​Have you ever tried having a conversation with someone whose eyes were fixated on the TV? Your conversation probably didn’t get very far.

What if that person wanted you to see / join in what they were watching on TV, so they constantly shifted their eye gaze between you and the TV? They probably would have been able to take in more of what you were saying then.  This is known as 'joint attention'. 

It’s the same with children. Joint attention is when a child divides their attention between an object and another person. For example, if your child looks at their toy bear, looks up at you, as if to say “look!” and then looks back at their toy bear. 

When does joint attention develop? 
Children typically start to develop joint attention at the age of 9 months, and continue to do so until mastering the skill at the age of about 18 months.

Why is joint attention so important?
This shared attention and engagement serves as a foundation for learning - otherwise, learning doesn’t happen. Joint attention must be mastered for children to develop good communication, cognitive and social skills. On the other hand, children who have difficulty with joint attention will usually struggle with many areas of development. 

Here are some important things to remember:
In children's development, non-verbal communication skills develop before verbal communication skills. Since joint attention is a non-verbal communication skill, it must be worked on before working on verbal communication skills in therapy.   

Below are 5 of my favorite tricks for improving your child’s joint attention:

1. Start with what your child is interested in
For example, your child will be more keen to interact with you when you show interest in the toy car that they are interested in - rather than the alphabet puzzle which you keep asking them to do.

2. Guide your child’s eyes
For example, if your child is interested in a toy, bring this toy slowly up to your eyes, and then slowly put it back down. This will help guide your child about where to look. Since you are starting with the toy that they are interested in, their eye gaze will likely follow your hand movements. 

3. Go with the pace your child is setting
For example, if your child is making car sounds while they play with a car toy, you can make car sounds too! Try not to break the momentum by placing demands on your child (e.g. "say car! say it!").

4. Use environmental sounds to draw your child in 
For example, your child might enjoy it when you make some animal sounds as you both play with the animal toys together. 

5. Remember the aim of your interaction 
The aim is to achieve shared attention and engagement - not to force your child to say everything you want them to say. The greater the demands you put on them, the less motivation they will have to engage with you. 

I hope you find these tips helpful when working on your child's joint attention. 

Speak soon, 
The Expat Speechie 
Chiman Estephan MSLP, MSPA, CPSP, ACAS
© Copyright 2019. The Expat Speechie www.theexpatspeechie.com. All Rights Reserved. ​​

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Children love to play games. You can play many games with your child which create fun opportunities for supporting their speech development.

When working on a child's speech, one of the tools I use are 'picture cards'. This is because most children learn better with visual support. Picture cards are simply cards with pictures of objects with the target speech sounds which a child is working on. For example, below are picture cards which I've used to teach children to say the 'c' sound at the beginning of words.



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​There are plenty of picture cards (for all sounds of the English language) which you can download free on the internet, or you can even make your own picture cards with your child as a fun and creative activity at home. Once you have your child's picture cards ready, here are my 8 favourite speech games below, which you can play with your child:

1. Word hunt: You can do this at home by hiding the cards around the room. When your child finds a card, they can practice saying the word in a short sentence with the correct sounds.

2. Games with counters: Start by turning the picture cards face down on the table. Take turns to flip a card over and place a counter (use a different colour for each person's counters) on the card when the sounds are produced correctly in the word. Once every card has a counter on it, count who has the most counters on the cards - that person wins. 

3. Ball games: Thinking of words that start with a target sound before taking a turn to throw / kick the ball.

4. Bowling: stick one picture card on each bowling pin. Each time your child takes a turn at bowling, they can practice saying the words on the pins that fall down.

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8. Memory matching: For this you will need two copies of the picture cards. Turn the cards over so that the pictures can’t be seen. Then take turns turning over two cards each, saying the words on each card and keeping the pairs that match.
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Playing games with picture cards are a great way to stimulate and support your child's speech  development at home. Taking turns during these games will give your child constant modeling, as well as opportunities to practice saying their sounds correctly in words and sentences.

Have fun and speak soon!
The Expat Speechie
​

 Every child has the right to a voice. 

Childhood Apraxia of Speech (CAS) can make it really hard for a child to speak and to be understood by others. About one third of the children I work with each week have CAS. They range from the age of 3 years to 17 years; they are each unique in their own way. 

So, this month, let's talk about CAS. 

What is CAS?
CAS is a motor-speech disorder where a child has difficulty connecting speech messages from their brain to their oral articulators (lips, tongue and jaw). This disruption between the brain and mouth can make it really hard for a child to speak - even though they know exactly what they want to say.  

CAS is often also referred to as ‘Verbal Dyspraxia’.

 
How is CAS Diagnosed?
A Speech Language Therapist can diagnose CAS.
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There is no standardized test for CAS, at this stage. However, during a Speech Assessment testing for CAS, a Speech Language Therapist will usually look into your child’s:

1. Oral-motor skills (e.g. the strength and range of movement of their lips, tongue and jaw)
2. Sound production in isolation vs. in words
3. Use of stress / emphasis on sounds in a word
4. Automatic speech (e.g. counting to 10) vs. spontaneous speech
5. Sequence sounds in alternating productions (e.g. p-t-k-p-t-k)
6. Overall ability to be understood
7. Language ability
8. Speaking background information

There is a general consensus among Speech Language Therapists about several characteristics that are associated with CAS. Some of these include:

• Inconsistent speech production
• Speech that is difficult to understand
• Clearer automatic speech and imitated speech than spontaneous speech
• Atypical prosody
• Physical groping
• Vowel distortions

 
What Treatment is Available?
Scientific evidence shows that Speech Therapy is effective for CAS.
Speech Therapy should address both short-term and long-term improvements in your child’s communication.
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1.Short-Term Objectives:

If your child is non-verbal, or very hard to understand, it is very important that they are given / taught an alternative method to communicate while they work on their verbal skills. Alternative means for communication can include (but are not limited to) sign language, picture boards or using an Applications on a tablet. These alternative means for communication will act as your child’s voice while they work on developing their verbal skills. These alternative means to communicate are also likely to reduce frustration which your child may experience because of not being able to communicate verbally.
 
2.Long-Term Objectives:

Long-term objectives usually involve a focus on your child's motor-speech / verbal skills.

Scientific studies have found that children with Apraxia usually respond well to:

• Frequent repetition of words and phrases
• Consistent and regular practice
• Shorter, but intensive practice sessions 
• Tactile prompts, verbal cues and visual cues used during speech practice 
• Speech Therapy starting earlier in life; this is likely to result in better speech outcomes

I have seen many children with Apraxia make wonderful progress with the PROMPT Method. You can read more about the PROMPT Method here.
 
I want to end this post by saying, no matter how old your child may be, please do not give up hope on their ability to speak, or to learn to communicate with others meaningfully by using an alternative communication method. I have been blessed to witness children saying their first words well into their teenage years... I have also been part of the journey of teenagers finding their voice through an App. Nothing is more rewarding than helping children find their own voice. 
 
Speak soon,
The Expat Speechie

This month’s post was written by guest writer, Dr. Plern Pratoommas, Early Intervention and Child Development Specialist. ​

Hello Expat Speechie fans!
The first half of this post will be a bit more informational and the second part are responses to some commonly asked questions that I get from parents.

What is Early Intervention?
Early Intervention is a broad term that refers to various therapy and education services for infants and toddlers who have delays or disabilities. Early Intervention can also be provided to children who are “at-risk” due to preterm birth or low birth weight.

Early Intervention is provided by different types of professionals from different fields. This is why you’ll sometimes hear the term “multidisciplinary” to describe Early Intervention services.  Professionals on your child’s Early Intervention team may include: Occupational Therapists, Physical Therapists, Speech Therapists, Special Educators, and Developmental Therapists. However, there might be other medical or educational professionals that are involved in your child’s program. For a brief description about professionals who work with infants and toddlers with delays or disabilities, please see: https://www.understood.org/en/learning-attention-issues/treatments-approaches/early-intervention/at-a-glance-specialists-who-work-with-babies-and-toddlers

What is the purpose of Early Intervention?
The main purposes of Early Intervention is to:

1) support optimal development in children with special needs or delays, and
2) mitigate challenges or “secondary disabilities” that may develop later on because of the child’s disability.

Early Intervention is based on the assumption that children can adapt to their environment despite their challenges and condition. Therefore, it is important that the professionals who work with your child adopt this assumption as well and use a strengths-based approach in their work (focusing on the strengths and positives, not just the deficits).

Early intervention is still considered a relatively new and evolving field, even in countries like the United States. With recent research on brain development, we are learning more about the amazing capacity of infants to learn about the world even at birth. Early childhood is a period when brain development takes place at a rapid rate and is now known to be a critical time in human development. For this reason, Early Intervention has become more of a focus in recent years. The important point to remember about Early Intervention is this: The earlier we “intervene”, the less effort is needed to influence the brain’s ability to be shaped by experiences. So… intervening early is a good investment.

For more information on brain development in early childhood, please visit: https://developingchild.harvard.edu/science/key-concepts/brain-architecture/

What does Early Intervention look like?
Early Intervention might look different depending on where you live, since the system for children and family-related services is heavily shaped by social, cultural, and political factors. In some countries, such as Australia, Early Intervention services are publicly-funded and of no cost to families. In other countries, such as Thailand, parents may have to seek supports and services on their own from the private sector.

Early Intervention can follow different formats and take place in different settings, such as, child care programs, nursery school, preschool, direct intervention in the child’s home, therapy at community clinics or hospitals, parent coaching and training programs.

There are many variations to how Early Intervention is provided to families across countries. In my experience, Early Intervention is typically delivered in the family’s home or in other “natural settings” where other children (without disabilities) spend a lot of time such as, child care centers and preschools. Early Intervention sessions usually involve a specialist working with both the parent and the child on important developmental skills.

Highly-qualified professionals know a lot about typical child development, atypical child development, and ways to effectively support a child’s learning and development. A highly-qualified Early Intervention professional is knowledgeable and understands how children learn and they are effective in transferring this knowledge to parents.

Who benefits from Early Intervention?
For a child who is diagnosed with a disability, Early Intervention is important because the way in which the child learns best and the rate that they learn may require specialized knowledge, specific intervention strategies and specialized approaches. For example, children with Autism are most likely to benefit from programs that are comprehensive, intensive, and focused on key areas that are delayed in Autism (communication, play, and joint attention).  

Specialized knowledge and intervention strategies are particularly important when the child’s parent or caregiver has limited information about their child’s diagnosis. Support from a qualified professional is required for the child’s optimal health and functioning.  

Many Early Intervention programs and models in the United States, such as Routines-based Intervention (McWilliam, 2015), stress the critical role that Early Intervention professionals play in building capacity of parents and caregivers to embed learning opportunities into naturally-occurring daily routines to optimize child learning and development.  

Although the end goal of Early Intervention is to promote optimal child development, parents and caregivers have become an essential part of the process and have therefore, become beneficiaries themselves.

For children whose development is “at risk”, Early Intervention is particularly important, given the vulnerability of brain development during the first few years of life.

Below are some common questions that a lot of parents have asked me:

What should I look for when seeking out Early Intervention services for my child?
Despite variations in service delivery, most experts agree that the core purpose of Early Intervention is to accomplish these goals:
1.    To support you in your role as your child’s primary caregiver
2.    To help you prioritize goals and learn effective strategies for interacting with and teaching your child
3.    To support your child in his/her learning and development by teaching important developmental skills, promoting prosocial behavior, supporting emotional-social, motor, and cognitive development, motivating your child to learn and engage with the people around him/her
4.    To minimize any additional challenges that may arise as a result of your child’s condition
5.    To promote positive relationships (between you and your child and between the child and his/her interventionist)

If you do not feel like the professional you are working with is providing you with the tools to accomplish the objectives above, please talk to them about it. Alignment of expectations and goals is critical to the success of the intervention. Feel free to discuss this even before you start receiving services by being open and honest about what you are expecting from the professional you are working with. It may feel uncomfortable at first, but aligned expectations and goals will ensure a more successful intervention program for your child.

I have some ongoing concerns about my child’s development. Should I just wait and see how things turn out before doing anything?
The short answer to this question is no. Time is precious, especially in early development. Taking action earlier on does not mean that your child will end up being diagnosed with a disability. Sometimes, children are delayed in some areas but with enrichment activities to promote that specific area of development, they are able to catch up.

A lot of professionals ask me if they should mention anything to parents when they notice delays and my answer is always, YES! The conversation does not need to imply that something is “wrong” with the child. Given our understanding of the importance of early childhood, adults need to be responsible for supporting the child in any way they can to help them develop to their fullest potential.

What’s the danger in waiting?
If your concerns are minor (e.g. you wonder if your child is crying more than usual, or you notice that your child is not reaching yet), there may be no imminent danger in waiting a little while. However, there are certain “red flags” that are cause for more concern and you should explore these concerns NOW.

Although all children reach developmental milestones at different ages, there are general trends (an expected sequence) that is common in early development and should be monitored. For example, if your child is six months old and (1) is not lifting his head up when on his stomach, (2) moving his body in a more coordinated way, or (3) looking at you, smiling, or interacting in the way that other babies are, then you should seek out advice from a specialist as soon as possible. Or, if your child is two years old and has not spoken a single word yet, see a specialist as soon as possible. When you bring these concerns up to others, some people might tell you, “oh, your brother/sister also spoke late, don’t worry”, or “he’ll grow out of it”, but if you feel in your gut that something is not right, trust your gut. A parent’s intuition is usually right.

There are many early screening tools that are available to help you figure out for sure whether your child’s behaviors are delayed or developing normally. Here are some useful resources:
https://www.cdc.gov/ncbddd/actearly/milestones/index.html

If you have some concerns about Autism, you can complete a screening for your child yourself at:
https://m-chat.org/

An important principle in child development is that children learn through repeated interactions, over time. The benefit about taking action earlier is that you have more time to influence your child’s learning and development. As the brain develops in early childhood, there is something that happens to brain cells called, “synaptic pruning”, whereby whatever unused networks in the child’s brain will prune away to make room for other networks that are more frequently used. When we have concerns about a child but choose to wait, we miss out on opportunities to positively influence a child’s development.

Where do I start?
A good place to start would be to arrange a Developmental Assessment for your child. This can be done by a Clinical Psychologist, Child Developmental Specialist or a Multidisciplinary Team. The outcomes of the Assessment will provide a picture of where your child is at in different developmental areas (communication, motor-skills, etc.). These findings will be used to identify potential goal areas for your child’s Early Intervention program. If you cannot find a Clinical Psychologist, Child Development Specialist or multidisciplinary team, you can ask your child’s Pediatrician or other medical professionals.

In Thailand, it is common for services for children with disabilities to be provided by the medical field. However, it is important for parents to know that accessing services at hospitals is NOT your only option. There are many public institutions that provide Early Intervention services, as well as providers in the private sector. You may want to contact organizations like the Rainbow Room (https://www.facebook.com/specialrainbow/) to inquire about service providers in your area. Do some research, go out and visit as many places as possible, speak to as many professionals as you can, seek out consultation and advice from professionals, and have conversations with your family about what you want for your child. Services should align with what your goals and priorities for your family are.

What if no one believes me?
Find someone who does! Continue reaching out and connecting with as many people as you can. You will find someone. Emotional support is one of the most important things.

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This article was written by guest writer, Dr. Plern Pratoommas
Early Intervention & Child Development Specialist
ESDM Certified Therapist

I hope you found this article as helpful and informative as I did!
Speak soon,
The Expat Speechie


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References
Bruder, M. B. (2010). Early childhood intervention: A promise to children and families for their future. Exceptional Children, 76(3), 339-355).
Center on the Developing Child at Harvard University. (2016). From best practices to breakthrough impacts: A science-based approach to building a more promising future for young children and families. Retrieved from http://developingchild.harvard.edu/resources/from-best-practices-to-breakthrough-impacts/
Gray, R. & McCormick, M. C. (2005). Early childhood intervention programs in the US: Recent advances and future recommendations. The Journal of Primary Prevention, 26(3), 259-278.
Guralnick, M. J. (2001). A developmental systems model for early intervention. Infants and Young Children, 14(2), 1-18.
Guralnick, M. J., & Albertini, G. (2006). Early intervention in an international perspective. Journal of Policy and Practice in Intellectual Disabilities, 3(1), 1-2.
McWilliam, R. A. (2015). Future of early intervention with infants and toddlers for whom typical experiences are not effective. Remedial and Special Education, 36(1), 33-38. doi:10.1177/0741932514554105
Meisels, S. J., & Shonkoff, J. P. (2000). Early childhood intervention: A continuing evolution. In J. P. Shonkoff, & S. J. Meisels (Eds.), Handbook of early childhood intervention (2nd ed.) (pp. 3-31). New York, NY: Cambridge University.
Ramey, C. T., & Ramey, S. L. (1998). Early intervention and early experience. American Psychologist, 53(2), 109-120.

As a parent, you can use books to develop some of your child’s important social and language skills.

Here are five skills you can work on using books: 

1. Joint Attention 
You can use books to develop your child’s ability to attend to you and the object of their interest (in this case a book). Joint Attention is such an important skill to work on because it is necessary for any learning to happen.

How to do this: Sit face to face with your child and place a book in the middle, with the book upside down to you. To increase your child’s engagement, follow your child’s lead with the book, allow them to spend as much time as they like looking at pages of interest while you make comments on what they can see. Occasionally, raise the book to your eye-level to guide your child’s gaze towards you during the interaction. 

2. Sustained Attention 
Sustained Attention is another important skill you can work on with your child using books. To improv your child’s Sustained Attention, engage your child in activities involving books and gradually increase the length of these activities over time. 

How to do this: You can start with reading one page of a book your child is interested in on Monday, increase it to two pages by the middle of the week, then three pages the following week, and continue to increase the number of pages over time. 

3. Early Social Skills:
Books are great for teach in your child early social skills like turn-taking and sharing items. 

How to do this: You can take turns with your child to hold the book, turn the pages, point to pictures, make comments on what you see and to read words. 

4. Receptive Language (Understanding Language):
Books can be used to expand your child’s understanding of words, concepts and the world around them.

How to do this: As you look through a book with your child, describe / comment on what you see while pointing to the pictures. You can use emphasis and repetition to help your child understand new concepts.  For example, if your child points to the picture of a dog inside a box, you can say “dog in the box... in”. 

5. Expressive Language (Using Language): 
You can use books to improve your child’s phrases and increase the length of what they say. 

How to do this: While you look through a book with your child, model words which your child may not have yet, and expand on what your child says. For example, if your child points to the Humpty Dumpty in the book and says “fall”, you can expand on this with a longer phrase like, “Humpty Dumpty fell”. 

Books can be very useful for teaching your child many social and language skills. In this post, I’ve included just a few of them. 
Happy Reading!

Speak soon,
The Expat Speechie 

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“What I want to tell the world about Autism is that there is so much more to Autism than what meets the eye. The problem with Autism is that it does not have a face. It looks NORMAL . What you see is just the tip of the proverbial iceberg...”

​Anonymous parent of a child with Autism.

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“NO WORDS can describe how I felt when I knew that my son has Autism.
But being depressed about it won’t change anything. So my husband and I tried to get all information of what to do. My son had a communication and social problem. We were really lucky to have started with really supportive Therapists. We did the early intervention really fast, but we also learned that we as parents and everyone around our son had to help out too. For 3 years our son was in his own little world, he was stimming, singing and avoiding all eye contact. But slowly he started to change. I believe he has been trying. He needs a little time to find his way towards us. I believe that he had, and still has sensory issues from noise, touch and taste. All of that is quite overwhelming for him. So we did our best to get all the help he needs.
It has been 3 years going to Speech, Floortime, OT, Sensory Integration and Social Therapies. Every month, our son started to change, bit by bit. Yes, there were up and downs. But his hard work paid off. He started from telling us what he wanted, toy, apple, toilet and of course, iPad. Every single year he improves. But this year is his eye contact. I guess only parents who have a special, beautiful child would understand how I feel.
Every single case is different, so please to every single parents who is going through this stressful path, hang in there and please have hope and believe in our child. They need us to believe in them and give them patience and lots of comfort and love for them to find their way to reach to us (they are trying really hard to let us know that they do love us but just cannot express the way that we do).”

Anonymous parent of a child with Autism.

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“Don’t feel sorry for people with Autism and their family. Admire them for their effort to live in a world that doesn’t always accommodate to them. Be curious and open-minded. Let them teach and show you about their Autism.”

Dr. Kwan Hansongkitpong
Clinical Psychologist
Founder of Autism Awareness Thailand & Clinical Director at Little Sprouts Children’s Centre.

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“What I want to tell the world about Autism is.....there’s a person behind the diagnosis,
get to know them.”

Max Simpson
Parent of a child with Autism.  
Founder & Director of Steps with Theera, a vocational training centre for young adults with special learning needs. 

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“For me, Autism is more a quality that some people have which makes them see the world in a different way, not the wrong way, just different. We need to be able to recognise what this group of people can teach us about ourselves and the world around us. Embrace different.”

Lisa Hargraves
Speech Pathologist Advanced Clinician,
Therapy Focus, Australia.

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“What I want to tell the world about Autism is that the saying is true, once you have met an individual with Autism, you have only met one individual with autism.
It is important to remember that individuals with Autism see the world differently which may lead them to communicate in various ways. It is imperative to communicate in a way in which they can understand by being clear and concise, and also understand that they may be trying to tell you something with the behaviors they are engaging in.”

Chandni Kumar
ABA Supervisor,
Centre for Autism Recovery & Education (CARE).

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“What I want the world to know about Autism is that no matter how different individuals with Autism may seem, they are the same as every other individuals. We all need love and understanding to strive in this world we share.”

Kiratinoot Luanganggoon (Kira)
Pediatric Occupational Therapist.

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“In my opinion, we can never completely understand Autism, because individuals with Autism are so different from one another - they teach me something new about Autism every day. Instead, we can endeavor to be life-long students of individuals with Autism, by watching, listening and thinking about the BIG picture when it comes to Intervention, rather than focusing on isolated skills; and most importantly, shaping our own approach to each individual.”

Chiman Estephan,
The Expat Speechie
Advanced Certified Autism Specialist  & Speech Language Pathologist


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It is truly amazing what parents will do for their child.

Last year, I met a family in Thailand who told me that they had moved to the US for one year so that their child could receive a specific therapy called PROMPT. When we met, PROMPT was not available in Thailand, so this family asked if I was willing to travel overseas to do the training. A couple of weeks later, I found myself on a plane to Australia to get trained in PROMPT.

Fast forward to a few months later, I am now using PROMPT with many of the children and teenagers who I’m working with. Some of them have made absolutely incredible progress. For example, after just a few months, a non-verbal teenager can now say a range of words and even combine two-to-three words together in phrases!

So, what is all the fuss about PROMPT? Here is what you need to know:

What is PROMPT?
PROMPT is a type of speech therapy. PROMPT stands for Prompts for Restructuring Oral Muscular Phonetic Targets. Basically, the Speech Therapist uses touch and pressure specific points on your child’s face to activate certain facial muscles, and guide the movement of their jaw, lips and tongue. There is a different PROMPT for each sound in English, and in most cases, a sound can have more than one type of PROMPT.  PROMPTs can be used to ‘re-write’ old motor-speech patterns or develop new motor-speech patterns.

What makes PROMPT different to other therapies?
Compared to other therapies, PROMPT works better to improve speech because it gives more support through the additional element of touch. Not all children respond equally well to learning speech by listening (auditory cues) or by looking (visual cues). But when these two cues are combined with PROMPTs (touch cues), the child has something which they can feel, physically guiding their face to move from one sound to another to make words.

How is PROMPT used in a session?
Firstly, your child will learn to say target words with the support of PROMPTs applied to their face. This is done through repeated practice, which re-writes old motor-speech patterns and allows them to learn new ones.

Then, your child will learn to apply these words practice in activities which require turn-taking. This second step helps them to apply what they have learned to interactions with others and will help them generalize their new speech skills to daily interactions.

Who can benefit from PROMPT?
The great thing about PROMPT is that it can improve the speech of both children and adults with a range of difficulties. I use PROMPT with children and teenagers with Speech Sound Disorders, Autism, Developmental Delays, Apraxia, as well as non-verbal children and teenagers. PROMPT can also be used to improve the speech of children and adults with a hearing impairment or to modify accents.

I am really thankful for this family who helped bring PROMPT to Thailand and for the wonderful impact it has made here so far. 

Speak soon,
The Expat Speechie
 
Source:
Introduction to PROMPT Technique Workshop: Manual Australian Version. (2014). The PROMPT Institute. P.H.C Inc.