How can the Miller Method enhance your intervention strategies?  What does it add to current occupational therapy practices?

Occupational therapists treat adults by restoring functional skills like dressing and washing clothes.  Since “play” is a child’s occupation, OTs who specialize in pediatric populations often do a fine job of facilitating playful engagement by using Sensory Integration techniques, adaptive response, and following the child’s lead. These are essential skills and in the Miller Method we also structure our intervention based on what organizes the body and “captures” the child’s interest. However, an ability to “play” is based on more than sensory regulation and emotional engagement.

Filling in the Gaps

Play is composed of specific action-object systems that are surprisingly universal.  During the period of sensori-motor exploration, a child develops play systems like filling and dumping buckets, stacking blocks, sending cars down ramps, and pulling objects on string. If a child has not been able to establish these systems because of neurological challenges, he will not be able to spontaneously call them up when he needs to “play”.  Without specific intervention he will not be able to scoop sand into a bucket and then dump it, no matter how emotionally invested, and no matter how good the therapist.  The child needs to establish motor maps by repeatedly experiencing the action-object system in a perceptually clear way. 

At LCDC, this is how we teach children to play. We work on simple action-object systems and create complications within the child’s reach. We use hand-over-hand to shape an action and pace a system, but we do not turn an activity into a “task”.  Although insistent and expectant, we do not use force and we do not reward with extrinsic reinforcement.

So how do we get scattered and rigid children to repeatedly perform an action-object system without running away or throwing a tantrum?

The Elevated Square

The elevated Square contributes to a different, more “grounded” psychological state for the child.  On the floor, many children on the autism spectrum toe-walk, flap their hands and twiddle their fingers in front of their eyes, or simply wander aimlessly.  On the Elevated Square these otherworldly behaviors diminish markedly.  For example, many who toe-walk continuously on the ground walk quite normally on the Elevated Square.  This change seems to occur because the children have moved from an undefined reality, in which they float along on their toes, twiddling or hand flapping with little body/ self awareness, to a highly defined reality which requires their rapt attention as they carefully, and body-consciously, move one foot in front of the other to traverse the structure.

The properties of the Elevated Square help counter some of the significant challenges that children on the autistic spectrum confront. One of these challenges is an uncertain sense of their bodies in space—or of space itself. It is this uncertainty which may account for the tendency of many autistic children, when introduced to a new setting, to run and collide with one wall of a room after another in an effort to establish the spatial extent of the room.  Unable to process the room in purely visual terms, the children seem to need these collisions to help map the room for themselves.  Some who don’t collide with the walls and lack spatial boundaries simply run in endless circles in the center of the room. . In the following clip Dr. Miller describes the disorganized body experience of an autistic child.

Now, suppose that in the center of that room there is a well-defined structure (with color that contrast with space around it) that slows the child to walk along a 14 inch path 2.5 feet above the ground around a 5 by 8 foot structure.  The structure stands out.  It is both visually and proprioceptively salient: in other words, the repeated visual impression and body feeling the child gains as he or she repeatedly –and carefully—steps around and turns corners on the square vividly establishes that space and the child’s body actions in that space.

Another reason for the square’s effectiveness is the constraint it places on the actions of the child.  The child can only go in one direction at a time. Random, scattered action is not possible on this structure; the structure demands focused and directed action as the child repeatedly walks around it.  Soon the child begins to understand –as he or she walks around it—that continuing around the square will result in a return to the starting position. We introduce object-systems on the controlled and circular environment of the square.  The structure of the square both enhances and clarifies the perceptual experience of the activity, and allows us to successfully introduce and complicate the action object systems.

The Elevated Square serves different purposes for different kinds of children.  For easily “scattered” children with system-forming disorders, the square provides the external organization the children desperately require in order to function. However, for children with closed system disorders, the square provides the framework in which they can be taught to expand their systems, move from one system to another, and include people as well as gestures and spoken words within these systems.