Mand-Model Approach and Milieu Teaching

(note:  this is another installment in an ongoing series on various language therapies)

Mand-Model approach -This is an extension of the incidental teaching model.  The mand-model approach involves the teacher or caregiver modeling and/or manding (requesting) a response from the child.  In modeling, sometimes known as child-cued modeling, the teacher or caregiver observes the focus of the child’s interest (e.g., a ball) and models the correct verbalization (e.g., “that’s a ball”).  If the child makes the correct verbal response the teacher or caregiver then praises the child and provides the object of interest.

example: child reaches for a candy – caregiver keeps candy out of reach, while saying “candy. Say, ‘Candy please!” – caregiver gives candy immediately if child requests, or after a time delay, while modeling correct request if child doesn’t request


Milieu Teaching -As a naturalistic, conversation-based teaching procedure, in milieu teaching the child’s interest in the environment is used as a basis for eliciting elaborated child communicative responses.  Milieu teaching includes other strategies, such as incidental teaching, mand-model, and time delay.  It is based on behaviorism, but rewards are from natural environment.  With incidental teaching the teacher waits for response, while mand-model requires asking (mands) for response.  While often the subject of research, few SLPs seem to actually claim to use milieu teaching.  Maybe it’s the odd pronunciation.

Literature Based Language Intervention

Literature based language intervention involves using books that do not specifically control for reading difficulty to address other skills, such as sentence structure, vocabulary and comprehension.  It saw increasing popularity in the 1980s and 1990s, when language therapy in general saw a shift from skills based intervention to “holistic” “collaborative” models.  Literature based language intervention is effective as one component of an overall approach, especially when the book is determined by the skill.

example: the therapist decides to work on questions, and so chooses the book, “Who’s Your Mommy?” which has repeating stack

Incidental Teaching and Interrupted Behavior Chains

Incidental Teaching – Incidental teaching overlaps or is often used interchangeably with manipulating the environment, naturalistic teaching, communication temptation, and milieu teaching.  It uses changing the environment, or changing the routine, to encourage initiation.

examples:  wear a hat, put the trash can on the table, instead of giving a pencil for a writing assignment give a ruler, walk past an intended door


Interrupted Behavior Chain – This is a type of communication sabotage, or incidental teaching.  A specific routine is identified that the child knows well, and one step is intentionally omitted – intended to elicit protests or requests.

example: child is taught to prepare her own breakfast by getting milk, cereal, spoon, as well as the steps involved – one day one step is “sabotaged,” for example the adult may place the box of cereal out of child’s reach

Graphic Organizers / Semantic Mapping

(note:  this is another installment in an ongoing series on various language therapies)

Graphic Organizers/ Semantic Mapping – I usually think of Venn diagrams, main ideas, and/or details when I think of these, but graphic organizers actually come in tons of different forms.  As opposed to many language therapies, graphic organizers are often for older students. These can be useful for organizing, learning, and/or remembering a variety of language skills, as well as writing, reading, math, etc.  Many great examples of graphic organizers can be found on the Internet, on sites such as and

Semantic mapping is basically using graphic charts to enhance vocabulary or semantic skills. It helps with word associations, categorization, characteristics, describing, and defining.



Venn Diagram

Semantic Map

Semantic Map

Click for blank Similarities and Differences Venn PDF

Click for Similarities and Differences Venn PDF


Three F’s: False Assertions, Following the Child’s Lead, & Focused Stimulation

False Assertions – These may be considered a type of communication temptation.  False assertions are (often) obviously incorrect statements made with the intent to encourage the child to correct.  They’re great for negation, and also underutilized for expanded negation.

example: “Look at the elephant!” when joint attention is on a cow, encouraging child to say “That’s a cow!,” and/or “That’s not an elephant!”

example of expanded negation: “I could have lifted that truck.” encouraging something like, “You couldn’t have lifted that truck.”


Following the Child’s Lead – This occurs when the teacher comments on things a child is looking at, and/or imitates play behaviors.  Following the child’s lead involves observing and listening to the child, and waiting for the child to talk – great for working on initiation.

examples: an autistic child looks at his hands, so you make comments about his hands – a child makes a play noise (such as a car zooming) and you imitate.


Focused Stimulation -The teacher picks a target and attempts to use it over and over again.  In focused stimulation you can use children’s books, songs, blocks, pretend play.  It encourages, but does not necessarily expect child’s production.  Several target words may be combined in a single activity.

example:  the target structures, “off” and “on” may be repeated by the clinician fifty times in a Mr. Potato Head activity in an attempt to elicit the words from the child, such as… “The eye goes on his face.  The hat goes on his head.  I’ll put a different hat on his head.  I’ll take this off his head.”

Expansion and Extension

Expansion and extension are two of the main types of conversational recasting.  Recasting, which is sometimes called, “responsive modeling,” is used to describe a larger category of techniques used to add or correct a child’s utterance without interrupting the flow of conversation.  Imitation and targeted questions are other types of recasting.

Expansion – Expansion takes what the child says, and adds grammar and semantics to turn into a comparable adult utterance.  The point is to keep the communication flow going smoothly, while not making the child realize that he is being corrected.

example: “doggy house” may become “That is the dog’s house.”

Extension – Extension takes what the child says and adds information.  Extension is typically used in conjunction with expansions.

example: “doggy house,” may become “That is the dog’s house. He is a large dog.”  

Expansion and extension are extensively confused.  It helps for me to think of when a balloon expands, it stays the same.  It does not add anything as would, say, an extension on a deadline.

Cycles Approach and Discrete Trials

Cycles Approach – The cycles approach is more a way of structuring overall therapy rather than a specific strategy. The therapist works on one or more specific skills for one or two sessions. Then she works on different skills the next sessions, and then goes back through each skill “cycling” through them, gradually increasing expectations. Goals are added or subtracted as needed for each cycle.  The cycles approach typically requires more intensity, and is good for treating multiple deficits, ensuring that no skills are missed.




Discrete Trials – Discrete trials is a method of intervention common to ABA therapy. Discrete trials intervention breaks up objectives into small repeated steps. This is useful for skills such as attending, imitation, and following basic directions. There are five distinct parts: (1) antecedent/ the set up and/or presentation; (2) the trainer’s prompt, or assistance; (3) the child’s response, (4) the consequence, and (5) a short pause between the consequence and the next instruction

example: Adult shows two cards, one for happy and one for sad. Adult says, “Who’s happy?” Child does nothing. Adult points to the correct card, and provides hand over hand assistance to the child to point to the correct card. If child points to the correct card, adult gives small piece of candy. Adult pauses and repeats and moves on when child no longer needs assistance.

Communication Temptations

Communication temptations are a type of manipulating the environment or incidental teaching that involve caregiver tempting or luring child to talk.  These are good for increasing initiation, social skills, such as asking for help, or asking questions.  Communication temptations often require starting something, pausing, and waiting until child does something.Image

examples: Put a desired object on high shelf, encouraging child to ask for it. Put a desired object in a tight jar. Give child just a few legos and wait for him to ask for more.
“Accidentally” do things, like walk past the room, don’t turn on the light, etc.

Child Directed Speech and Choices

child-directed speech – aka “motherese- uses frequent questions, exaggerated intonation, extra loudness, lots of repetition of key words, slower tempo with more pauses – not “baby talk”

examples: Is that a car? That car looks fast. That car is red. Do you like the car?


choices/ forced choicecan be very specific to a specific child, and so are an excellent teaching tool – great for labeling in general, or for labeling/using specific language skills – ways to make easier or harder…

  • Hold desired object and a non-desired object. “Do you want the cookie…or the paper?”
  • Change the foil. “Is this a pencil or a perpendicularagram?” when you want to make it more obvious that the correct choice is pencil, versus, “Is this a pencil or a pen?”
  • Change the position. “Are you 4 years old, or 20 years old?” versus, “Are you 20 years old, or 4 years old?” It’s naturally easier when the choice is in the last position.

Language Therapy Strategies – Chaining

Chaining starts with part of a skill, then keeps that skill while adding another part, then keeps those two skills while adding another part, and so on continuing until the larger target is learned.  There are two main types usually used:  forward and backward.  Forward is sometimes used in teaching speech articulation, such as with mulit-syllabic words, and backward chaining is often used in teaching self help skills, such as brushing teeth or making a bed.  Chaining as a language teaching tool has been demonstrated to be effective, and it seems to carry a large untapped potential.  With chaining you’re basically using successive approximation, or gradually increasing the length and complexity of an utterance.

example: adult says, “Say, ‘I’m’” – child says, “I’m.” – adult says, “Say, ‘I’m three’” – child says, “I’m three” – adult says, “Say, ‘I’m three years” – child says, “I’m three years” – adult says, “Say, ‘I’m three years old.” – child says, “I’m three years old.”

Language Therapy Strategies – Carrier Phrases

With carrier phrases, the caregiver repeats the same phrase, with substitutions for one part.  Use of carrier phrases is similar to focused stimulation.  These are good for increasing sentence length, and for working on specific target structures.

examples: 1)  When reading a book, the caregiver may say, “I see a dog. I see a horse. I see a car.” to try to entice child to use the phrase, “I see a ….” for other objects.  2)  “I have…” may be used as a carrier phrase for labeling body parts, such as:  “I have hands.”  “I have a nose.”  “I have shoulders.” etc.

(Note:  I’d been planning on posting these strategies together, but it just got too big for that.)

A Comprehensive List of Autism Therapies (Part Two of Three)

Orton – Gillingham Approach – uses “multi-sensory” methodology – “triple enforced” learning means that students may use visualizations/mental imagery, written, and spoken modalities – highly structured, systematic and hierarchical – has been around since the 1930s – primarily for dyslexia, though claims to help various language disorders, including autism – when used as intended, it is intensive and expensive – research generally positive, though some contradictory

Pivotal Response Training (PRT) – pivotal is another word for crucial, and includes general areas, such as motivation, social initiation, and understanding rather than specific behaviors – derived from ABA, but is more child initiated, play based, and does not focus on specific behaviors – part of Early Start Denver Model approach – research seems generally positive but limited

The PLAY Project – (Play and Language for Autistic Youngsters) – uses DIR/Floortime model – focus is on teaching parents to become interventionists using strategies of DIR/Floortime, such as following child’s lead – intensive and expensive, but perhaps a little less so than most other approaches – research limited, but generally positive

PECS (Picture Exchange Communication System) – approach most effective for establishing communication motivation and initiation – children are taught to use basic pictures to request objects and basic needs – the official approach, taught by the Pyramid Educational Consultants, is, wait for it…intensive and costly, although probably not as much as many other methods – research generally positive, though mainly for short term use and in single settings – difficult to implement, as at least early on requires multiple caregivers

Rapid Prompting Method (RPM) – the main provider of this is called HALO, which labels their method Soma-RPM, developed by a mother (named Soma) with an autistic son – uses stimuli such as rapid speech and paper tearing to supposedly match the preferred modality of the autistic individual – appears to at least sometimes use facilitated communication to “encourage” communication via pointing – has received media attention from PBS, HBO, and CBS – not backed by any good research, and the long debunked methods of facilitated communication have had multiple tragic results

Relationship Development Intervention (RDI) – developed by Dr, Steven Gutstein – intensive training program, primarily for in home use, intended to gradually strengthen social connections – has multiple catch phrases, such as dynamic intelligence, emotional referencing, flexible thinking, relational information processing, etc. – the RDIconnect company trains certified consultants, who then train parents their specific strategies – potentially expensive, and independent research almost nonexistent

Relational Frame Theory (RFT) – extremely confusing theory of language , using operant conditioning principles and loads of jargon – I haven’t heard of anybody actually using this to treat language disorders, but there is tons of information on the internet from its adherents as if RFT is the greatest thing since sliced bread, and that it can treat everything from stress to autism

Reciprocal Imitation Therapy (RIT) – Dr. Brooke Ingersoll – uses principles of ABA and pivotal response training to specifically address imitation and play abilities – involves parallel play and ties imitation into social reasons for imitating – starts by adult imitating, and providing opportunity for child then to imitate – spends more time selecting things with intrinsic interest than traditional ABA like therapy – seems possibly helpful for specific groups – research very limited at this point

TEACCH – Treatment and Education of Autistic and Communication related handicapped Children – school based program developed state-wide in North Carolina, and sometimes used elsewhere – prototype TEACCH model places several children in small self-contained classes, usually with one teacher and one aide – intended to provide autistic individual with structure and organization, with such things as physical boundaries, routines, visually based cues, etc. – sometimes used along with other strategies – some research suggests it may be beneficial, but as usual, almost all research has not been independently verified – also, research results seem to be largely dependent upon skills and experience of staff

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A Comprehensive List of Autism Therapies (Part One of Three)

I’ve been meaning to do this post for years.  A while back I started a list of short summaries of all the autism treatments I’ve heard of, which just kept growing as I kept hearing of more.  My purpose was, and is, to provide some listing for parents and professionals to get a general, but comprehensive, idea of what’s out there.  What started as a simple endeavor, however, has blossomed into a huge amount of information much too big for one sitting.  My more in-depth research for the following approaches honestly depressed me.  Most of us know that there are a lot of snake oil salesmen on the autism gravy train, but it is just extremely difficult parsing through the scads of information (including the piles of dubious and/or refuted claims) not just with these combined, but even with each individual approach.  To make this as comprehensive as possible, I’ve included any therapy, including those designed more for reading or language,  whose proponents claim the therapy to be beneficial for people with autism.

My first part of this three part post will alphabetically cover approximately half of the most commonly used autism treatment programs.  My second part will cover the second half, along with my general opinion on these approaches.  In part three, I intend to provide a comprehensive list of the specific language interventions, or techniques, found throughout these programs – as well as many additional ones not found in any them, despite their effectiveness with language intervention.  At that time I also intend to provide all parts combined in a handy PDF file, for convenient reference.  So, here goes…

Applied Behavior Analysis (ABA) – uses methods of behaviorism, such as classical conditioning, rewards and punishments – intensive – popularly used with autism, but is designed for any severe language disability – there are different ABA based interventions, such as Lovaas Method, and Early Start Denver Model – extensively researched, generally positive, but not conclusive, and seems more effective with certain subgroups – has reputations for both being successful and for creating “robotic,” emotionless children

Applied Verbal Behavior (AVB) – a form of ABA that uses principles of behaviorism focusing on teaching the child to realize that language can get him what he wants – uses terms directly from B.F. Skinner, such as mands and tacts

Animal Therapy – mainly includes dog therapy or horse therapy (so far) – It seems that dogs can be helpful in creating some motivation for socialization. However, the type of dog, the incredible cost for a trained dog, and the lack of research should all be considered. – Horse Therapy, AKA Equine Therapy, seems to be gaining in popularity especially in autism – appears to be beneficial, but, as with many of these therapies, should not ignore directly addressing specific communication disorders that involve disabled people communicating with other people

Auditory Integration Therapy (AIT) – popular ones are the Tomatis and Berard methods – aims to reduce hypersensitivities to sound through systematic desensitization process using music – the use of AIT to treat all sorts of cognitive ailments, from communication disorders to ADHD to preparation for childbirth has continued despite organizations such as the American Speech Language Pathology Association (ASHA) issuing position statements against it – may be mildly helpful, but these practitioners have a history of making huge claims that are unsupported

Biomedical Treatments – there are many of these, too many for me to adequately cover in a short synopsis – a good short review of the research can be found in this link – these include vitamins B6 and C, melatonin, amino acids, folic acids, antifungal agents, gastrointestinal medications, hyperbaric oxygen chambers, immune therapies, chelatin, and more – to this point, for these “alternative” therapies, the jury is way out on any of them that may consistently work for large groups of people with autism

CogMed – commercial software specifically designed to treat working memory in ADHD and other cognitive deficits – 25 sessions cost approximately $2,000 – there seem to be some benefits, but more research needed – gains may be short term and not generalizable to deficits outside of working, or short term, memory

DAN! (Defeat Autism Now) – created by Autism Research Institute, which owns the domain, so often first place people happen upon for information – DAN! as a program label has been discontinued, but the ARI seems to still be promoting its foundations that autism as a biomedical disorder should be treated primarily as a combination of lowered immune response, external toxins from vaccines and other sources, and problems caused by certain foods – DAN! and ARI have been the subject of much controversy, but has been extremely influential for many years – advocates ABA, and Theory of Mind, but with no specific language therapy

DIR/ Floor Time – by Dr. Stanley Greenspan – DIR stands for Developmental, Individual-Difference, Relationship-Based – it includes following the child’s lead, and using things that already interest the child. It assumes six milestones of typical emotional and communicative development and attempts, through intensive play and interaction, to guide children through each of these stages – has some very good parts, but the program itself can be grueling and expensive

Elimination diets (casein/gluten free diets) – The current thinking is that there is at least some evidence showing that a casein-free diet, when combined with a gluten-free diet, can help improve the behavior of some children with autism. Although the casein-free diet combined with a gluten-free diet is popular, there is little evidence in the current scientific literature to support or refute this intervention. Scientists have concluded that there are currently not enough published studies to draw a meaningful conclusion. Strong caution should be taken when modifying diets of autistic children, who are often finicky eaters anyway, to ensure that they are getting adequate nutrition.

Fast ForWord – Educational software produced by the Scientific Learning Corporation, with emphasis on phonological awareness. Suggested to help auditory comprehension, memory, attention, and other cognitive skills, as well as reading. Expensive and time consuming. Has been extensively researched, with debatable (and often debated) results

Continue reading →

Stuttering’s “Monster Study”

The twentieth century saw a slew of research studies that gained notoriety as much for the ethical boundaries they pushed as well as the psychological insights that were gained.  The attention garnered by these studies, which included the Stanford prison experiment, Stanley Milgram’s shock experiment, and John Watson’s “Little Albert,” helped highlight the need to create ethical standards and reviews in research.  The “Monster Study” was different, though.  Its lessons went long swept under the rug.

"Little Albert's" Monster

“Little Albert’s” Monster

In 1939, Wendell Johnson, who is now the namesake of the University of Iowa’s eminent Speech and Hearing Center, together with one of his graduate students, Mary Tudor, undertook an experiment to gain more information into the behavioral nature of stuttering. Specifically, Johnson sought to question the prevailing theory that stuttering’s cause was entirely genetic, and therefore, little could be done to therapeutically help stutterers.  While Johnson’s ultimate goal may have been noble, his methods and subsequent cover-up led to this one, out of all of the era’s questionable studies, as the one that was dubbed the “Monster Study.”

Tudor was sent to an orphan’s home to pick subjects to test Johnson’s view that stuttering develops when speakers are criticized for normal mistakes.  Johnson, himself a stutterer, ultimately developed the diagnosogenic theory of stuttering, despite later hiding the research used to support this view that the diagnosis causes the disease.  Out of 22 test subjects, half (five previously identified stutterers, and six identified as having normal speech) were given sessions every few weeks in which they were criticized harshly for every mistake, and during which Tudor tried to convince them that they were stutterers.  Tudor also instructed teachers to be critical of the speaking of this group of children.  The other half were generally complimented on their speech.  The experiment lasted for nearly five months.  While the exact effects were disputed, the fact that these kids were harmed is very clear.  Tudor attempted three follow-ups, and in later correspondence to Johnson she expressed remorse for not being able to reverse the study’s earlier “deleterious effects.”


Johnson’s Namesake at the University of Iowa

And so for decades, few outside of the participants, and Johnson’s colleagues at Iowa, knew about the study.  Meanwhile, the department named after Johnson grew into one of the more prestigious institutions of Speech-Language Pathology in the world.  Then, a 2001 story in the San Jose Mercury News brought what had been local whispers of a “Monster Study” into the national limelight.  The story was re-published in newspapers across America, immediately igniting a firestorm of controversy.  It also spawned litigation, ultimately leading to nearly million dollar settlements for 3 still living subjects, and for the descendants of three others.

Unfortunately lost in the details was Johnson’s big question.  Can you create a stutterer?  The results of Tudor and Johnson were themselves mixed.  According to their own ratings of the previously non-stuttering children, two kids from the normal group developed more stuttering, but two didn’t, and two others were even marked as improved.  While its effects on stuttering were ambivalent, the experiment clearly did have other negative consequences for its participants.  There were admitted increases across multiple areas of behavior, such as increased shyness, tics, anxiety, inhibition, and self-esteem.

Most insidious, perhaps, was the results of Johnson’s own actions.  Not only did he fail to publish results which were, at the best, ambivalent toward his hypothesis, he continued promoting his view that caregivers are almost solely responsible for stuttering.  Directly due to the diagnosogenic theory, therapy was greatly reduced for decades of stutters.  In its place, therapists worked almost exclusively with parents.  While we still don’t know exactly what causes stuttering, the research has clearly indicated a strong genetic component which can be triggered or exacerbated by events in the environment.  And critically, direct therapy can, and often does, help.

This fantastic story in The New York Times has many more details.  This article describes some more recent developments.

Piaget’s Constructivism

As a pioneering psychologist in the merging studies of cognition and learning, Jean Piaget helped change the common assumption that as thinkers, children are merely less complex versions of adults.  His twentieth century work built upon the classical roots of Socrates, and more recent work of Lev Vygotsky, Jerome Bruner, and others who believed learning to be a process facilitated, rather than caused, by teachers.  At the forefront of constructivist assumptions are the notions that the most effective learning takes place when learners are active and motivated participants in the process.

Visual of assimilation - accommodation cabinet

Visual of assimilation – accommodation cabinet

While constructivism as a system has been criticized as being too subjective and difficult to manage, as with so many complex systems it has several components that stand out as applicable outside of the larger theory as a whole.  The notions of assimilation and accommodation are two of my favorites.  Assimilation occurs when a learner adds new information, basically layering it on top of the old.  Accommodation occurs when a learner must change previously learned information before placement of new information is possible.  Assimilation is like placing files in a file cabinet, while accommodation is like needing to add new folders, or rearrange existing ones.  Because of this, learning is said to get more difficult as we age, with the tendency of older people to get what has been deemed, “hardening of the categories.”

Piaget and the constructivists also coined all kinds of terms, such as schema and equilibrium, not to mention those associated with the famed stages of development, such as the sensorimotor, concrete operational, and preoperational stages.  Piaget’s ballyhooed notion of object permanence (the understanding that an object exists even when out of sight) has been extensively studied and debated.

As with seemingly all mind related theories, the popularity of constructivism has followed the pendulum of favorability.  There are many specific aspects of constructivism, though, that should stand the test of time.  Some additional good information can be found hereThis, also is kind of cool.

Study Asks “Why do SLPs Select Specific SLI Tests?”

lshss april 2013

A study of survey responses regarding Specific Language Impairment testing was discussed in the April (2013) Language, Speech, and Hearing Services in Schools.  The authors basically found out what tests SLPs were giving and compared those to test characteristics, such as validity, reliability, etc.  They generally found that characteristics such as the inclusion of multiple facets, and testing time seemed to be more important in test selection, than characteristics such as reliability, accuracy, and validity.  SLPs also like to give single word vocabulary tests.  The synopsis is at this link.

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