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Milieu Communication Training for Late Talkers

Kimberly Gilbert
Department of Psychology, Hofstra University
Hempstead, NY

Abstract
Milieu communication training (MCT), an intervention designed to elicit early
communication and language behaviors in young children with a variety of
developmental disabilities, has a large empirical evidence base supporting its
efficacy. This article discusses components of MTC, as well as reviews research
supporting this intervention approach for children identified as late talkers.
Intervention for children with delayed language development—whether they
have general developmental delays, specific language delays, or autism spectrum
disorders—begins with the dilemma of how and where to start. Simply stated, if a
child is not talking, how do we help him to begin? Classic behavioral approaches to
early language intervention made use of imitation procedures and tangible rewards for
imitation, often beginning with motor and vocal imitation, and proceeding to verbal
imitation. Although these methods are effective for some children (e.g., Lovaas, 1987;
Tsiouri & Greer, 2003), they are not universally successful, particularly for children
with few imitation or vocal skills, or for children for whom the basic meaning of
communication, as a means to an end, has not yet been established. In addition, these
approaches run the risk of producing a very passive style of communication with little
generalization to functional use of language (Paul & Sutherland, 2005).
In response to this dilemma, behavioral theorists such as McGee, Morrier, and
Daly (1999), Rogers-Warren and Warren (1980), and Warren and Yoder (1998) began
to develop methods that drew on the strengths of behavioral programming: its
predictable, formal structure; use of task analysis; and attention to antecedents and
consequences of behavior. They attempted, however, to address the weaknesses with
which it is associated, including the need to establish basic communicative behavior
that supports the development of speech and to generalize communicative acts beyond
the training setting. These efforts paved the way for the development of the use of
natural environments and contingencies carefully engineered to elicit spontaneous
communicative acts that could be shaped toward more conventional, functional
language. These methods are known by a variety of labels, including incidental

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 teaching, mand-modeling, and milieu teaching. What these methods share is an
understanding that language grows out of a desire to communicate, and
communication begins with an intention to affect the thoughts or actions of another
human being.
These approaches, which we will subsume here under the umbrella term, milieu
communication training (MCT), have one of the largest empirical evidence bases of any
method of intervention designed to elicit early communication and language behaviors
in young children with a variety of developmental disabilities (ASHA, 2008). One
version of MCT has been studied extensively by Yoder and colleagues (e.g., Yoder &
Stone, 2006; Yoder & Warren, 1998, 1999a, 1999b, 2001, 2002), and it will be
discussed in some detail here as an example of a promising approach to
communication intervention for late talking children.

Components of MCT
The principles of MCT approaches include
• Training in everyday environments
• Arranging the environment to promote communication (e.g., putting
objects of interest in sight but out of reach)
• Offering preferred toys and activities so that participation is self-
reinforcing
• Building routines that the child enjoys
• Encouraging spontaneous communication by using “expectant waiting”
and refraining from prompting
• Waiting for the child to initiate teaching episodes by gesturing or
indicating interest in a desired object or activity
• Providing prompts and cues for expansion of the child's initiation
• Rewarding child responses with access to a desired object or activity
(intrinsic reinforcement), rather than a tangible reward unrelated to the
communication act (extrinsic reinforcement)

Phase 1: Responsivity Education/Prelinguistic Milieu Teaching

(RE/PMT)
RE/PMT is a naturalistic, child-led teaching methodology focused on
increasing, first, the frequency, and later the sophistication of expression of
intentional communication. The overall goal of RE/PMT is to increase the number and
complexity of communicative acts. The intervention contains both a parent
component, involving training caregivers to be highly responsive to the child’s
communicative behaviors (e.g., RE or responsivity), and a direct intervention
component in which the child is encouraged to use gestures, eye contact,

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 vocalizations, and to initiate communication (e.g., PMT or prelinguistic milieu
intervention). RE/PMT has been used with children who are functioning
developmentally between approximately 9 months and 15 months and are at
chronological ages between 2 and 6 years (Warren & Yoder, 1998; Yoder & Warren,
2002). It is aimed at children with developmental delays who are not using gestures
and vocalizations at a frequency and in a manner consistent with the onset of
language. Initially, containing only the child-focused PMT component, the intervention
has evolved to include parent training (RE) as a result of observations regarding the
need to facilitate generalization of the skills learned in direct instruction. Through
direct intervention with a clinician and generalized play at home, the adults work to
increase the frequency and complexity of intentional communication.
In this initial, RE/PMT phase of treatment, the clinician engineers opportunities
for the child to become highly motivated to communicate. For example, the adult
might place a novel, colorful toy on a high shelf, where a child cannot reach it without
help, and wait for the child to request the object. The clinician might also introduce
objects, such as interesting cause/effect toys, and activities, such as singing “Row,
Row, Row Your Boat” while rocking back and forth together, that are appealing to the
child. Here, the clinician provides the child with a small amount of time with the
enjoyable object or activity, then withdraws it, and waits for the child to request more.
Additional activities could involve contingent motor or vocal imitation, imitating the
child’s action or vocalization in an exact or expanded manner immediately after the
child’s act (Gazdag & Warren, 2000), in order to establish a back-and-forth, turn-
taking sequence.
Allowing intervention activities to build on the child’s interest helps to ensure
that routines the child enjoys, and will be motivated to request, are developed. These
routines, in turn, offer the opportunity for more frequent opportunities for
prelinguistic expression of intentions (Bakeman & Adamson, 1984), which serve as a
foundation for more functional communication and the acquisition of conventional
language. Thus, RE/PMT provides an environment that is conducive to child
engagement and the establishment of routines that serve as a context for
communicative acts.
Such play routines can incorporate both typical play behaviors, such as
pushing a car along a track or throwing a ball, and more atypical ways of playing,
such as tapping on metal objects, spinning toys, or vocalizing into containers. For
example, if a child enjoys vocalizing into containers, then the interventionist will build
routines based upon this play interest. After the child vocalizes “ah” into the
container, the adult may take the container and imitate the vocalization “ah” until the
routine builds reciprocally, each taking a vocal turn. Once this contingent vocalization
is established, then the interventionist may model “ah-ba” to work toward increasing
both the frequency and complexity of the child’s vocalization. This type of routine

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 building continues in this way, following the child’s interest, working toward the
prescribed goals of the session.
Once a child is vested in such routines, time delays can assist in increasing the
frequency of nonverbal vocalizations, such as “ah” or “ba,” coordinated eye gaze, use of
conventional and unconventional gestures, such as pointing or clapping, and
combining the components of intentional communication acts, such as eye gaze,
vocalization, and gesture. RE/PMT can also be used to foster the generalization of play
skills as children learn to expand routines to include other toys or objects (Yoder &
Warren, 1998, 1999a, 1999b, 2002) apart from those introduced initially.

Phase 2: Milieu Language Teaching (MLT)

Once prelinguistc communication is frequent and fluent, a child then moves
into a phase of treatment called Milieu Language Teaching (MLT). This phase employs
similar activities, such as environmental arrangement, responsive interaction
strategies, and contingent imitation. The main difference at this phase of intervention
is that adults “up the ante” as to what child behaviors receive an immediate response.
Although during RE/PMT, preverbal intentional acts, such as gestures, gaze, and
vocalization would be met with an immediate positive response by the adult, in the
MLT phase, the adult holds out longer for a word or word approximation before
responding to the child’s intention. If, for example, a “Row Your Boat” routine has
been established and the child consistently requests the adult to restart the routine
with a gaze to her and a vocalization, the adult in the MLT phase will now respond to
this behavior with a verbal prompt (“Again? You want to do it again?”). Initially the
adult will restart the routine after her own verbal prompt. Over time, she will use
expectant waiting to encourage the child to produce an approximation of the target
word (again), which may initially be just a vowel (“ah”), and will be shaped to a closer
approximation of the target over time.
A key principle of all phases of MCT is avoiding frustrating the child. Although
adults use expectant waiting to elicit child communication behaviors, if the child does
not produce the desired act within 10-15 seconds, the adult still provides what the
child wants, although perhaps for a very short time, then tries again. Adults also
change objects and activities when the child tires or becomes frustrated with the
current focus of interaction, making an effort to allow the child to choose the next
focus for interaction, from a set of choices provided by the adult or pre-arranged
around the environment. Part of the lesson being taught by MCT is that
communication is an affectively rewarding activity; children will not be motivated to
learn to communicate if they encounter frustration. Rather, the aim of this approach
is to demonstrate to the child that using communication brings rewards more quickly
than using other, maladaptive behaviors, such as hitting or banging the head.
Moreover, the approach aims to show the child that, in interaction with other people,
it is possible to obtain more enjoyable activities and more interesting objects than the

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 child can procure on his own. In this way, the child learns that engaging others
through communication provides highly rewarding outcomes.

Efficacy of Milieu Language Approaches

In general, milieu approaches like these have been shown to be associated with
increased ability to initiate communication in young children who did not show this
ability previously (Matson et al., 1993; Yoder & Warren, 2002), and have been
successfully implemented by both clinicians (e.g., Hancock & Kaiser, 2002) and
trained parents (Culatta & Horn, 1981; Kaiser, Hancock, & Nietfeld, 2000; Wetherby &
Woods, 2006). Several investigators using milieu approaches (Kaiser, Hancock, &
Neitfeld, 2000; Yoder & Warren, 2002) supported a combination of clinician and
trained-parent intervention as a way to maximize the effectiveness of the intervention.
Nonverbal children have developed speech using milieu approaches (e.g.,
Koegel, Koegel, & Surratt, 1992), and increases in the frequency, spontaneity, and
elaboration of language have also been documented (Delprato, 2001; Goldstein, 2002;
Koegel, 2000). For example, Warren and Yoder (1998) showed that children with
mental retardation showed increases in generalized receptive and expressive language
that was maintained 12 months after PMT treatment (Yoder & Warren, 1999, 2001).
When the responsivity portion (RE) with parents was added to PMT (Yoder & Warren,
2002), gains were also noted in spoken language, and the communication gains were
maintained for 12 months in the RE/PMT group. Yoder and Stone (2006) compared
two communication interventions, the Picture Exchange Communication System
(PECS) and RE/PMT for preschoolers with ASD. Results suggested that RE/PMT
facilitated object exchange and the initiation of joint attention more than PECS for
children who began the study with some initiating of joint attention. PECS was found
to facilitate requests more than RE/PMT in children with limited joint attention prior
to treatment.
Few studies have applied milieu approaches explicitly to the treatment of late
talkers with specific language delays. However, both Girolametto, Pearce and
Weitzman (1997) and Robertson and Weismer (1999) showed increases in lexical
diversity, verbal output, and language complexity in late talkers who experienced
treatment with programs similar to MCT. Improvement took place whether the
treatment was delivered by parents trained in the method (Girolametto, Pearce, &
Weitzman, 1997) or by clinicians (Robertson & Weismer, 1999).
More research is needed to document the efficacy of Milieu Communication
Training for late talking toddlers, as well as to establish the kinds of children who
might benefit most from this approach. However, MCT appears to be a promising
intervention for a range of children with delays in the early stages of language
acquisition. Its relatively strong empirical track record in children with general
developmental delays and those with ASD suggest that late-talkers, too, are likely to
benefit.
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