to Adapt to
Change: Stacking Cups and Bowls
    Successfully coping with surroundings
requires the child to adjust her approach to
changing circumstances. To get at this capac-
ity during the Umwelt assessment, the child
is required to stack cups and bowls in differ-
ent ways. The task is graduated from simple
stacking of cups (then bowls) with their
openings facing upwards to those involving              Figure 3 with additional cues to determine
progressively more complex adjustments. At              how close a child is to making the shift from
the most complex stacking level, the child is           one kind of organization (vertical stacking)
required to alternately stack cups and bowls,           to another (lateral).
with the cup presented upside-down over the
bowl and the bowl presented right-side-up               Problem Solving and Learning from
over the right-side-up cups (Figure 2).                 Experience: The Elevated “Swiss
                                                        Cheese” Board
                                                            The next two tasks examine, although in
                                                        different ways, the child’s ability not only to
                                                        adjust to changing circumstances but to learn
                                                        from the experience. One task examines the
                                                        child’s response to the elevated “Swiss
                                                        Cheese” Board (Figure 4); another, called
                                                        “Croupier” (Figure 5), examines the child’s
                                                        manner of coping with progressively more
                                                        demanding tasks involving the use of rakes
                                                        and obstacles to gain a desired object.

    The final sequence tests the child’s abili-
ty to shift from a stacking mindset to one in
which he is required to place a cup in each of
six bowls spread out in front of the him
(Figure 3). Closed-system Type A children
typically show such a strong perseverative
tendency that they persist in stacking the cups
given them—instead of placing a cup in each
bowl—even after the examiner has modeled
placing one or two cups in the bowls in front
of them. Often, we will repeat the set-up in
502                                                                   ICDL Clinical Practice Guidelines

                                                   moment. If there is little or no awareness of
                                                   the body or body-self as a separate entity
                                                   independent of what the body is engaged
                                                   with, then the child becomes so captured by
                                                   the ongoing body-object system in play at
                                                   that time that he cannot spontaneously
                                                   detach from the ongoing system. Only as the
                                                   child develops the notion that his body and
                                                   its parts have an existence independent of the
                                                   object or event system with which he is
                                                   engaged can the executive function emerge
                                                   (which makes possible a child’s spontaneous
     The ability to learn from experience          expansion of his systems). In other words,
comes into play when the child on the “Swiss       body-world polarity is a prerequisite for
Cheese” Board inadvertently steps in a hole        executive function.
(care being taken that the child does not fall).        Among typical children, this capacity
Then, as the child continues to cross the          emerges gradually in the course of the first 2
board, we are able to determine whether or         years of development. For example, by 6
not the child now avoids the holes by step-        months of age, the child has achieved suffi-
ping over them. In the rake-obstacle task, we      cient differentiation between her body and
seek to determine if the child—shown               others to demonstrate a clear preference for
pulling a desired object toward himself—can        her mother over others. Between 6 and 9
learn to push it away from himself through         months of age, the child is able to relate to
the gap and then toward himself. Often we          (establish systems with) either a person or an
will test the limits by placing the desired        object. By 9 or 10 months of age, the child
object closer and closer to the gap to deter-      can relate to another around an object (child-
mine at what point the child will understand       object-person system) as evident in the abili-
the need to first push the object away before      ty to give an object to a caregiver on request
it can be brought closer. Once the child push-     (Trevarthen & Hubley, 1979). And, of course,
es the object away, we return the next object      by 24 months of age, the child becomes self-
to the center of the horseshoe ring to deter-      consciously aware of her ability to accept or
mine if the child has generalized this under-      refuse requests.
standing to the new object given or will revert         Children whose development has been
to the original, unsuccessful effort to bring      compromised often fail to achieve these basic
the object toward himself.                         body-object-other capacities. For example,
                                                   they may not differentiate between one per-
             INTERVENTIONS                         son and another, and they may not be able to
                                                   give an object on request. They remain fixed
    Before a child can achieve executive con-      in a “single track” involvement with a partic-
trol of his own systems, he must first achieve     ular property of an object or event and show
a certain awareness of his body and the dis-       striking difficulties in relating their bodies to
tinction between his body and that of others,      people and objects in their surroundings.
as well as the object or event system with              The following section details some ways
which his body is engaged at a particular          in which these difficulties become apparent.
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                   503

Body-world problems may become apparent                      The following illustrates the treatment
with child-object systems, child-person systems,        approach Damon received at the Language
and child-object-person systems. For example,           and Cognitive Development Center (LCDC),
picking up and dropping an object or flicking a         in Boston, MA. Although children at LCDC
light switch on and off are child-object systems,       participate in both school classes (limited to
while peek-a-boo and chase games are child-             six children with three teachers), as well as
person systems. On the other hand, rolling a            individual therapies guided by the Center’s
ball back and forth with mom or dad is a                orientation (cognitive-developmental systems
child-object-person system that combines                therapy, speech/language therapy, movement
both object and people worlds. The problem              and occupational therapies as well as manual
for developmentally challenged children                 arts), for clarity, this discussion relates only
stems from the unusual way they form or fail            to the child’s work in cognitive-developmen-
to form systems in the world of objects and             tal systems therapy. (A chapter appendix out-
the world of people and their difficulty in             lines a typical daily curriculum for nonverbal
forming systems that combine the two worlds.            or limited verbal children.) The word “we”
                                                        refers to all the therapists at the Center who
        Strategies for Developing                       worked with Damon.
         Body-World Awareness
                                                        Improving Damon’s Human Contact
    Strategies for developing body-world                     We begin each 45-minute therapy session
awareness include “rough and tumble” activi-            with about 5 to 10 minutes of big-body work.
ty, mutual face-touching, estabilization, deep          This entails a combination of pleasurable
pressure, swinging, elevation, and introducing          “rough and tumble” activity, guided bouncing
causal systems. One goal of these strategies is         on a trampoline, and swinging him in a sheet.
to guide children from closed, disconnected,            We follow this activity by gentle, mutual face
or scattered ways of being into functional,             touching coupled with subtle destabilizing
social, and communicative exchanges.                    (i.e., tugging him front and back and left to
                                                        right in a way which makes it necessary for
An Intervention Case Example: Damon                     him to constantly “right” himself).
                                                             Our experience with these procedures is
    Damon, the 3-year-old described earlier,            that—when introduced carefully—they result
is a child on the autistic spectrum with a              in the child smiling or laughing and in
closed-system disorder, Type A. His various             improved eye contact. Then, when certain big
problem areas are:                                      body systems (jumping, swinging, “rough
1. Poor human contact (won’t look at peo-               and tumble”) are abruptly interrupted, the
    ple) or include them in his systems.                child often indicates by natural signs a wish
2. Perseverative tendency—has great diffi-              to continue the activity.
    culty shifting from one action-object sys-
    tem to another.                                     Working with Damon’s
3. Does not seem to hear or follow direc-               Perseverative Tendency and
    tions (“word deaf ”).                               Difficulty Following Directions
4. Does not communicate his needs except by                 Following the big body work just
    pulling the adult toward the desired object.        described, we introduce Damon to the
5. Does not participate in “make-believe” play.         Elevated Square. Before describing work on
504                                                                  ICDL Clinical Practice Guidelines

the Square, it is important to understand why          Placing the child on the Elevated Square
we used it.                                        effectively limits the child’s options for
                                                   movement because of the constraints the
The Elevated Square                                Square places on movement. The Square
     The Elevated Square we have designed          serves different purposes for different kinds
(see Figure 6) is about 5 feet by 8 feet, with     of children. For easily “scattered” children
boards about 14 inches wide. The structure is      with system-forming disorders, the Square
21/2 feet high, which places most 3- to 6-year-    provides the external organization the chil-
old children at or near eye level with most        dren desperately require in order to function.
adults. The short side pieces of the square are    However, for children with closed-system dis-
removable, making it possible for the thera-       orders, such as Damon, the Square provides
pist to stand in the middle in easy reach of the   the framework in which they can be taught to
child. Removing the side pieces also creates       expand their systems, learn to move from one
the conditions in which the child must make        system to another, and to include people with-
a detour in order to get to a person on the        in these systems. Contributing to these
opposite side. The steps used with the             changes is the enhanced awareness of body
Elevated Square are attached to each other         and other that the elevation seems to induce.
with Velcro and—because they are designed          This changed state is evident not only in the
to fit snugly in the channels of the Elevated      improved eye contact almost immediately evi-
Square—are readily used as obstacles or            dent but in the finding that many children
small platforms placed around the square so        who toe-walk on the ground walk with their
that the child can respond to “Up!,” “Down!,”      feet firmly grounded when elevated.
and “Around!,” as well as “Get up!” and “Sit
down!” Finally, there are stations at each cor-    Working the Short and the Long Sides
ner of the square, which can be adjusted to            Once Damon climbs the steps that places
the child’s height to provide the best possible    him on top of the Square, we begin a system-
conditions for effective eye-hand coordina-        atic process of both expanding his systems and
tion with the various tasks placed on these        including people within them. First, a parent is
stations. The last piece of equipment is the       placed at one end of the short side of the
slide, which connects to the Square but can        Square and a therapist on the other side. The
be readily removed.                                parent is instructed to say “Come!” while
                                                   using the manual sign (beckoning). The vector
                                                   of the board, coupled with the parent calling
                                                   and with the therapist’s support, quickly
                                                   allows Damon to move to his mother. She then
                                                   briefly hugs him, does mutual face-touching
                                                   with him, turns him around and directs him
                                                   toward the therapist, who also says and signs
                                                   “Come!” Once Damon is responding to
                                                   “Come!” appropriately, the same procedure is
                                                   used on the long side of the Square. This con-
                                                   tinues until Damon can respond to “Come”
                                                   from mother and therapist from both the short
                                                   and long distances on the Square.
Chapter 19. The Miller Method®: A Cognitive-Developmental Systems Approach for
Children with Body Organization, Social, and Communication Issues                                    505

    Once Damon develops the appropriate                 as lining up blocks, to the exclusion of all else.
response to a command while on the Square,              Once he becomes comfortable with the
the next step is for his parents to help him            Elevated Square, we address this issue by set-
expand his response to their settings. The              ting up a multisphere arrangement designed to
goal is to get Damon to generalize “Come!”              reduce Damon’s perseverative tendency and to
to first short and then longer distances on the         make it possible for him to transition without
ground at both the LCDC and at home until               distress from one system to another.
he responds from various distances to every-                 A sphere is any activity that we introduce
one in his family.                                      repetitively with the expectation that the
                                                        child will “take it over” and transform it into
Turning the Corners                                     an internalized system. Therefore, a multi-
    Turning the corners may be difficult for            sphere setup is one in which the child learns
Damon because it requires a sudden shift of             to cope with two, three, or four different
direction. However, turning corners to get to a         spheres. The rationale for the multisphere
person just around the corner of the Square is          procedure is that the child perseverates
an important part of understanding how the              because (a) he lacks knowledge of how to
body must adjust to changing circumstances.             detach from the action-object system, and (b)
When turning the corner is mastered at one              because the child has no sense of the system’s
location on the Square, Damon generalizes               continuing existence once it is left (the “out
the skill by performing it at other locations.          of sight/out of mind” phenomenon). Based
Successfully coping with corners as well as             on this rationale, our procedures are designed
short and long sides of the Square enables              to teach the child that he can detach from a
Damon to become quite comfortable working               compelling system and still return to it. The
on the Square.                                          assumption is that by demonstrating this to
                                                        the child, then the child’s perseverative
Understanding Detours                                   impulse will be attenuated. We do this by first
    Next, Damon is shown how detours work.              engaging the child in a particular action-
This is taught by placing Damon on the short            object system and then interrupting it by
side of the Square and removing the short               leading the child to a second, then a third, and
piece. His mother stands on the opposite side           then a fourth system and repeating the
and calls and beckons as before. Eventually,            process as follows.
Damon, seeing the gap, looks around the                      After the child becomes engaged with
Square and then navigates around it until he            A—the first sphere (for example, pouring
gets to his mother. In doing so, he demon-              water over a water wheel) —we interrupt this
strates a beginning understanding of how                sphere at the point of maximal tension (the
detours work. He then has to perform detours            point at which the child most needs to con-
with others calling him across the gap from             tinue the activity). When this is done, the
both directions and using both short and long           child experiences—in Lewinian (1935)
sides of the Square.                                    terms—a tension state related to the need to
                                                        continue that activity. By maintaining that
Using Multispheres to Cope with                         tension state while having the child become
Damon’s Perseverative Tendency                          engaged with B—a second, entirely different
     One of Damon’s most serious difficulties           sphere (sending marbles down a zigzag
is his tendency to perseverate with a task, such        ramp) —the first sphere continues to remain
506                                                                    ICDL Clinical Practice Guidelines

“alive” for the child even while the child          guide his behavior solely by using words. He
becomes engaged by the second sphere. (It is        will do better when spoken words are paired
this duality of experience that begins to make      with signs, as do most nonverbal children on
it possible for the child to relate and soon eas-   the autistic spectrum (Konstantareas, 1984;
ily shift from one sphere or station to another.)   Konstantareas, Oxman, & Webster, 1977;
After a number of cycles involving two (AB),        Miller & Miller, 1973).
then three (ABC, hanging up cups), and four              To increase Damon’s capacity to respond
(ABCD, cutting clay) spheres, the child begins      to spoken words, we follow the principle of
to demonstrate by glancing at the different         inclusion described earlier under “Defining
spheres a sense of possible relations between       Central Concepts.” By repeating the appropri-
them. After a few sessions, he is no longer dis-    ate word while Damon is performing the rele-
tressed when one sphere is interrupted because      vant action, he soon includes both word and
he understands that he will soon return to it.      manual sign as part of his action system. We
     But merely being able to shift clockwise       use this technique with the words “Up!,”
from A to B to C to D spheres—although              “Down!,” “Push!,” “Pull!,” and “Around!,” fol-
important—is not sufficient for Damon to            lowed by “Pick up!,” “Drop!,” “Pour!” and
cope flexibly with his surroundings. At this        many others. For example, as Damon steps up
point, we begin to vary the stations. In other      on the block in his path, we say “Up!” while
words, after A, Damon expects to move from          pointing upward. We continue in similar fash-
A to B. Instead, Damon—clearly unhappy—             ion with Damon’s pushing and pulling actions.
is guided past Station B to Station C. This         Each time that Damon performs the action we
process is continued over a number of ses-          also narrate what he is doing by saying,
sions until Damon can tolerate shifts from          “Damon is pushing (going up, down, etc.).”
one station to another in all possible combi-            We support Damon’s behavior by using a
nations—ACBD, DBAC, and so on.                      vocal tone that expresses the delight we feel
     Once Damon can cope with shifting in all       at the child’s performance. We find this affec-
possible combinations on the Elevated               tive narration to be far more relevant to the
Square, stations are shifted to the ground.         development of the child’s receptive language
Here, without the support of the Square,            than using the term “Good job!,” with its
Damon generalizes his new ability to shift to       doubtful meaning to the child.
various stations set up on the ground. After             In developing receptive language, we
Damon masters this sequence, he is placed in        find it important to gain a clear sense of the
a position where he can scan all the stations.      extent to which the child is guided by just the
He is then asked to choose which one he             spoken word in contrast to the word in con-
wishes to go to. When he can express a pref-        text. In doing so, we:
erence for one system over another by               • Determine if the child can give an object to
pointing, sign, or word, we have evidence of             us when it is right in front of us and we tap
the emergence of new executive functioning.              an extended hand while saying, “Give!”
                                                    • Determine if the child can retrieve a des-
Developing Damon’s Language                              ignated object in plain sight some 8 to 10
                                                         feet away.
Receptive Language                                  • Determine if the child can bring a famil-
   Damon, as described earlier, is “word                 iar object (out of sight) from an adjacent
deaf,” which means that it is not possible to            room after we designate that object.
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