A Review of the Miller

Method and Relationship Development Intervention

as Treatments for Autism

ToniAnne GiuntaCaldwell College

The Miller Method

Miller Method Overview

• What is it? – Definition, history, central concepts

• What does the Miller Method claim to do…and HOW is this done?

• What research support does it have?

• ABA vs. Miller Method

Search Criteria• PsycINFO

• Miller Method AND autis*• Miller Method AND developmental dis*• Miller Method AND ASD

• YouTube• Miller Method• Miller Method Autism

• http://www.millermethod.org/

• http://millermethodcommunity.ning.com/

“We maintain that each child – no matter how

withdrawn or disorganized – is trying to find a way to cope with the world. Our task is to help that child use every capacity or fragment of

capacity to achieve this.”-Philosophy of the Miller Method

(“What is Miller Method?,” 2009)

What is the Miller Method?

• An integrated approach that addresses problems of body organization, social interaction, and communication in school, clinic, and home settings as presented by children on the autism spectrum

• Cognitive-developmental systems theory

(Miller & Eller-Miller, 2000)

Founders

• Arnold Miller, Ph.D. • Director of

Language and Cognitive Development Center (LCDC)

• Affiliate Professor of Psychology, Clark University

• Received his doctorate in clinical psychology from Clark University.

(“About the Millers,” 2009)

Founders

• Eileen Eller-Miller, M.A., C.C.C.-S.L.P• Education Director of LCDC until

her death in 2004• M.A. in speech and language

pathology from Columbia University

(“About the Millers,” 2009)

History

• Heinz Werner (mentor from 1954-1964)

• For the next 45 years, the husband-wife team built on Werner’s developmental “theory”

• Founded Language and Cognitive Development Center (LCDC) in Boston, MA in 1965

• Rewarded research and demonstration grants from the U.S. Department of Education to help “developmentally challenged children achieve their fullest potential”

(“About the Millers/What and where is the LCDC” 2009, http://www.millermethod.org/)

Central Concepts: Systems

• “Organized, coherent ‘chunks’ of behavior that are, initially, quite repetitive”• Mini-systems• Integrative systems• Broken systems

• “Unlike typical children, those on the autistic spectrum show system aberrations that interfere with performance and development…this means that before such children can progress, careful attention must be given to their system problems.”

(Miller & Eller-Miller, 2000, p. 490-491)

Central Concepts: Executive Function

• “Emerging capacity”• Initially, systems are driven by

external events• Gradually, the child

deliberately forms systems based on an inner plan• Choosing one system over

another• Altering systems• Combine previously developed

systems

• The failure for this shift to occur Developmental Delays

(Miller & Eller-Miller, 2000)

Central Concepts: System Disorders

Disorder Type A Type B

Closed-system Dominated by only a few systems; unable to respond to any stimuli not related to their current systemMinimal executive functioning

Have multiple systems; move from one system to another; prohibit others from entering their systemsExecutive functioning with many objects/systems

System-forming Unable to form systems due to poor sensory-motor coordinationMinimal executive functioning

Unable to form systems because “too sensorily driven” by various stimuliLittle executive functioning

(Miller & Eller-Miller, 2000)

What does the Miller Method claim to do?

• Help children achieve executive control over their systems

• Help children enrich their limited systems

• Helps children with disabilities restore to typical developmental progressions

• This can only be done through body awareness• Rough and tumble activities• Mutual face touching• Deep pressure• Swinging• Elevation(Miller & Eller-Miller, 2000)

“Children unable to follow directions often began for

the first time – when elevated – to respond to manual signs and spoken

words.”-Cognitive Designs, Inc.

http://www.cognitivedesigns.com/playthings.html

The Elevated Square

• 5 ft x 8 ft

• 2.5 ft high

• Middle

• Steps

• Slide

• Stations at each corner

(Miller & Eller-Miller, 2000)

The Elevated Square• Limits the child’s options for

movement, which improves• Eye contact• Direction following• Sign-word relationships• Body awareness• Motor-planning • Social-emotional contact• Focus• Ability to cope with obstacles• Attention to surroundings• Problem solving(Cognitive Designs, Inc., 2008d; Miller & Eller-

Miller, 2000)

Around

Sit down

Up

Down

The Elevated Square

• Closed-system disorders• Expand systems• Move from one system to another• Including others in the system

• System-forming disorders• External organization so the child can

function

(Miller & Eller-Miller, 2000)

The Elevated Square

1. Walking short and long sidesResponding to directions

2. Turning cornersChanging circumstancesCoping

3. Understanding detoursNoticing gapsNavigating

(Miller & Eller-Miller, 2000)

“We chose sign language to link action to spoken

language after preliminary research indicated that body

gestures could facilitate spoken language.”

-Arnold Miller and Eileen Eller-Miller

(Miller & Eller-Miller, 1973, p. 74)

Sign and Spoken Language Program

• Relates objects and events to signs and spoken words

• Manual signs adapted from American Sign Language

• 4 segments• Actions• Food• Familiar Objects/Events• Two-word

Combinations(Cognitive Designs, Inc., 2008b)

Symbol Accentuation Reading Program

• Children who can speak or sign 2-3 word phrases but cannot read or write

• Phase 1: Establishing sight words - http://www.cognitivedesigns.com/symbol.html

• Phase 2: Transition to Phonetic Reading - “Sam and the Boys”

• Phase 3: Phonetic Reading and Writing - http://www.cognitivedesigns.com/symbol.html

(Cognitive Designs, Inc., 2008c)

Sam and the Boys

(Cognitive Designs, Inc., 2008c)

Multispheres

• Sphere – “Any activity that we introduce repetitively with the expectation that the child will ‘take it over’ and transform it into an internalized system”

• “Out of sight out of mind”

Child engaged in a

sphere

Interrupt the

activity at

maximal

tension

Tension

state: Introdu

ce second sphere

Repeat

(Miller & Eller-Miller, 2000)

Receptive Language• Helps children who are “word deaf” – not possible

to guide his behaviors by using solely words

• Repeating the appropriate word while the child is performing the action

• Narrating what the child is doing as he is performing an action

• “Vygotsky test” http://millermethodcommunity.ning.com/video/dillon-passes-the-vygotsky

• Differentiating objects at a distance by pointing, touching it with a long stick, or squirting it with water

(Miller & Eller-Miller, 2000)

Expressive Language

• Interrupting situations to elicit signs or words• E.g., on elevated square, “scavenger

hunts,” videotapes in action

• The use of signs “pulls” spoken language and contributes to language development Using your

hands

Using tools

to extend

the reach

of hands

Using gestures that simulat

e actions

Spoken words

(Miller, 2002b; Miller & Eller-Miller, 2000)

Success Depends On…

1. The child’s age

2. Neurological status

3. The child’s relationship with his parents

4. System characteristics

5. Support demand stance

(Miller & Eller-Miller, 2000)

Miller & Eller-Miller (1989)

The Umwelt Assessment• Determines present system functioning through 16

tasks – “provides information as to the relative emphasis the child places on things as opposed to people” (Miller, 1996, Spring/Summer)

• 2-3 hours

• Oral summary of findings + video

• Recommendations sent within 2-3 weeks

• $1000

• “Parents or caregivers are directly involved in the assessment and often contribute information which allows the examiner to gain access to the child’s functioning” (“For parents/caregivers of children with autism or PDD, 2009, )

The Umwelt Assessment

Capacity to interact with a person and an object

Capacity to adapt to change

Problem solving and learning from experience

(Miller & Eller-Miller, 1989)

Miller Diagnostic Survey

• Survey that gathers information about the child so a program can be created for the child

• 107 Likert-type questions about behaviors from earlier and current stages of development

• Completed by parents before and after a school year at LCDC

• Computer program organizes the responses – “A statistical analysis comparing the two developmental profiles will determine which changes in scored categories are statistically significant” (Miller, 2002)

• LCDC staff member writes a report of recommendations

• $100(Miller, 2002c, Spring/Summer, “Miller diagnostic survey,” 2009,http://www.millermethod.org/)

Miller Diagnostic Survey

Disclaimer. While the MDS has been shown scientifically to be both a valid and reliable instrument, it is not a substitute for direct, face-to-face evaluation of a child by a qualified professional. The formulations derived from parents responses to MDS questions, should be viewed as useful preliminary formulations that need to be confirmed by face-to-face assessments.

(“Miller diagnostic survey,” 2009, http://www.millermethod.org/)

Training in the Miller Method

• Workshops • LCDC• 4 days• Provide “dramatic alternatives to

behavioral approaches [and] ‘compliance training,’ which assumes that children must first sit at a table before they can learn”

(“For professionals seeking training in the Miller method,” 2009, http://www.millermethod.org/)

Training in the Miller Method

• Certification: Miller Method Specialist• Professional discipline in one of the following

areas: clinical or developmental psychology, pediatric nursing, occupational therapy, physical therapy, psychiatry, social work, special education, speech and language pathology

• Workshop participation• Supervision – 50 weeks, 1 hour per week• 3 case studies• Written examination of “searching questions”(“For professionals seeking training in the Miller method,” 2009,

http://www.millermethod.org/)

Training in theMiller Method

• Parent-Child Training• 12 hours over 3 days

• Distance Consultation• Video conferencing• Phone consultation• Internet consultation

• http://millermethodcommunity.ning.com/video/video-conferencing

(“Distance consultation,” 2009, http://www.millermethod.org/)

PsycINFO• Yielded 3 results…

• 1 textbook• 2 doctoral dissertations

• Cook, C. E. (1998)• Qualitative study• Data collection procedures: videotapes, staff

interviews & journals, parent interviews

• Shore, S. M. (2008)• Study design: written survey, recorded

interviews

Miller & Eller-Miller (1973)

• Literature review (preliminary research)

• Participants – 19 children with autism, average 11 years old

• Body awareness – “This was apparent in the sudden cessation of autistic mannerisms, the steadiness of eye contact” (p. 70)

• 50 functional signs

• Procedure – 1 hour per day on school days

• Generalization – High levels, low levels, ground, different rooms, outside

Miller & Eller-Miller(1973)

• Results• One-sign words – “All children could

respond appropriately” (p. 77)• Two-sign words – “The children seemed

somewhat less able to understand and respond appropriately” (p. 78)

• Intercorrelations• Length of time in program• Age

Miller & Eller-Miller (1973)

• 3 case studies• E.g., “Philip’s parents report that most of his bizarre

mannerisms have disappeared” (p. 81)

• Conclusions• “Even severely autistic children can benefit from the

present approach” (p. 82)• However… “We cannot answer these questions

decisively because we have not conducted a controlled study in which all factors but the use of the boards are held constant. Our clinical observations, however, support the importance of elevated boards” (p. 82)

Testimonials• “She would scream a lot and tantrum…but in the second

week of the program she made her first sign…from that time everyday she would come up with a new sign.” –Angela Bogus’ mother

• “Approximately four months after Johnny started the school year, he started to speak…in my heart, I know that if I did not bring Johnny to LCDC he may have never learned to talk.” –Janet Abramson, mother

• “I discovered the Miller Method on the Internet, then arranged to come to Boston for an Umwelt Assessment…my son now does chores willingly, he is productive and helps around the house…there is not enough I can say about these wonderful people who have virtually saved my son’s life.” –Shirley Simmons, mother

(Miller, 1998, Fall/Winter; Miller, 1999, Summer; Miller, 2007, Spring/Summer)

“If we view such aberrant behaviors [stereotypy] as asocial or ‘bad’ then we

follow the path of behaviorists who try to

make the children look as normal as possible by

having them sit quietly in their seats like typical

children.”-Cognitive Designs, Inc.

http://www.cognitivedesigns.com/video.html

ABA vs. Miller Method

Miller (1996, 2002a)

ABA Miller Method

Built on the foundations of…

B.F. Skinner and animal research

Developmental psychologists Werner, Vygotsky, & Piaget

How children with autism are taught

Prerequisite of sitting quietly at a desk they can be taught

Their entire bodies should be used actively and repetitively while narrating/signing what they are doing – “like a sports announcer”

Attitude toward learning

“Compliance training” –rewarded for sitting at the table; undesirable behavior punished through ignoring or aversive measures

Importance of using the entire body (e.g., by climbing on elevated structures) to improve attention and focus

Miller (1996, 2002)

ABA Miller Method

Definition of Stereotypy

Negative, abnormal-looking behaviors that must be extinguished immediately; serve no immediately apparent function

Valuable sources of organized, integrated behavior that must be expanded so they can become more functional; the very best behaviors that children can manage

Treatment of Disruptive Behavior

Ignore it or place the child in time out until the child is “ready” to rejoin the group – “this merely intensifies the child’s autistic isolation”

Breakdown of child’s ability to cope; providing nurturing “special time,” introduce a repetitive and calming ritual

Comparing ABA with the Miller Method

• http://millermethodcommunity.ning.com/

Green (2008)Evidence-Based Practice

Relies on scientific methods to separate opinions and speculations from demonstrated facts

Direct testing of interventions

Controlled (experimental) analyses comparing the intervention to no intervention

Objective and reliable measurement of the intervention and its effects

Replications by multiple investigators, not just one person or group – especially if they are the developers/principle promoters of the intervention

Publication in peer-reviewed journals

Green (2008)

Non-Evidence-Based Practice

Indirect, subjective evaluations

Uncontrolled, descriptive studies

No comparison of control and treatment conditions

Reports in self-published books or journals

Self-reports, anecdotes, and testimonials in books, workshop handouts, media reports, and websites

Theories based on speculations

Miller Method References

About the Millers. (2009). Retrieved from http://www.millermethod.org/

Cook, C. E. (1998). Implementation of the Miller method in an early intervention program for children with pervasive developmental disorder (PDD): A case study. (Doctoral dissertation, Kent State University). Retreived from http://proquest.umi.com.ezproxy.caldwell.edu:2048/pqdweb?sid=1&attempt=1&maxresults=30&maxtopics=56&maxpubs=32&sq=STYPE%28dissertation%29+AND+AU%28Cook%2C+Christine+Elizabeth%29&RQT=309&xsq=STYPE%28dissertation%29+AND+AU%28Cook%2C+Christine+Elizabeth%29&did=738058571&skip=1&rqt=309&vinst=PROD&mfgquery=STYPE%28dissertation%29+AND+AU%28Cook%2C+Christine+Elizabeth%29&fmt=6&ssm=S&startpage=-1&vname=PQD&sortby=N&vtype=PQD&TS=1289333071&clientId=5222

Cognitive Designs, Inc. (2008a). CDI video library. Retrieved from http://www.cognitivedesigns.com/video.html

Cognitive Designs, Inc. (2008b). Sign and spoken language program. Retrieved from http://www.cognitivedesigns.com/sign.html 

Cognitive Designs, Inc. (2008c). Symbol accentuation reading program. Retrieved from http://www.cognitivedesigns.com/symbol.html

Miller Method References

Cognitive Designs, Inc. (2000d). Symbolic playthings. Retrieved from http://www.cognitivedesigns.com/playthings.html 

Discussion forum. (2009). Retrieved from http://www.millermethod.org/ 

Distance consultation. (2009). Retrieved from http://www.millermethod.org/ 

For parents/caregivers of children with autism or PDD. (2009). Retrieved from http://www.millermethod.org/

For professionals seeking training in the Miller method. (2009). Retrieved from http://www.millermethod.org/

Green, G. (2008). Evidence-based practice: Improvement or illusion? Association for Behavior Analysts International Autism Conference, Atlanta, GA.

Miller Method References

Key publications. (2009). Retrieved from http://www.millermethod.org/ 

Miller, A. (1996, Spring/Summer). The Miller umwelt assessment. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ 

Miller, A. (1996, Fall). Contrasting the Miller method with behavior modification. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ 

Miller, A. (1997, Spring). First independent Miller method outcome study. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/

Miller, A. (1998, Fall/Winter). Angela returns to LCDC/Lynnfield. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ 

Miller, A. (1999, Summer). A mother’s thanks. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/

Miller, A. (2000-2001, Winter/Spring). Elevation study under way at LCDC. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/

Miller Method References

Miller, A. (2002a, Spring/Summer). Contrasting the Miller method with the ABA approach. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/  

Miller, A. (2002b, Spring/Summer). The LCDC story. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/  

Miller, A. (2002c, Spring/Summer). The Miller diagnostic survey (MDS): Two major issues in the field. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/  

Miller, A. (2007, Winter/Spring). Letter from a parent whose child attended LCDC. The Miller Method Newsletter. Retrieved from http://www.millermethod.org/ 

Miller, A., & Eller-Miller, E. (1973). Cognitive-developmental training with elevated boards and sign language. Journal of Autism and Childhood Schizophrenia, 3(1), 65-85. Retrieved from http://www.springerlink.com/content/p11m054675p6l531/fulltext.pdf

Miller, A., & Eller-Miller, E. (1989). From ritual to repertoire: A cognitive-developmental systems approach with behavior-disordered children. New York: John Wiley & Sons, Inc.

Miller Method References

Miller, A., & Eller-Miller, E. (2000). The Miller method: A cognitive-developmental systems approach for children with body organization, social, and communication issues. The interdisciplinary council on developmental and learning disorders: Clinical practice guidelines: Redefining the standards of care for infants, children, and families with special needs. (pp. 489-515). Retrieved from http://www.millermethod.org/

Miller diagnostic survey. (2009). Retrieved from http://www.millermethod.org/ 

Shore, S. M. (2008). Examining five promising approaches for treating children with autism spectrum disorders. (Doctoral Dissertation, Boston University). Retrieved from http://proquest.umi.com.ezproxy.caldwell.edu:2048/pqdweb?sid=1&attempt=1&maxresults=30&maxtopics=56&maxpubs=32&sq=STYPE%28dissertation%29+AND+AU%28Shore%2C+Stephen+Mark%29&RQT=309&xsq=STYPE%28dissertation%29+AND+AU%28Shore%2C+Stephen+Mark%29&did=1460436821&skip=1&rqt=309&vinst=PROD&mfgquery=STYPE%28dissertation%29+AND+AU%28Shore%2C+Stephen+Mark%29&fmt=6&ssm=S&startpage=-1&vname=PQD&sortby=N&vtype=PQD&TS=1289333193&clientId=5222

What and where is the LCDC?. (2009). Retrieved from http://www.millermethod.org/ 

What is Miller method?. (2009). Retrieved from http://www.millermethod.org/

Relationship Developmen

t Intervention

(RDI)

RDI Overview

• What is it? – Definition, history, central concepts

• What does RDI claim to do…and HOW is this done?

• What research support does it have?

• Is it a worthwhile intervention?

Search Criteria• PsycINFO

• Relationship Development Intervention AND autis*

• Relationship Development Intervention AND developmental dis*

• Relationship Development Intervention AND ASD

• RDI AND autis*• RDI AND developmental dis*• RDI AND ASD

• YouTube• Relationship Development Intervention• RDI

• http://www.rdiconnect.com/

Books

“…regardless of his or her abilities and limits, there

was something more I wanted to give them

[children with autism]. I wanted my patients to

smile when I walked into the waiting room, because

they were happy to see me, not because they received

an M&M as a reward.” -Steven E. Gutstein

(Gutstein, 2000)

Founder & History

• Steven E. Gutstein• Ph.D. in clinical psychology from Case

Western Reserve University• 20 years studying relationships as a child,

marital, and family therapist• Rationale for creating this intervention:

• http://www.youtube.com/watch?v=XbdaJtPEBfk

• First book on RDI published in 2001 • As of 2009: 5000+ families in 16 countries

are practicing RDI(Gutstein, 2002; Gutstein, 2009)

What is RDI?

• Teaches children with autism the value of interpersonal relationships

• Shared experiences

• Parent-directed, NOT a direct intervention for children

(Freeman, 2007; RDI Program Standards and Code of Ethics, 2008)

What is RDI?Parents learn

the techniques

through videotapes, consultants, and books

Parents conduct 9 hours of

therapy per week

Simple shared interactions

Distraction-free environments, move to more typical settings

(Freeman, 2007)

RDI in Action

• Emotion sharing with Mommy• http://www.youtube.com/watch?

v=pp1LHVkocc4&feature=related

• Building blocks with Dad• http://www.youtube.com/watch?

v=YCgf05d6y7o&feature=related

Parent Roles

• Slow down communication

• Avoid over-talking, frequent questioning, and prompting

• Simplify physical environments

• Slow down the pace of daily activities

• Provide opportunities for experience-sharing

• Journaling and reflection on a regular basis

(Gutstein, 2005; RDI Program Standards and Code of Ethics, 2008)

What does RDI claim to do?

• Help develop emotional feedback systems

• Increase guided participation

• Fix dynamic intelligence, the core deficit of autism

• Establish neural pathways in the area of the brain that regulates emotion and motivation

(Freeman, 2007; Gutstein, 2009; Gustein, 2005)

RDI claims that children with autism will…

• Make true friends who genuinely appreciate them

• Communicate more creatively (communication will become less scripted)

• Receive more invitations and have more desire to accept them

• Become good collaborators and valued team members

• Make meaningful contributions to others’ lives

• Become more fun to teach

• View their parents as real people versus as objects

• Allow feelings versus scripts to guide their actions (Gutstein, 2002b)

RDI claims that children with autism will…

• Act in more flexible manners and be more accepting of change and transitions

• Become more curious about discovering new features of their worlds

• Consider several alternative solutions to problems

• Think in terms of “gray” areas (versus “right or wrong, black or white”)

• Seek out and value others’ perspectives and opinions

• Be more aware of their unique identities

(Gutstein, 2002b)

What research support does RDI

claim to have?• ONE peer-reviewed journal article

• Between-subject design• 17 children with ASD in treatment group

• Received RDI therapy• 14 children with ASD in control group

• Unspecified behavioral intervention or social skill group

• Children in treatment group scored higher on the Autism Diagnostic Observation Scale

• Children in the treatment group were more likely to transition from special to general education

(Freeman, 2007)

HOWEVER…

• Small treatment group sample

• No random assignments, no subject matching

• Children in the treatment group…• “High functioning,” no significant cognitive

impairments• One year younger• Higher IQ’s (an average of 12 points higher!)• More children with Asperger’s Syndrome • Did all children benefit?

(Freeman, 2007)

Is RDI a worthwhile treatment?

• Freeman, 2007:• “Based on the scientific research to

date, there is not enough evidence that RDI is an effective treatment for decreasing the symptoms associated with autism” (p. 156)

Is RDI a worthwhile treatment?

• Association for Science in Autism Treatment, 2010• “Preliminary data that may support this intervention

are cited on the developers’ website and in one published but uncontrolled study (Gutstein, Burgess, & Montfort, 2007). However, the intervention has not been evaluated in peer-reviewed studies with strong experimental designs.”

• “Researchers may wish to conduct studies with strong scientific designs to evaluate Relationship Development Intervention. Professionals should present this intervention as untested and encourage families who are considering this intervention to evaluate it carefully.”

RDI ReferencesFreeman, S. K. (2007). The complete guide to autism treatments: A parent’s handbook: Make sure your child

gets what works! Lynden, WA: SKF Books USA, Inc.

Gutstein, S. E. (2000). Autism Aspergers: Solving the relationship puzzle. Arlington, TX: Future Horizons, Inc.

Gutstein, S. E. (2005). Relationship development intervention: Developing a treatment program to address the unique social and emotional deficits in autism spectrum disorders. Autsim Spectrum Quarterly, 8-12.

Gutstein, S. E. (2007). Evaluation of the relationship development intervention program. Autism, 11 (5), 397-411.

Gutstein, S. E. (2009). Empowering families through Relationship Development Intervention: An important part of the biopsychosocial management of autism spectrum disorders. Annuals of Clinical Psychiatry, 21 (3), 174-182.

Gutstein, S. E., & Sheeley, R. K. (2002a). Relationship development intervention with children, adolescents, and adults. New York: Jessica Kingsley Publishers

Gutstein, S. E., & Sheeley, R. K. (2002b). Relationship development intervention with young children. New York: Jessica Kingsley Publishers

RDI Program Standards and Code of Ethics (2008).

http://www.rdiconnect.com/

http://www.asatonline.org/intervention/treatments/relationship.htm

Question Period