​

“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.
 
 

​I have heard some crushing stories from local Thai and Expat parents describing how their child received an Autism Diagnosis in Bangkok. Far too many times, their stories sound like this:

“We were in the room with the doctor for less than five minutes, when suddenly they told us that our child has Autism”.

One parent even told me, “when I asked what this meant, they said Google Floor Time”.

What is even MORE shocking is that, many times, the child DOES NOT actually meet the criteria for Autism!

Parents often ask me, “do you think my child has Autism?”. As a Speech-Language Pathologist and a Certified Autism Specialist, I believe that there is a due Assessment process which must be followed before providing an accurate and reliable diagnosis. If you suspect that your child might have Autism, here are five things your child's Assessment process should involve:

1.      Firstly, information will be collected
A reliable diagnosis will consider your child’s skills and ability in a range of environments, not just the clinic. For this reason, information about your child needs to be collected. As a parent, you know your child best and spend the most time with them – you can provide a wealth of insight about them. During a pre-Assessment consultation with the person assessing your child, you will be asked many questions about your child’s development history up to their current skills and ability. Information will also be collected about your child from other people. This is likely to include your child’s classroom teacher and any current or previous therapists who work with your child.
 
2.      Diagnosis is a multi-disciplinary process
It is very likely that either a Pediatrician or a Clinical Psychologist will lead your child’s Assessment and make the diagnosis, as they are specialized to do so. These individuals will ask questions about your child’s overall development, observe your child and administer formal Assessment tools such as checklists and observation scales.
 
Professionals who specialize in different areas of development should also be involved in the evaluation. The Assessment should involve a Speech-Language Pathologist to evaluate your child’s communication, if there are concerns in this area. Also, an Occupational Therapist can evaluate your child's sensory needs, motor skills and emotional self-regulation. 
 
3.      Criteria must be met in two specific areas
For a child to be diagnosed with Autism, they must meet the criteria listed in the Diagnostic and Statistical Manual – Fifth Edition (DSM-V) in BOTH areas outlined below.

A.     Social Communication Deficit:
This includes the verbal and non-verbal aspects of social communication or the ‘unspoken rules’ of social interactions.
·        These verbal aspects include difficulty with back-and forth conversations, initiating conversations, maintaining conversations or ending conversations.  For instance, I have worked with a child who did not give others a chance to speak during conversations.
·        The non-verbal aspects which children find difficult include interpreting emotions, making eye-contact, engaging in imaginative play and gestures.
 
B.     Repetitive and Restricted Routines:
This includes verbal and non-verbal repetitions.
·         Children with Autism may repeat things over and over verbally, which is referred to as ‘echolalia.’ For instance, I have worked with a child who recited the same YouTube video repeatedly. 
·        They usually display repetitive movements such as hand-flapping and rocking.
·        They tend to become very upset and have very low tolerance for a disruption or change in their routine.
·        They are either much more sensitive to sensory stimulus around them, or they do not seem to respond to sensory stimulus. For example, I once worked with a child who repeatedly walked around my office to run their hands across all the furniture.
·        They might seem ‘obsessed’ with a certain topic of interest which they insist to keep bringing up and talking about.
 
It is crucial to understand that if your child has one or more of the characteristics above, this does not necessarily mean that they have Autism. In fact, many children and adults have one or more of the characteristics outlined above. An Assessment is crucial for an accurate and reliable a diagnosis.
 
4.      The Assessment will take a while
The Assessment process is lengthy because as well as formal tools being administered, your child will also be observed informally in the clinic and outside the clinic (e.g. at school). Children behave differently in different settings and different variables must be accounted for (e.g. if they are in an new environment, your child’s mood that day, if they are unwell or tired). Reliable conclusions can be drawn by collecting a wide sample of observations, which can take multiple sessions.
 
5.      Finally, results will be reported and explained
The results of the Assessment will be written in a report, which will also include recommendations for supporting your child in their areas of need. The results and observations will also be discussed with you during a post-Assessment consultation. I understand that this is a very tough discussion for parents to have and can often be emotionally overwhelming. However, it is important to remember that you have taken the first (necessary and brave) step towards helping your child. This post-Assessment consultation will help you further understand your child’s skills and needs as well as how to best support them moving forward. Here are some questions which you can ask during this discussion:
“What does Autism mean?”
“What areas will my child need support in?”
“What are your recommendations?”
“What is my role in intervention?”
“What is the next step to support my child?”

I hope this information has been helpful to you, dear parent, who is reading this post. Please help to empower other parents to understand more about obtaining an Autism diagnosis for their child by sharing this post.

Speak soon,
The Expat Speechie

Related Posts:
Autism: The 'A' Word
How Can I Support My Child Who Has Autism

I am excited about this month's post, which has been written by our guest, Mui Kometsopa, Centre Manager of The Rainbow Room Foundation, Architect and mum. Mui has merged her expertise in architecture with her experience of working with families who have children with special needs to bring you these practical tips below.
​
​As an architect, I strongly believe that physical environment can influence human behaviour, especially social interaction within that space. With just minor arrangements and a few adjustments, you can actually set up home environment that fosters interaction and improves your child's communication. The keys to shaping the home environment are to maximise opportunities for a child to communicate their needs and to minimise sensory distraction.

Here are 9 tips for parents:
1. Open up living space
Light up the room, ideally with natural sunlight. Removing partition or furniture that blocks the flow of space will help to create visual connection within the room. The open living space will encourage people to see what others are up to. The more we see each other, the more opportunities there are for social interaction.

2. Identify specific areas for specific activities 
A well-structured and organised environment will enable a child to predict the situation and tasks they have to do in a certain area such as dining, reading, homework, play, etc. Clear structure will help to reduce anxiety and promote self confidence.

3. Re-position furniture
When we need a child’s attention, the position recommended to maximise interaction is to sit directly in front of them. For example, rather than push your child’s working table up against a wall, float the table to allow extra seat on the opposite side. 

4. Use padded flooring 
In play areas, a padded floor is recommended not only for your child safety, but also for your own sake. Since the best position to create ‘joint attention’ is at your child’s eye level, you will be spending a lot of time on the floor, rolling, crawling - playing with him. A padded floor will be more comfortable for you and safer for your knees. 

5. Put the shelves up high 
High shelves can certainly help to minimise visual distractions. When toys and other objects are out of a child’s reach, they will need an adult’s help to reach them. This provides more opportunities for communication. Open shelves are better since they allow a child to clearly see what is available to play, which helps reduce anxiety.

6. Categorise toys 
Toys can be categorised conceptually or thematically. You can put pictorial or written labels on the boxes so they are easy to use and maintain. Toy boxes can be rotated to reflect interest of your child in that day. Toy grouping can encourage a child to build a connection between related toys and create a story while playing. Thematic play also motivates expressive language and social interaction. 

7. Label up! 
Labels are handy. Not only can they help to expand your child’s vocabulary, but they also can help you organise the entire house! Labels on enclosed containers such as storage boxes or solid cabinet doors can reduce anxiety for some children (and adults).

8. Ensure safe exploration 
As a parent, you probably realise how much kids love to explore household items. While your child is roaming the house to learn new things, make sure your space is child-safe. Cover electrical outlets, and store dangerous or breakable objects up high. Locking unsafe items away can reduce situations where you have to use the word ‘no’ or ‘don’t’, allowing you to interact with your child in more positive and enjoyable ways.

9. Create display wall
A little wall of your child’s art, writing or print display at home is a powerful reinforcement to promote his self esteem. The wall should be located where everyone can clearly see it and talk about it. This can be placed along the hall way, in the living room, or on the fridge door. Be as creative as you like but be aware not to bombard the space with pictures which might cause visual over stimulation. 
​
Many children with hyper-sensitivity experience sensory overload which can be distracting and interfere with their focus. The basic principle is to remove or reduce sensory disturbance from the environment. It is essential to be aware of your child’s sensory sensitivity and how the environment might affect them.
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I hope you enjoyed reading this article as much as I did and took away these practical tips to apply at home!

Speak soon,
The Expat Speechie

Last month, I attended a workshop held by Michelle Garcia Winner, the founder of Social Thinking. To say I was excited is an understatement. Social Thinking is my preferred approach when working with children who have multiple speech and language needs. As Michelle emphasized, Social Thinking goes far beyond just teaching “social skills”. She explained that it involves applying language and cognition (thinking) to social skills and solving social problems.

Interestingly, the longest research study ever conducted on happiness, found that people who have strong and lasting social relationships are generally the happiest. Social Thinking is so important for forming and maintaining these social relationships with others.

Why is Social Thinking so important?
There have been many times during my speech therapy sessions when I think to myself, “I really wish this child knew how to tell me (and others) that they did not understand what was just said to them” or “if only they knew what to do when someone does not understand what they have said”. At that point, I will usually stop the activity we are working on and we will practice these skills instead. Skills like these are often over-looked because most children learn them naturally. However, some children do not and need to be taught these skills in a structured setting such as therapy. Communicating that they have not understood what was said to them and knowing what to do when others have not understood them are just two examples of the endless skills which the Social Thinking approach promotes.

What does Social Thinking involve?
In my opinion, Social Thinking forms a bridge between Speech Therapy (as language is needed to communicate) and Psychology (as communicating with others involves attention, thinking and perspective taking).

Social Thinking is quite complex and it involves many skills including:
• ​Expressive Language (using language) and Receptive Language (understanding language)
• Social skills
​• Problem solving
• Attention
• Short-term memory
• Meta-cognition (thinking about thinking)
 
Will my child benefit from the Social Thinking approach?
This approach is mostly suitable for children with moderate-to-high level of language and thinking skills. Your child can benefit from this approach if they have social learning difficulties or need support in their social communication skills. This approach often teaches the ‘hidden curriculum’ as Brenda Myles writes about in her book, which some children do not learn naturally. I have personally seen many children who have Autism, Down Syndrome, social learning difficulties in  elementary, middle-school and high-school make fantastic gains from using this approach.
 
What will my child learn through this approach?
Your child will learn skills in the social communication areas where they require support. To determine these areas, a Speech Therapist will gather information from you and possibly your child’s teachers. The therapist will then assess or observe your child’s social communication skills to identify areas of need.

Based on the findings from the assessment, a plan will be put together outlining the social communication areas where your child needs support.

During therapy, your child might then work on skills such as perspective taking, where they learn that two people can look at the same thing and have different thoughts about it. Your child might work on “whole-body listening” where they are taught to pay attention with their bodies. This is such an important skill for social interactions as well as for learning in classrooms. Another skill your child might work on is thinking about others and how to start conversations based on their interests. They might then learn how to maintain these conversations.

Social Thinking is a great approach for working with children with social learning difficulties. I hope to see more of this approach being applied in Bangkok within the coming years, to equip children with such important life-skills.

Speak soon,
The Expat Speechie

Some bilingual children learn both of their languages from birth, whereas other children learn a second language well after their first. In Thailand, local families speak Thai at home, so children are usually  first exposed to English once they attend an English-based school. Children who learn English during their school years face the challenge of learning a new language while trying to keep up with academic content. Some content is likely to be missed during this process [1]. It is commonly assumed that after some time and English exposure, these children just “catch-up”, however, in Thailand where the local language is Thai, this is not necessarily the case.

There are several studies which have looked at how learning English at school can impact a child’s performance at school. The findings will surprise you...

 How long does it take a child to become proficient in English?
Studies have shown that it can take a child anywhere between 1- 6.5 years of exposure to English to become proficient in English [2]. This is also influenced by other factors such as family, education, social and individual factors [3.]

How does English proficiency impact a child’s academic performance?
An Australian study published last year found that school-aged children who are not yet proficient in English are likely to face academic difficulties compared to their peers [4]. This study also found that children who had better English proficiency when starting school achieved higher academic outcomes overall towards the completion of primary school [4].

What do these findings mean?
These findings suggest that children who first learn English through exposure at an English-based school, could struggle with learning academic content at school for up to 6.5. years. These findings were based on populations living in countries such as Australia and the US, where the main language is English to begin with. However, in a country like Thailand, where the local language spoken is Thai, this could take even longer.

As a result, it is likely that local Thai children might be over-identified as requiring Speech Therapy during their school years. I often find myself teaching children concepts in English which I then realize during the session that they already have sound knowledge of in Thai (e.g. ‘past’ and ‘future’ tense). In these cases, the child’s underlying difficulty is not language, but specifically English. Thus, an ESL program is often more suitable for these children.

How can we use this evidence practically?

Teaching Modifications
Children who are learning English at school would benefit from the use of strategies such as modeling, repetition and emphasis in the classroom. These strategies will help support their understanding of instructions and material presented in class. Once their understanding is supported, their performance when completing tasks will likely improve.

Individualized Programs
Several children who learn English at school require individualized programs to be tailored to support their learning and performance at school. Before a program can be recommended, there needs to be a strong understanding of the child’s Thai language skills. If the child has adequate Thai language skills, then they can be enrolled in an ESL program. However, if a child is having difficulty with both Thai and English, Speech Language Therapy is recommended, as there is likely to be underlying language impairment.

Increasing Awareness
There is a greater need for spreading information about the benefits of being bilingual as well as the difficulties a child is likely to face if they are expected to learn English while at school. This might encourage local parents to expose their children to both Thai and English from a young age if they intend to send them to an English-based school in the future.

Increasing Exposure
Attending day-care or pre-nursery is a fantastic way for children to become exposed to English from a young age. Attending playgroups or arranging play-dates with other English-speaking children will also help.

Local Thai children who first learn English at school are likely to face difficulties keeping up with academic content. Increasing exposure to English from a young age is likely to help with this. Certain classroom modifications and programs such as ESL can be provided for these children during their school years.

References
1.      Macswan, J., & Pray, L. (2005). Learning English bilingually: Age of onset of exposure and rate of acquisition among English language learners in bilingual education program. Bilingual Research Journal, 29, 653-678.
2.      Brinkman, S. et al. (2009). Population monitoring of language and cognitive development in Australia: The Australian early development index. International Journal of Speech Language Pathology, 11, 419-430.
3.      Halle, T. et al. (2012). Predictors and outcomes of early versus later English language proficiency among English language learners. Early Childhood Research Quarterly, 27, 1-20.
4.      Dennaoui, K., Nicholls, R. J., O’Connor, M., et al. (2016). The English proficiency and academic language skills of Australian bilingual children during the primary school years.  International Journal of Speech-Language Pathology, 18: 157-165.
 

Yesterday, I saw a child for his weekly Speech Therapy session. When I walked in he greeted me in an unusually grumpy way with his arms crossed. I asked him, “what's wrong?” and he replied, “I don't want to learn anymore, I never get ANY free time to play on my iPad!” I sat down next to him and said, “I understand that you are frustrated, I also feel frustrated when I have too much work and no free time.” He looked up at me in surprise. We spoke about this some more, and eventually, he transitioned into the session smoothly.

Non-compliance is a common issue faced by therapists during sessions. Parents also face this problem during home practice and so do teachers during their lessons. Children show non-compliance for a number of reasons. Some of these include, finding a task too challenging, being under-stimulated by an activity, being sick and so forth.

Here are some tips which can help:
 
1.      Acknowledge the child’s situation or feelings
When you do this, you are validating what they are feeling. This is more likely to have a positive effect compared to if their feelings are disregarded. You can say things like, “I understand there is a lot going on around us today which is distracting you” or “this is tricky, but you are trying really hard.”
 
2.      Identify clear start and finish points for activities
Children, like adults, respond better when completing tasks they find difficult or they do not enjoy when they understand ‘how long’ the process will take. Before completing an activity, you can explain the beginning point of the activity (e.g. where they are expected to copy your ‘s’ sound five times) and the end point (e.g. once they have completed fifteen productions of the ‘s’ sound on their own).
 
3.      Avoid teaching when the child is unwell
When I am sick, the last thing I want to be doing is learning something new or practicing a task which I find difficult. Children are the same. I am yet to have a productive session with a child who is sick. When children are sick, try to postpone their therapy sessions, home practice and even going to school. This will give the child an opportunity to rest and recover. It will also prevent them from forming a negative  association between the task they are completing and the feeling of being unwell.  
 
4.      Use a visual progress chart
Children generally respond well when information is presented visually to them and when they can see their progress. You can use a visual progress chart made up of boxes which the child can 'tick' for each speech-sound production. Also, you can get creative with this. For instance, if you are teaching the ‘s’ sound in a session, draw a picture of a snake and boxes inside this picture for ticks. Once the child has ticked all the boxes inside the snake, you can move onto a new picture for the next sound.
 
5.      Give specific praise
A behaviour is likely to be repeated when it has been positively rewarded. If you want a child to repeat a behaviour, give them praise which is specific to that behaviour. For instance, if you are working on a lisp and the child says the ‘s’ sound correctly during an activity, your praise can be “I like how you said that s sound” or “great job keeping your tongue inside your mouth.”
 
6.      Break-down tasks
Several tasks can be overwhelming for children who have a speech or language delay. This can  lead to  behavioural difficulties during sessions or home practice. Be mindful of how many steps your activity requires and try to break these down into different stages.
 
7.      Revisit the child’s goals
Some children have meltdowns in sessions because they feel the activity is ‘too hard’. Other times, children act out because they are not being challenged enough. Revisiting the child’s goals will allow you to reflect on the level of difficulty of their activities and ensure that they are aligned with the child's strengths and challenges.
 
8.      Understanding and addressing fidgeting
I remember when I was growing up, most of my free time was spent playing on the swings at the park or rolling down grass hills. Nowadays, children spend most of their free time indoors. If children don't release their energy during free time then they will be more likely to so during learning time. One way to address fidgeting is to encourage children to have more play-time outside. Another way to address fidgeting is to use a wobble disk or fidget toys that the child can squeeze with their hands.
 
9.  Involve unstructured learning
For children who are below the age of four, play-based therapy works really well in teaching children speech and language skills. For more information, here is the link to my post on ‘Why Play Is The Way'.
 For school-aged children, consider activities such as role-plays with peers or conversation-like interactions in groups to replace traditional, structured learning.
 
10.  Replace expectation with interaction
Therapy sessions and home practice should not feel like a test. When teaching speech and language skills, the final goal is always preparing children to apply this during real-world interactions. Try to involve interactive activities as often as possible to re-enforce this. For instance, some children respond better to activities where we ‘take turns’ making sentences with target words rather than expecting them to make all the sentences on their own.
 
11.  Involve the child’s interests
When you involve a child's interest in their learning, they are likely to be engaged and learn more during activities.

Non-compliance is a re-occurring difficulty faced by therapists, parents and teachers. This post has outlined some of the strategies which can be used to minimize this during therapy sessions, home practice and in classrooms.

Speak soon,
The Expat Speechie