Blog Posts

Introducing the Early Start Denver Model (ESDM)

21/5/2019

In 2010, the ESDM was named “top 10 medical interventions” by TIME Magazine.

This month's post was written by guest writer, Dr. Plern Pratoomas. Dr. Plern is an Early Intervention and Child Development Specialist, who is currently the only ESDM Certified Trainer in Thailand. When Dr. Plern first introduced the ESDM for children with Autism to me, I was left in awe. Many children who I work with have Autism, and the more I learned about the ESDM, the more I realised how beneficial this could be for their overall development. If you would like to know more about the ESDM, you can read about it below.
Speak soon,
The Expat Speechie

What is the Early Start Denver Model (ESDM)?
The ESDM is an intervention designed to address the challenges faced by young children with Autism. The overarching goal of ESDM is to bring the child back into the social world so they can engage in social learning. ESDM therapy prioritizes the building blocks required for social learning - by teaching early interaction skills such as imitation, joint attention, communication, and turn-taking, ESDM therapy aims to fill in the developmental gaps that are commonly seen in children with Autism.

The ESDM uniquely combines two different approaches by blending together developmental principles and behavioral teaching techniques into one comprehensive intervention program. The ESDM is developmental in its approach, as it is grounded in developmental research and how typical children learn and grow. However, the ESDM is also behavioral because it incorporates teaching techniques and procedures from the field of Applied Behavior Analysis (ABA).

At its core, the ESDM is relationship-based, which means that the way in which ABA teaching procedures are used in therapy is very natural and a heavy focus is on back-and-forth engagement, social communication, and social interaction.

The ESDM uses a trans-disciplinary approach because Autism impacts all areas of a child’s development. One team member acts as a “team lead” and is responsible for providing the intervention, while experts from other fields provide ongoing feedback and consultation. In essence, there is only one treatment plan that incorporates a multidisciplinary perspective. This approach streamlines intervention for the family and ensures that the therapist focuses on the integration of skills across different developmental domains.

What does the ESDM offer that other programs do not?
The ESDM is manualised with clear instructions and guidelines on assessment, teaching content, and teaching procedures. The ESDM is curriculum-based, which means that results from the assessment (“ESDM Curriculum Checklist”) determine the goals and objectives that an ESDM therapist will choose to target in the intervention.

To ensure standardization of treatment and therapist skills, the ESDM has an ESDM Teaching Fidelity Rating System to measure and maintain the quality of therapy implementation. All of the above ensures that ESDM intervention is both customized to each child’s needs but standardized in regard to quality and content.

If you are more familiar with social-developmental interventions (e.g. DIR/Floortime, SCERTS, RTI), the ESDM might seem too behavioral. If you are more familiar with behavioral interventions, the ESDM may seem too developmental. Since ESDM is a unique blend of these two approaches, it is important to note the ways in which the ESDM is different from other interventions.

The ESDM differs from most developmental interventions in these ways:

There have been a number of peer-reviewed studies published over the last 10 years that provide empirical support for the effectiveness of the ESDM in improving outcomes in infants and toddlers with Autism. Out of all developmentally-based early intervention programs available for young children with Autism, ESDM is the most studied model to date.
The ESDM is manualized and there are clear guidelines on how to conduct the assessment and deliver the intervention. The ESDM Fidelity Rating System ensures fidelity of implementation and maintains a standard for those learning and/or using the model.
The ESDM is data-driven and utilizes Response to Intervention. Therapists monitor child progress on a daily basis by using data-collection systems that track each child’s performance on his or her teaching objectives over time. When a child does not make progress on an objective, therapists use a decision tree to decide how they can adapt the intervention to ensure continued progress.
Within its developmental framework, the ESDM utilizes teaching practices that are grounded in Applied Behavior Analysis. ABA teaching procedures such as prompting, shaping, and chaining, are all part of ESDM intervention and therapists must be able to deliver high-frequency, intensive teaching during therapy sessions.

When comparing the ESDM to other behavioral approaches (e.g. Discrete Trial Training or other traditional ABA programs), ESDM is different in these ways:

The ESDM uses a curriculum that is based on scientific findings in child development research, thereby ensuring that the teaching content is functional and relevant to the lives of children and their families.
The ESDM focuses explicitly on reciprocal social interaction, the quality of relationships, positive affect, and adults’ ability to be sensitive and responsive to the child, which are often overlooked or not focal points in ABA programs.
The development of language is viewed from a developmental perspective, which posits that language development is social in nature and therefore, must be developed within the context of social interaction and engagement, rather than in a discrete or isolated manner that is more common in behavioral programs.

What does ESDM therapy look and feel like?
If you were to walk into an ESDM therapy session at its best, you would see:

Well-developed activities with joint participation by both therapist and child
Shared smiles and glances between therapist and child
Both therapist and child co-constructing activities together and shared engagement throughout… lots of dyadic engagement and interaction
Frequent turn-taking and a balance of control between therapist and child
The therapist is skilled at presenting multiple learning opportunities and supports the child to be successful
Parents are present and involved in sessions
The therapist is responsive and sensitive to the child’s attempts to communicate and express him/herself
Behaviors are managed skillfully by the therapist and the child is able to regulate arousal/affect and be ready for learning
The therapist models ways the child can use to communicate a variety of different messages. The therapist respects and reinforces child’s attempts to communicate.
There is a balance between object-based and social games during sessions

Where does ESDM therapy take place?
ESDM therapy can take place across many locations, including in the family’s home, at school/daycare, or out in the community.

Who is the ESDM for?
As an early intervention program, the ESDM was developed to be used with infants, toddlers, and preschoolers with Autism. Children as young as 1 year old up to the age of 5 years can benefit from ESDM therapy.

Who delivers ESDM treatment?
The treatment can be delivered by a range of early childhood professionals (e.g. Special Education, ABA, Speech and Language Therapy, Physical Therapy, Occupational Therapy, Psychology) or trainees who work with children with Autism and who have read the ESDM manual can deliver ESDM treatment within their own practice. However, ESDM Certified Therapists have been through additional, more rigorous training and have met fidelity of implementation with multiple children.

What is the effectiveness of the ESDM for young children with Autism?
There is a growing body of research that demonstrates the effectiveness of ESDM intervention. For a list of published articles, please visit: https://www.esdm.co/research-articles

Finally, if you are a parent and think that the ESDM might be a good fit for your child, please contact Little Sprouts Children's Centre to inquire about Thailand’s first official ESDM program (managed and supervised by an interdisciplinary team of professionals, including supervision and training by an ESDM Certified Trainer).

If you are a professional and would like to pursue formal training and/or ESDM certification, please contact Plern Pratoommas at plern@outlook.com. For more information about the official ESDM training/certification process, please visit: www.esdm.co

This article was written by Dr. Plern Pratoomas,
Early Intervention and Child Developmental Specialist,
ESDM Certified Trainer and Therapist.

Reference:
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement. Guilford Press.

Why Joint Attention is Everything

23/3/2019

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.

8 Fun Speech Games To Play With Picture Cards

19/1/2019

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.

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.

5. Post-it: Your child can make a 'post-box' at home, where they can 'post' a picture card each time they say the word correctly.

6. Magic bag: You can start by placing all the cards in a bag. Then taking turns to pull one card out while closing your eyes. Practice saying the word on the picture cards in a sentence.

7. Fishing: Place a piece of Velcro on the back of each picture card and on the bottom of each fishing rod. Take turns ‘fishing’ for a picture card. Each time you catch a picture, practice saying the word in a phrase.

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.

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
Chiman Estephan, MSLP, MSPAA, CPSP, ACAS
© Copyright 2019. The Expat Speechie www.theexpatspeechie.com. All Rights Reserved.

Why Oral Motor Exercises Do Not Improve Speech - What You Can Do Instead.

6/1/2019

Happy New Year Parents!
In my first post this year, I want to address a question which parents often ask me: "do non-speech oral motor exercises improve speech?"

What are Non-Speech Oral Motor Exercises?
Non-speech oral motor exercises are widely used around the world when working with children who have speech difficulties. Non-speech oral motor exercises include:
- actions of the lips, jaw, tongue, soft palate, larynx and respiratory muscles (e.g. ‘blowing a horn’, ‘sucking on a straw’ and ‘blowing bubbles’), which aim to improve strength, range of movement or coordination.
- sensory stimulation (e.g. massaging the area around the child’s mouth)
(McCauley et al., 2009)

Do These Exercises Work? What Does The Research Say?
Even though these exercises are commonly used, there is no scientific evidence proving that non-speech oral motor exercises improve speech.

Wait! What? Why?
A practical way to understand why these exercises do not improve speech is:
Picture yourself training to run a marathon. You stretch your limbs daily and do muscle-strengthening exercises, however, you never actually practice the act of running. It would not be reasonable for you to expect that your daily stretching and strengthening exercises will improve your running, because you haven’t actually done any running. The same goes for children who are working on their speech. For a child’s speech to improve, the child needs to practice the act of speaking.

In terms of the research, some of the explanations about why non-speech oral motor exercises do not improve speech include:

- There are differences in the neural system’s organization for non-speech oral-motor tasks vs. speech (Moore & Ruark, 1994).
- Oral-motor exercises lack generalization to speech, because they focus only on a ‘fragment’ of the complex act of speaking (Lof, 2003).
- Oral-motor exercises focus on increasing oral-muscular strength, however, many children who have Apraxia of Speech or Cleft Palate exert the same amount of force when using their jaw and lips as children with typically developing speech (Forrest, 2002).

So Then, What Will Improve My Child’s Speech?
Below are five things that will improve your child’s speech:

1. Speech Practice - For a child’s speech production to be improved, the child needs to practice speaking. This can be done during Speech Therapy or during practice at home. You can read more information about working on speech at home by clicking here.
2. Functional Practice - If your child is not talking yet, start by working on the most important words that they would need to be able to say at this stage. Functional words include (but are not limited to): ‘no’, ‘yes’, ‘go’, ‘eat’, ‘water’, ‘more’, ‘help’, ‘hurt’ and ‘more’. Functional words like these are likely to have the most impact on your child’s daily life, at this stage.
3. Short Practice - Recent evidence has shown that short bursts of practice are more effective in improving speech than practice for long periods where children are likely to become fatigued and bored.
4. High-intensity - Evidence shows that intensive practice which involves lots of repetition of the same words and phrases is likely to result in better speech outcomes.
5. Fun Practice – Speech practice can involve movement (e.g. treasure hunt to find target word cards), games (e.g. memory game with picture cards) and involve rewards (e.g. verbal praise / tangible rewards).

As a parent of a child with speech difficulties, you want the best available therapy for your child that has been scientifically proven to improve speech. You can always ask your child’s Speech Therapist about the scientific evidence behind the method used in your child’s speech sessions.

In the meantime, you can read about how to help your child with their speech at home on my website by clicking here.

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

References:
Forrest, K. (2002). Are oral-motor exercises useful in the treatment of phonological/articulatory disorders? Seminars in Speech and Language, 23 (1), 15–25.
Lof, G. L. (2003). Oral motor exercises and treatment outcomes. Perspectives on Language Learning and Education, 10 (1), 7–11.
McCauley, R., Strand, E., Lof, G.L., Schooling, T., & Frymark, T. (2009). Evidence-based systematic review: Effects of nonspeech oral motor exercises on speech. American Journal of Speech-Language Pathology. 18, 343-360.
Moore, C., & Ruark, J. (1996). Does speech emerge from earlier appearing oral motor behavior? Journal of Speech and Hearing Research, 39, 1034–1047

Childhood Apraxia of Speech (CAS)

14/11/2018

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.

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:

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

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
© Copyright 2018. The Expat Speechie www.theexpatspeechie.com. All Rights Reserved.

Early Intervention: What is it and why is it so important?

7/10/2018

This month’s post was written by guest writer, 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, Plern Pratoommas
PhD Candidate
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
Chiman Estephan, MSLP, MSPAA, ACAS, CPSP

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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.

The 'Naughty' Kid: Ryan's Story About Growing Up With ADHD

31/8/2018

I was diagnosed with ADHD at the age of 31. Growing up in a country in Asia, my parents didn't know what ADHD was. I was often labelled the 'naughty', 'careless', 'wreckless' and 'messy' child.

However, after learning more about ADHD, I can now reflect back on different stages of my childhood and adolescent years and understand how the signs, symptoms and behaviours for my case have presented themselves and how it affected me.

When people think of a child with ADHD, many think of the stereotypical ‘hyperactive wall climber’ running from room to room causing havoc. But this wasn’t me. For me, I struggled with sitting still and paying attention. As a kid I needed to move and fidget. Even when tasks required me to sit, I could not. I can recall memories when a primary school teacher called my mother to inform her that I couldn’t remain seated during my exams. My parents dismissed the incident saying that I just wanted to play. In another occasion when my parents enrolled me in a performing arts school to learn to play an instrument, they found me in the back of the dance class. The school principal noticed my inability to stay seated or focused on repetitive tasks and felt my energy was better suited in the dance class...

Needless to say, on many occasions, my inability to remain still and pay attention meant I was strongly disciplined for being ‘naughty’ and was often punished by my parents. Throughout my schooling, I recall challenges learning subjects that involved abstract concepts, organisation, prioritisation and problem solving, particularly science and maths. Organising complex ideas for essays and university assignments were troublesome, in my case essay writing took longer than my peers to complete. I felt as though I had to work extra hard just to get the job done. Poor self image and self esteem began to creep up on me, leading me to feel shame and anxiety. While I confided in friends and family to discuss my challenges, I often found it difficult to sustain my train of thoughts to resolve them.

It wasn’t until I found myself in a stressful working environment where I really struggled to cope, that I decided I really needed to get to the bottom of my issues. I decided to see a psychiatrist for what I thought was work related stress. However, as our sessions continued each week, we explored the reasons behind my stress. It became apparent that the difficulty I faced at work was compounded by my struggle to concentrate, remain focused on the task, prioritise, organise and manage my time. It also didn’t help that I can be forgetful, messy, and impulsive; suffered from poor self image and mood swings from time to time. While these traits can often point to other mental health conditions such as anxiety or depression (conditions to which individuals with ADHD are vulnerable to) my diagnosis for ADHD was confirmed after completing the TOVA assessment under the advice of my psychiatrist.

Reflecting on my experience, my message to parents and teachers is: take notice of the signs and behaviours your child exhibits. If you suspect that your child is suffering from the challenges associated with hyperactivity, inattentiveness and impulsiveness speak to a qualified therapist and have your child assessed. Not doing so could mean that your child will struggle to live up to their true potential, or take advantage of some the positive qualities associated with ADHD.

Fortunately for me, I now understand my struggle and also enjoy the unique qualities that come with my ADHD. But that is perhaps a topic for another day!

Ryan

Five Skills You Can Teach Your Child With Books

5/8/2018

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

Three Fantastic Insights from Applied Behaviour Analysis (ABA)

9/6/2018

Applied Behaviour Analysis (ABA) is a controversial therapy approach. Some parents and therapists love it because of the positive outcomes they have seen on behaviour, but others don’t want anything to do with it (to put it nicely!) because of its structure and ridgidity.

But over the years, the more I work with children who have Autism, each of them so unique, the more I crave filling my therapy toolbox with a range of different therapy approaches. There is no such thing as a child who “does not respond to therapy”- it is more likely that the child is just not responding to the therapy approach being used at that time. So, earlier this year, I decided to add another therapy approach to my toolbox by completing training in ABA. I was pleasantly surprised that there were so many great insights.

Here are three of them:

1. How we can understand children's behaviour
A good start to addressing a ‘problem’ behaviour is to understand its function or why it is happening. For example, a child might seem to be screaming constantly for no apparent reason, but when looking at the situation in more detail (by identifying what happens just before the child screams, what happens right after they scream), the reason will become clearer. This type of assessment is called a ‘Functional Behaviour Analysis’. Once we understand the function of the behaviour (i.e. why the child is doing something), we can teach them more ‘appropriate’ behaviours that can still achieve the same function.

For example, I worked with a child who would scream whenever he was given a toy car. After looking into this further, it became apparent that this child dislikes toy cars, and was screaming to avoid the toy car. This child was then taught to say “no” every time he wanted to refuse the toy car. Eventually, the child started saying “no” to refuse unwanted toys, instead of screaming.

2. How we can teach children complex tasks
Children with special learning needs can have difficulty with activities which are important for everyday life. These activities are often complex, involving several steps, and can be quite overwhelming for a child with Autism.

For example, in the case of washing hands, this involves:
1.turning the tap on
2. putting hands under the water
3. putting soap on the hands
4. rubbing the hands together
5. rinsing the soap off the hands
6. turning the tap off
7. drying the hands

ABA gives insight into how to teach these complex tasks by breaking them down into simple, separate steps and giving positive reinforcement (e.g. praise) after each step is completed. The positive reinforcement is gradually faded, as the child can complete each step independently. Children with Autism tend to respond well to this systematic approach.

3. How our response can shape a child’s behaviour
Children are so clever. From a really young age, they learn that a behaviour will either get them what they want, or lead to an unwanted outcome. ABA highlights how to respond to behaviours so that they are repeated (if appropriate) or faded (if unwanted).

For example, when a child cries because they want candy and then they receive candy. In this case, giving the child the candy will stop them from crying in the moment, but it will also encourage the crying behaviour every time they want candy!

On the other hand, if a child does their homework and gets iPad time as a reward, this iPad time is likely to motivate the child to do their homework again in the future.

I now appreciate having ABA as another therapy approach in my toolbox and can already see the positive impact it is having on some of the children I work with. A therapist should always choose the therapy approach that a child responds to best. I believe that every child can make progress when the right therapy approach for them is used.

Speak soon,
The Expat Speechie

What I Want To Tell The World About Autism: Messages From Parents, Therapists & Educators

4/4/2018

“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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Welcome to my blog! I am an Australian Speech Language Therapist and Advanced Certified Autism Specialist now living permanently in Bangkok.This blog brings you free tips & techniques to support your child's communication.

Welcome to my blog!
I am an Australian Speech Language Therapist and Advanced Certified Autism Specialist now living permanently in Bangkok.
This blog brings you free tips & techniques to support your child's communication.