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Milieu Teaching and Autism Ranking: Insufficient/Mixed evidence

Craft lesson for student with autism

Milieu teaching is a behavioural intervention in which individuals are taught language skills and behaviours within the natural environment (the milieu). The teaching is delivered in places (such as the kitchen) and in situations (such as when a child wants a snack) in which individuals are most likely to want to communicate with other people.

Teaching begins when an individual shows an interest in activities or materials (for example, by standing next to a table with snacks on) or begins to communicate (for example by pointing to a snack).

The teacher responds by using one or more specific techniques including

- Modelling: demonstrating the desired behaviour so that the individual can imitate it, for example, by saying “Snack”

- Manding: asking questions or providing verbal instructions to encourage the individual to provide the desired response, for example, by saying “What do you want?”

- Time delay: waiting for a short period of time in order to prompt the desired response, for example, waiting ten seconds for the individual to say “Snack”

There are several variations of milieu teaching such as prelinguistic milieu teaching (where the focus is on teaching pre-verbal skills to very young children) and enhanced milieu teaching (where the focus is on responding to and interacting with the child).

The individual elements which make up milieu teaching (modelling, manding and time delay) can be delivered as standalone techniques, can be used together in specific milieu teaching programmes (such as the Responsive Education and Prelinguistic Milieu Teaching programme) or can be used together as part of multi-component social communication programmes (such as the Comprehensive Communication Intervention for Minimally Verbal Children With Autism).

Our Opinion

There is insufficient high quality research to determine if specific forms of milieu teaching (such as prelinguistic milieu teaching or enhanced milieu teaching) provide any benefits to children on the autism spectrum.

There is no high quality evidence to suggest that specific forms of milieu teaching (such as prelinguistic milieu teaching or enhanced milieu teaching) provide any benefits to young people or adults on the autism spectrum.

However we believe that the key elements of milieu teaching (such as modelling, manding and time delay) may help to improve the communication and social skills of some young children on the autism spectrum when combined within much larger multi-component programmes, such as those which follow the NICE guidance on psychosocial interventions for children and young people on the autism spectrum.

There is a need for more research studies which use more rigorous and robust research methods; which compare milieu teaching with other, similar interventions; and which identify the specific components of milieu teaching, if any, that are most effective.

Disclaimer

Please read our Disclaimer on Autism Interventions


Audience

According to Choi and Kim (2005), milieu teaching is “recommended for individuals with disabilities who are at the early stage of language development” which includes children on the autism spectrum.

Aims and Claims

Aims

The aim of milieu teaching is to increase and improve a range of communication skills. For example according to Goldstein (2002),  

  • “a variety of communicative functions are being taught to children with autism using milieu teaching procedures: preverbal communication (eye  contact,  joint  attention, and  motor  imitation); spontaneous productions of  'I like/love you', descriptions  of  drawings  and  car  play; social amenities such as ‘please, thank you, excuse me, you’re welcome, hello'; positive  interactions  with  peers; answers to ‘Where  is  ___?’ questions; phoneme [unit of sound] production; and simply increased talking.”

Claims

There have been various claims made for milieu teaching used with young children on the autism spectrum including improved communication.  For example

  • Hancock and Kaiser (2002) reported that “all children showed positive increases for specific target language use at the end of 24 intervention sessions, and these results were maintained through the 6-month follow-up observations.”
  • Kaiser et al (2000) reported “Most children’s complexity and diversity of productive language increased.”
  • Mancil et al (2009) reported “Results indicate that aberrant behavior decreased concurrent with an increase in total percentage of communication responses (PCR). The children maintained communication and low rates of aberrant behavior, and generalized their communication from the home to the classroom.“
  • Olive et al. (2007) reported that children learned to request items during play. 

Key Features

Milieu teaching is a behavioural intervention in which individuals are taught language skills and behaviours within the natural environment (the milieu). The teaching is delivered in places (such as the living room or the kitchen) and in situations (such as when a child wants a snack) in which individuals are most likely to want to communicate with other people.

Milieu teaching is also known as milieu training, milieu therapy and milieu communication training.

Characteristics

According to Choi and Kim (2005) milieu teaching has several characteristics.

1. “Teaching episodes are embedded within typical or routine activities in an individual's natural communicative environments (e.g. kitchen area, living room, child's bedroom, classroom, snack area, playground).”

2. “Teaching begins when an individual shows interest in activities or materials (e.g. standing by swing, sitting at a snack table) or initiates communicative interactions (e.g. pointing to an item, requesting an item verbally). Thus, a variety of stimuli items, like books, snacks, paper, pictures of trains, all commonly available in an individual's natural environment are used to teach language skills.”

3. “The student is taught to use his language skills for a number of communicative purposes, such as making requests, asking questions, commenting, and rejecting, and providing information.”

4. “Explicit prompts, including models, mands (i.e. questions or requests), and time delay, are used to elicit target language responses.”

5. “Natural consequences (e.g. access to requested items) are provided contingent upon appropriate communicative responses. For instance, a child's use of the correct target language response, "Drink juice", is followed by a cup of juice. Because language responses are taught and practiced under naturally occurring conditions, generalization is likely to be enhanced.”

6. “Milieu teaching incorporates only a few trials at a time. If a correct language response does not occur with prompting after only a few attempts, the desired consequence is nonetheless provided in order to preserve the motivation to under similar circumstances in the future.”

Teaching Procedures

According to Choi and Kim (2005) milieu teaching has three specific teaching procedures 1) model, 2) mand and 3) time delay, although other authors such as Goldstein et al (2002) report that incidental teaching techniques are also a key procedure in milieu teaching.

1. “The model procedure refers to demonstrating the desired language response so that a student can imitate it, for example, to repeat a particular word, phrase, or sentence, in relation to the focus of the child's interest. The model procedure is used primarily to teach verbal or signal imitation skills, and it is used for individuals who need to learn new or difficult target responses.”

2. “Mand refers to asking questions (e.g. ‘What do you want?’ or providing verbal instructions (e.g., ‘Tell me what you want’), to a student to elicit a specific response in relation to the focus of his interest (e.g. ‘Say, tie shoes’ when wanting to go outside to play). The mand procedure is used after a student is able to imitate the target language but lacks conversational or intraverbal skills.”

3. 'Time delay refers to the act of waiting for a short period of time after obtaining joint attention in order to prompt a response. For example, giving a questioning look for 5 seconds until a child produces the target language in response. The time delay procedure is used to increase the spontaneous use of the target language in situations where the child is likely to need material or assistance.'

Incidental teaching:  refers to teaching in which a teacher takes advantage of naturally occurring 'incidents' or situations to provide learning opportunities for the student.

Specific forms of milieu teaching

There are several variations of milieu teaching such as prelinguistic milieu teaching (where the focus is on teaching pre-verbal skills to very young children) and enhanced milieu teaching (where the focus is on responding to and interacting with the child).

The individual elements which make up milieu teaching (modelling, manding and time delay) can be delivered as standalone techniques, can be used together in specific milieu teaching programmes (such as the Responsive Education and Prelinguistic Milieu Teaching programme) or can be used together as part of multi-component social communication programmes (such as the Comprehensive Communication Intervention for Minimally Verbal Children With Autism).

Cost and Time

Cost

The costs of using milieu teaching will depend to a large extent on whether the teaching is incorporated within a larger, multi-component programme, who provides the teaching, how long it takes to implement the intervention, and whether support materials are purchased.

Time

Like many other interventions, the length and frequency of treatment will depend to a large extent on the needs of the individual. In some cases, the intervention will require many hours of work each day and be implemented over many years.

Risks and Safety

Hazards

There are no known hazards for milieu teaching.

Contraindications

There are no known contraindications (something which makes a particular treatment or procedure potentially inadvisable) for milieu teaching.

Suppliers and Availability

Suppliers

In practice, milieu teaching may actually be implemented by a variety of people, including parents and carers, as well as professionals such as teachers.

Credentials

There is no internationally recognised qualification for the delivery of milieu training. In practice, milieu training may actually be implemented by a variety of people, including parents and carers, as well as professionals such as teachers.

History

Milieu teaching was developed by a number of researchers, including Hart and Rogers-Warren, in the late 1970s and early 1980s.

They described milieu teaching as a collection of “naturalistic” instructional procedures that built on the incidental teaching methods described by Hart and Risley.    

Since the 1990’s various researchers have developed different forms of milieu teaching including

  • Hancock, Kaiser and others who developed enhanced milieu teaching
  • Warren, Yoder and others who developed prelinguistic milieu teaching

Current Research

We have identified 17 scientific studies published in peer-reviewed journals in which milieu teaching was identified as the main intervention or in which milieu teaching was identified as a core component of a multi-component programme. These trials included more than 100 children, most of pre-school age, diagnosed as being on the autism spectrum (including children with autistic disorder or pervasive development disorder - not otherwise specified).

  • Two of the studies (Christensen-Sandfort and Whinnery, 2013; Ogletree et al, 2012; Stephens, 2008) examined milieu teaching and three of the studies (Mancil et al, 2009; Ingersoll et al, 2012; Ingersoll, 2011) examined milieu teaching delivered alongside other interventions or compared to other interventions (such as functional communication training or responsive interaction).
  • Two of the studies (Hancock and Kaiser, 2002; Kaiser and Roberts, 2013; Kaiser et al, 2000) examined enhanced milieu teaching while two other studies (Kasari et al, 2014; Olive et al, 2007) examined enhanced milieu teaching delivered alongside other interventions (functional communication training or a voice output communication aid).  The study by Kaiser and Roberts, 2013 compared EMT delivered by therapists to EMT delivered by parents and therapists.
  • One of the studies (Franco et al, 2013) examined prelinguistic milieu teaching and three of the studies (McDuffie et al, 2012; Yoder and Stone, 2006a; Yoder and Stone, 2006b) examined a specific form of prelinguistic milieu teaching (RPMT) in comparison to the Picture Exchange Communication System.
  • One of the studies (Wetherby and Woods, 2006) examined milieu teaching as a component of a combined­, multi-component intervention package (the Social Interaction Project).

Most of the studies reported positive benefits including increased language skills and improved social interaction.  

The studies by Ingersoll et al (2012, 2011) reported more mixed results, suggesting that milieu teaching led to more overall language, prompted language, and requests than responsive interaction but that responsive interaction led to more comments than milieu teaching.

The study by Kaiser and Roberts (2013) reported that EMT delivered by parents and therapists was more effective than EMT delivered by therapists alone.Please note: we have not evaluated studies which included only some of the elements of milieu teaching (such as incidental teaching or manding) or where milieu teaching was not specifically identified as the main teaching technique.

Status Research

There are a number of limitations to all of the research studies published to date. For example

  • The studies identified included many different forms of milieu teaching including enhanced milieu teaching (Hancock and Kaiser, 2002; Kaiser and Roberts, 2013; Kaiser et al, 2000) and various forms of prelinguistic milieu teaching (Franco et al, 2013; Yoder and Stone, 2006a). This makes it difficult to be sure which aspect of the different forms of milieu teaching, if any, was responsible for any of the reported benefits.
  • Some of the studies (such as Mancil et al, 2007; Olive et al, 2007) combined milieu teaching with another intervention (such as functional communication training or a voice output communication aid) or used milieu teaching as one component within a multi-component intervention (Wetherby and Woods, 2006). This makes it difficult to be sure which of these interventions, if any, was responsible for any of the reported benefits.
  • Most of the studies (such as such as Ogletree et al, 2012; Ingersoll , 2011; Mancil et al, 2007) had a small number of participants (6 or less).  The study by Kaiser and Roberts, 2013 included 77 participants but it is not clear how many of those participants were on the autism spectrum and how many had Down syndrome.
  • The participants in the studies were restricted to children aged eight years or less. The parents and carers of the participants were not necessarily representative of all parents and carers of individuals on the autism spectrum in terms of gender, income, ethnicity, intellectual level etc.
  • Most of the studies (such as Christensen-Sandfort and Whinnery, epub; Hancock and Kaiser, 2002; Olive et al, 2007) used single-case design methodologies, such as case studies or multiple-baseline studies.  The study by Juneja et al, 2012 was a retrospective review.
  • The controlled study by Paul et al, 2013 was non-randomised and non-blinded.  None of the randomised controlled studies (such as McDuffie et al, 2012; Yoder and Stone, 2006a; Yoder and Stone, 2006b) was blinded and all three of these studies reported data from the same experiment on the same group of participants.
  • Some of the studies (such as McDuffie et al, 2012; Yoder and Stone, 2006a; Yoder and Stone, 2006b) were undertaken by researchers who were not independent of the intervention being studied.  Those researchers may therefore have been biased towards the intervention, however unconsciously.
  • Some of the studies (such as Hancock and Kaiser, 2002; Olive et al, 2007) had a fairly restricted set of participants and parents/carers of those participants – in terms of gender, ethnicity, income, education, intellectual ability etc.
  • Most of the studies did not examine if any benefits could be maintained over lengthy periods (several months) but most of the studies did take place in real world settings (at home or in school) with typical providers (parents and teachers).
  • None of the studies involved people on the autism spectrum to review the efficacy and ethical basis of the interventions provided.

For a comprehensive list of potential flaws in research studies, please see ‘Why some autism research studies are flawed’

Ongoing Research

  • Vanderbilt University is running a study to an efficacy study of an intervention to increase spoken language in preschool children who are minimally verbal.  Clinical Trials Gov Ref: NCT02291172.  For more details, please see Comprehensive Communication Intervention for Minimally Verbal Children With Autism Full Item (Open in New Window)

Future Research

Summary of Existing Research

There is insufficient high quality research to determine if specific forms of milieu teaching (such as prelinguistic milieu teaching or enhanced milieu teaching) provide any benefits to children on the autism spectrum.

There is no high quality evidence to suggest that specific forms of milieu teaching (such as prelinguistic milieu teaching or enhanced milieu teaching) provide any benefits to young people or adults on the autism spectrum.

Recommendations for Future Research

Future studies should

  • Use more rigorous and robust research methods (such as large scale, randomised controlled trials).
  • Compare milieu teaching with other, similar interventions to see which is most effective for teaching communication skills to different groups on the autism spectrum.
  • Identify the specific components of milieu teaching which appear to be most effective (such as length of treatment, intensity of treatment etc.).
  • Include a more diverse set of participants and parents/carers of those participants – in terms of gender, ethnicity, income, intellectual ability etc.
  • Examine if any benefits can be maintained over a longer period (several months).
  • Involve people on the autism spectrum to review the efficacy and ethical basis of the intervention.

Studies and Trials

This section provides details of scientific studies into the effectiveness of milieuteaching for people on the autism spectrum which have been published in English-language, peer-reviewed journals.You may be able to find more studies on milieu teaching in our publications database.

If you know of any other publications we should include please email info@researchautism.net with the details.

Please note that we are unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Related Studies and Trials


Other Reading

This page provides a select list of other publications on milieu teaching and people on the autism spectrum. 

If you know of any other publications we should include please email info@researchautism.net with the details.

Please note that we are unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Related Other Reading


Personal Accounts

We have been unable to identify any personal accounts about the use of milieu teaching for people on the autism spectrum.

If you know of any other accounts we should include please email info@researchautism.net with the details. 

Additional Information

There is some confusion over the difference between milieu teaching and similar, overlapping interventions such as incidental teaching, with different authors having different definitions for each. For example, Goldstein et al (2002) provide a very broad description of milieu language teaching which includes incidental teaching but also the natural language paradigm (the early version of pivotal response training).

Related Additional Information


Updated
19 Dec 2017
Last Review
01 Jan 2017
Next Review
01 Jan 2020