The Miller Method: A Cognitive-Developmental Systems Approach for Children with Body Organization, Social, and Communication Issues1
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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.
500 ICDL Clinical Practice Guidelines 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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