Increasing Communication in Toddlers Using Prelinguistic Milieu Teaching

There are a number of methods and techniques for working with toddlers who don’t yet communicate effectively with others.  When we think about these methods, we often group them into two larger categories: indirect and direct. Indirect, or input-based, methods rely on adults providing lots of rich language in a child’s environment; with these methods, however, we don’t require children to do anything in the moment. There is considerable evidence to support these input-based methods, especially for late-talkers and toddlers and preschoolers who struggle with the grammatical aspects of language. Despite the effectiveness of input-based methods in some situations, there are times when these indirect methods of language facilitation aren’t all that are needed.  In these cases, we might choose to use a more direct method of helping a child to communicate.  Direct methods involve expecting a child to do something – to use a gesture, or a word, for example – right in the moment when we are teaching them. This is where prelinguistic milieu teaching enters the picture.

Prelinguistic milieu teaching (PMT) is designed to help children who aren’t yet using intentional communication on a regular basis. To understand this, we first need to quickly discuss the difference between communication and language.  Communication is a broader term than language. It encompasses all the ways that we communicate a message to other people – head nods, pointing at things, shrugging our shoulders, sighs, vocalizations (sounds we make that aren’t actually words), talking, writing, and so on. Language is a more specific term – it refers to the words and sentences we use to communicate with others.  Young children communicate with gestures and sounds before they use actual words. This type of communication typically develops around 9-12 months and is called intentional communication.  PMT, then, is designed for children who are older than 9-12 months and who haven’t yet learned to intentionally communicate with gestures, eye contact and vocalizations, or who don’t intentionally communicate very often.  Our goal is to get these children consistently using gestures, eye contact, and vocalizations to express their wants and needs. Once they are doing that, we can help them start using words. 

When we use prelinguistic milieu teaching, we set up situations in which a child is going to want to communicate about something.  Much of the time with young children, this happens within routines or communication temptations.  So, the first step in using PMT is to establish a routine or a communication temptation. The routine or communication temptation can be almost anything at all – a song, pat-a-cake, tickles, rocking back in forth in a rocking chair, playing peek-a-boo, rolling a ball back and forth, sending a car down a ramp, swinging on a swing and stopping the swing for a moment, going down a slide repeatedly, handing out favorite snacks one by one…. the possibilities are truly endless.  The key is to find something a child likes, do it interactively and repeatedly and then, at the right moment, STOP.  Wait. Watch for any indication that the child wants the activity to continue. At first, this might involve the child glancing at the object he wants and then glancing back at you.  Or it might be a slight body movement, a sound he makes, or a gesture such as reaching or pointing.  As soon as the child does something to communicate, we say the word for what the child is trying to communicate (this is called linguistic mapping) and continue with the routine. Over time, we expect the child’s communication to become more and more advanced.  We show a child how to use gestures and his voice at the same time to keep an activity going.  And eventually, once a child has learned the power of communicating, we can work with the child to use actual words.

Here’s a quick snippet of what PMT might look like in action:

Child is getting tickled by an adult

Adult: I’m going to….adult wiggles fingers…tickle you!! [Establishing routine & using self-talk]

Adult tickles child, child giggles & adult laughs

Adult: I’m going to….adult wiggles fingers…tickle you!! [Establishing routine & using self-talk]

Adult tickles child, child giggles & adult laughs

Adult: I’m going to….adult wiggles fingers…tickle you!! [Establishing routine & using self-talk]

Adult tickles child, child giggles & adult laughs

Adult: I’m going to….adult wiggles finger and STOPS. [This is setting up a communication temptation as part of an interactive, mutually enjoyed routine]

Adult waits. [This is a time delay]

Child looks at and reaches hands out toward adult [This is the child communicating he wants more tickles!]

Adult: Tickle you!!! [This is “linguistic mapping” because the adult says what the child wanted after the child communicated]

Adult tickles child, child giggles and adult laughs [In behavioral terms, this is the reinforcement – or the reward – that makes it more likely the child will communicate again in this situation in the future.]

Prelinguistic milieu teaching has been shown to increase a young child’s use of communication – and this is thought to then lead to increases in language development.  Yoder and Warren (1998, 1999, 2001), for example, found that PMT led to increases in intentional communication acts (the use of eye contact, gestures, and vocalizations to communicate) and that these gains impacted later language development. Importantly, they also found that PMT only had an impact on child communication when the children in the study had highly responsive moms.  This led them to add “responsivity education” (RE) to the PMT training, so that the approach is now called RE/PMT (“Responsivity Training/Prelinguistic Milieu Training”); in this approach, parents are taught how to be responsive to their child, while clinicians use PMT with that same child.  Further research (Fey et al., 2006) indicated that RE/PMT was effective in increasing the use of communication acts for toddlers with developmental delays after 6 months of intervention.  Later research, however (Warren, et al., 2008) suggested that these gains in communication did not consistently led to later gains in language development.   It’s important to note that the RE/PMT training in the 2008 research was discontinued after 6 months; further research is needed to determine how long RE/PMT should be used in order to have an impact on later language development.

It should be also mentioned there are other ways of working with young children who don’t yet communicate with others on a regular basis.  For example, the use of signs or other types of augmentative and alternative communication (AAC) has also been shown to be effective in promoting language development (Romski, Sevcki, Barton-Hulsey, & Whitmore, 2015). Prelinguistic milieu training, though, is one powerful option to consider when working with young children who don’t yet consistently communicate through the use of vocalizations, gestures, and eye contact.

Becca Jarzynski, M.S., CCC-SLP is a pediatric speech-language pathologist and a Clinical Instructor at UW- Eau Claire.  You can find more of her blog posts at

Fey, M. E., Warren, S. F., Brady, N., Finestack, L. H., Bredin-Oja, S. L., Fairchild, M., ... & Yoder, P. J. (2006). Early effects of responsivity education/prelinguistic milieu teaching for children with developmental delays and their parents. Journal of Speech, Language, and Hearing Research49(3), 526-547.

Romski, M., Sevcki, R.A., Barton-Hulsey, A., Whitmore, A. (2015). Early intervention and AAC: What a difference 30 years makes. Augmentative and Alternative Communication, 31 (3).  

Warren, S. F., Fey, M. E., Finestack, L. H., Brady, N. C., Bredin-Oja, S. L., & Fleming, K. K. (2008). A randomized trial of longitudinal effects of low-intensity responsivity education/prelinguistic milieu teaching. Journal of Speech, Language, and Hearing Research51(2), 451-470.

Yoder, P.J. & Warren, S.F. (1998). Maternal responsivity predicts the prelinguistic communication intervention that facilitates generalized intentional communication. Journal of Speech, Language, and Hearing Research, 41, 1207-1219.

Yoder, P.J. & Warren, S.F. (1999). Self-initiated proto-declaratives and proto-imperatives can be facilitated in prelinguistic children with developmental disabilities. Journal of Early Intervention, 22, 337-354.

Yoder, P.J. & Warren, S.F. (2001). Relative treatment effects of two prelinguistic communication interventions on language development in toddlers with developmental delays vary by maternal characteristics. Journal of Speech, Language, and Hearing Research, 44, 224-237.