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Summary of Case Study
The case study refers to a preschool child, Dawn aged 4 years, who was the victim of child abuse. The student clinician and supervisor reported the abuse to the proper authorities and Dawn was removed from the situation and placed into foster care. Dawn presents with global language delays. Therapy has targeted pragmatic language, social interactions, and increasing verbal utterances. Dawn has a positive relationship with her speech therapy provider and due to the supportive and trusting relationship, this pairing will continue for future speech-language services while she is in foster care.
Dawn has experienced trauma or adverse childhood experiences (ACE) and therefore the intervention should be one that considers the needs of this population. Sylvestre et al. (2015) found that, across studies, children who are abused and/or neglected demonstrate delayed language skills when compared to their peers. Dawn is young, aged 4, and the studies reviewed by Sylvetre et al. (2015) have also shown that the younger the child is when exposed to trauma, the bigger the negative impact the on language development. When providing intervention or treatment to children who have a history of ACE, the National Scientific Council on the Developing Child (NSCDC) recommends that the adults working with the child should keep certain positive and supportive mindsets, such as viewing the child as one who is trying hard to communicate (NSCDC, 2004). The speech-language therapist working with a child with a history of ACE should also learn to de-escalate situations and avoid re-traumatizing the child by providing a supportive presence to help the child feel safe so that they can be ready to learn (NSCDC, 2004). Building a supportive and trusting relationship with an adult helps to protect the child from the physical effects of the ongoing stress, such as their body’s stress response system becomes hyper-sensitive which increases the fight-flight-or-freeze response (De Bellis & Zisk, 2014; NSCDC, 2004). The intervention team for Dawn is providing this by maintaining continuity of care with a therapy provider in which she has built a positive and supportive relationship.
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In order to increase communication skills a treatment option should be one that is responsive to Dawn’s emotional needs and one that targets multiple areas of language development. Milieu communication training (MCT) is an evidence based intervention used to increase early language behaviors in young children. This intervention method is also known as incidental teaching, mand-modeling, as well as milieu teaching (Gilbert, 2008). This intervention increases functional communicative acts, but also increases the client’s desire or motivation to intentionally communicate with others. As Dawn has previously demonstrated positive results with techniques such as the therapist feigning ignorance in order for her to produce verbal language, MCT should be explored across other environments and with other caregivers.
The principle components of MCT have been investigated by Yoder and colleagues (e.g., Yoder & Stone, 2006; Yoder & Warren, 1998, 1999a, 1999b, 2001, 2002), which are that the intervention be carried out in typical or familiar environments often with highly preferred toys or activities. The environment in which the MCT takes place is arranged to promote communicative exchanges or interaction from the client. The child-led initiation in the environment with the clinician followed interaction is key. Within MCT the clinician builds upon routines that the child may enjoy, utilize expectant waiting to encourage spontaneous communicative acts from the child, and will reward the child’s responses with access to or interaction with a desired toy or activity upon the production of verbal behavior and/or social interaction. The communicative acts are shaped and built upon over time. Data taken within MCT observes the frequency and complexity of the communicative acts produced by the child.
This technique is not only appropriate in a clinical setting but is more beneficial when taught to caregivers to increase verbal behavior and complexity in their child across environments (Kaiser & Roberts, 2013). With training from the clinician, there was a noted increase in parent or caregiver prompted communicative acts across environments in a heterogeneous group of children with a wide range of developmental disabilities. This finding is important as it suggests that MCT is beneficial for a wide range of children with developmental delays, i.e. Down Syndrome, developmental language disorder, autism, and beneficial as a program to be carried over with training from the clinician. This article does not target the population of children with a history of ACE, such as Dawn, but children with intellectual disabilities and autism. Dawn’s communication deficits are similar to those within these populations, such as reduced pragmatic language similar to children with autism and reduced verbal expression similar to children with intellectual disabilities. Another difference is that the article utilized parents and Dawn has been removed from her parents’ care. This may or may not be an effective intervention when utilizing Dawn’s recently introduced foster parents.
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The treatment intensity and frequency with MCT has no clear recommendations. The clearest conclusion is that within child characteristics, such as motivation and baseline play skills, are key factors in determining treatment intensity and frequency. Fey, Yoder, Warren, and Bredin-Oja (2013) found no differences between communicative outcomes between a group of children given weekly sessions when compared to those given daily sessions across 5 weeks. However, the data indicated that increase in frequency had a significant impact on growth of communicative acts in children who demonstrated a high level of toy interaction at baseline, meaning they interacted with at least nine toys during the initial 20-minute session. These children were present in each treatment group and those in the high frequency group were noted to demonstrate significant differences in growth when compared to like peers in the low frequency group. This indicates that when determining treatment frequency, the clinician may want to consider baseline skills to determine the effectiveness of the intervention. According to the case study Dawn demonstrated limited play skills at the beginning of therapy and therefore may not be an appropriate candidate for this intervention. However, Dawn has shown an increase in play skills with various toys during sessions and therefore may now be an appropriate candidate for MCT. Also, the participants within the study were younger than Dawn and had a diagnosis of intellectual disabilities and therefore this intervention may not be appropriate for Dawn.
Though neither Kaiser and Roberts (2013) and Fey, Yoder, Warren, and Bredin-Oja (2013) represent children who have experienced ACE like Dawn and the individuals studied have a diagnosis of intellectual disability or autism, the intervention may still be appropriate for this client. The intervention method is responsive to the child and creates internal motivation for social interaction and communication. These factors would promote communication gains with Dawn. Within the case study the practicing therapist has shown progress with techniques consistent with environmental sabotage to promote communication. The delivery of MCT with Dawn may need to be altered in order to be more supportive and less stress producing when compared to the articles’ methods. Specifically this would involve not withholding items for certain communicative acts but providing more verbal models and recasting of Dawn’s communication to build upon her abilities and skill level. This would align with the NSCDC (2004) recommendations of providing a supportive environment and utilizing de-escalation techniques. Differences would also include training the foster parents to carryover skills gained in therapy sessions as the parents are no longer present in Dawn’s environment. The training for the foster parents would also target a more supportive and responsive method in order to follow the recommendations from the NSCDC (2004).
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