But she looks fine when she's here!

How many times have I heard this yet the parents KNOW their child is anxious?! Maybe they've had to drag them kicking and screaming into school, maybe the child has tried to self harm or attacks their parents on a regular basis. I saw this on twitter and it sums up how anxiety is not one thing. We don't always see it. A child can mask: hide their issues at school but all the time building the pressure til they get to the save haven of home or maybe just the carpark in some cases. It's called the 'delayed effect'.

What anxiety looks and feels like.#anxiety #signs #mentalhealth #beaware #support pic.twitter.com/JZqxIYH6Dm

— SCS Training&Therapy (@SCStrainingLtd) March 3, 2018

It's not right just to say, 'it's parenting,' We need to listen, we need a team approach not 'them' vs 'us'.

Please help spread this word as it's a HUGE problem and children's mental health depends on more people being aware that anxiety does not have just one 'look'.

Bad behaviour? no, just a lack of awareness and understanding of SLCN

Many of the children I work with get in trouble because they have language and social communication difficulties which impact simple, everyday interactions. This is just a typical one from last week:

A lovely young lady I met recently, Ruby aged 12 years, was very upset to receive a detention for something that had happened in school. The teacher was one she knew but was a maths teacher, who was covering a science lesson. 

This is what Mr Jones, the teacher reported and says happened in lesson:

He'd asked the class to be quiet, Ruby 'decided to continue talking'. He asked her if she understood what he'd said, and she said, 'Yes,' but carried on talking. He became cross and told her to 'be quiet.' She was shocked and said, 'But it was quiet working and if you wanted the class to be silent, you should have said.' Mr Jones felt that Ruby was being difficult and disrespectful for no reason.  He discussed this with her, but due to her response he felt he was unable to get anywhere and had no option but to give a detention for her poor attitude.

Teacher who was normally in maths covered science		Ruby dislikes change and hadn’t been prepared
Teacher asked the class to be quiet	Ruby carried on talking	Ruby has a literal interpretation of language, so he didn’t say ‘silent’
Teacher probably looked at Ruby and pulled a face to indicate he wasn’t pleased	Ruby carried on talking	She can’t read facial expressions and would not be able to interpret his intentions
He asked her if she had understood	She said, 'Yes.'	In her mind she had got the right interpretation
He said, ‘I meant silence!’	She said, 'you didn't say that!'	She has difficulty with word definition and is sure she knows, whereas she might be slightly off or way off She also cannot read inference
She said, ' You should have said that then.'		Ruby has little understanding of the rules of modifying language to teachers. She doesn’t know it's rude
Teacher thought she was being disrespectful	As she would be if she was of typical social understanding and /or pragmatic ability	She hasn't got the language or pragmatic skills to interpret the situation
	Ruby wouldn't let the subject drop	She has a clear fairness rule/sense of justice which she thinks the teacher was being unfair as she didn’t understand
Teacher discussed it	Ruby didn’t give the response he expected	She doesn’t understand as she thinks she didn’t do anything wrong
Teacher would be upset with her and may be was possibly feeling a bit under-confident as he was not teaching his subject		She can’t put herself in others shoes/see their point of view

 That's not the worst one I heard this week either!

We need so much more awareness about language and social communication difficulties, it's NOT just children with ASD!

Please support the campaign to save the Communication Trust as they are working hard to help schools understand more see more here

What does anxiety look like in a pre-schooler?

I work with a fabulous nursery who have just taken over a pre-school too. I'd like to say who but it might identify the child so I won't. They have such a great balance of professionalism and caring. They also really understand children.

I saw a 4 yo chap today who sat in my little group and pretty much did everything that was asked of him. He joined in, answered questions, volunteered answers, helped another boy who was struggling. Only a minor protest when he didn't get a gold star first, in fact.

Last time I'd seen him was before xmas when his behaviour was awful: I'd even managed to be hit around the head with my own boot! He'd ripped things, stole things, grabbed items out of my bag and ran off with them, tipped the bubbles on the floor while maintaining eye contact in some sort of act of defiance, refused to co-operate, etc etc

In many nurseries he would have spent hours on the naughty step, been told off, been discussed by staff as the 'really naughty one'. In this one, however, they knew better: they knew that his behaviour was actually as a result of low self-esteem, poor confidence  and a desire for attention which didn't matter if it was positive attention or negative attention.

They've given him a good routine with firm boundaries, ignored what they don't want to re-inforce and praised what they want to encourage. He's really doing well and is miles away from the boy he was before xmas! I'm sure they're will be a few hiccoughs along the way but with the right support and understanding he's doing fantastically!

Working with demand avoidance needs a different approach!

I had a break through today! I won't get complacent as it might not happen again or at least not the next time I try the same things but.........

F is a beautiful, funny, witty, gorgeous little princess who is like a ray of sunshine...... until you ask her to do something, when she can turn into 'a monster from your worse nightmares' (parental quote, not my words but I do know what they mean). 

I have used demand avoidance strategies on her for a while but the session might go something like this:

Me: 'Ok, thank you for choosing the order of the session F, let's see, you chose the memory game first.'
F: 'yes, but I'm not doing your stupid game now........I'm playing with the plastic fruit'
Me: 'No problem, let's use the fruit for the game.'
F: 'Ok, but I'm not playing on the table.'
Me: 'No problem, let's sit on the floor to do it, we'll have more room anyway.'
F: 'NO and you can't make me!'
Me: 'Where shall we do it because look, (pointing at her written list) you said we'd do it and it's on the list?'
F: 'On the floor under the table.'
Me: 'No problem,' but actually wondering if I'll get out from under the small table she's referring to!

This might happen for all 4 planned activities or we may only manage 2!

Today I 'wondered' (alot!) and did not tell her to do anything at all. I acted as an equal, discussing her favourite things, commenting on her new shoes, drawing on a white board next to F drawing on her white board. I asked no questions but made lots of comments:

'I wonder where F would want to work' (she chose somewhere different to usual)
'I was wondering what F had for xmas'
'I wonder what order we should do these'
'I wonder if F could show me..'
'I wonder if F wants to carry on drawing while we do this activity'
'I'm not sure I know what to do here...'
'I think I need help with this...'

We managed all the activities and both of us looked far less stressed at the end. I will try that again but F may have changed the goals by next week!

We need a different approach, we can't be the adult and tell them what to do. We need to pick battles and  make different priorities but above all we need to understand that this child is very anxious and the anxiety means she needs to feel in control. She doesn't need reprimanding, she needs compassion and support. The children who need the greatest help may ask for it in the most unhelpful way (I don't know who said that, but it works for me)!

I love the ideas and activities  in Understanding Pathological Demand Avoidance Syndrome in Children: A Guide for Parents, Teachers and Other Professionals 

by Phil Christie ,‎ Margaret Duncan ,‎ Ruth Fidler ,‎ Zara Healy. If you work with someone similar to F, I'd highly recommend this book.

What should I expect for my child's language development?

We like these guidelines:

AGE	Comprehension	Expression	Use of Language
18 months	Points to familiar and common objects on re quest Understands  simple commands (e.g. Pick it up, fetch your shoes)	Uses at least 10 words meaningfully Attempts imitation of  words and short phrases Chatters nonsense to self with wide range of different sounds and intonations	Responds to other people e.g. answering questions
2 years	Shows body parts on request Associates 2 nouns in a simple command (e.g. put the paper in the bin)	Spontaneous use of approx 50 words which can be understood by familiar adults	Starts conversations with others
2 1/5 years	Understands simple short stories and conversations Follows simple stories with  pictures	Combines 3 words Begins to ask questions, use negatives and adjectives Participates in  rhymes and songs	Carries on conversation for several turns Responds to other peoples conversation
3 years	Selects objects pictures in relation to verb (which one do we wear?) Understands common prepositions (in, on, under, behind)	4 to 5 word sentences which are intelligible to most people Using plurals and past tenses, not always correctly Asking what, where, who questions
4 years	Gives solutions to situations (what do you do when you are cold), Identifies some colours, comparatives and superlatives (big, bigger, biggest)	Uses complete sentences Asks ‘why’, ‘when’ and sometimes ‘how Relates stories and simple sequences of events’	Enjoys jokes Talks about own experiences Assume adult  shares their knowledge
5 Years	Follows a simple story without pictures Asks meaning of abstract words Size, shape, colour, quantity and position words used as aids to reasoning and understanding	Mastering irregular nouns and verbs (mice, men, drank, say)

if you are concerned please get in touch www.private-speech-therapy.co.uk

What is normal speech development?

I'm always being asked what is normal or typical for speech development. This is the best guide I have found:

Normal Speech Development

2 ½ - 3 years

Sounds used	Sounds emerging
M n
P b t d k g
	f  s
W y h

3 – 4 years

Sounds used	Sounds emerging
M n
P b t d k g
F s	‘Sh’  v  z l  ‘ch’  j
W y h

 4 - 5 years

Sounds used	Sounds emerging
M n
P b t d k g
F v s z ‘sh’  ‘ch’ j	Th  r
W l y h
	Sp, st, sk, bl, pl, gr

These are based on developmental norms for English (Elks & McLachlan)

If you are worried, please get in touch www.private-speech-therapy.co.uk

As our knowledge of neuro-science develops, it must inform our practice

Natasha Hallam and I were discussing the importance of keeping up-todate with current research and knowledge with George, aka Autism Advocate Dad at the recent SCERTS training in Sheffield, with Emily Reuben. This is true for all aspects of our work but especially true when working with children with social learning challenges. 

With advances in MRI technology, our knowledge of neuro-science is developing so we can see how our approach to working with children and young people with ASD should progress.

Children with a diagnosis of ASD have delays or difficulties in:

• the development of communication
• the development of social relationships
• play and imagination

Studies of children with  social language difficulties actually show physical neurological differences in the way they process social stimuli. If a neuro-typical baby look at people's faces, an area of the brain called the limbic system “lights up” with a heady cocktail of dopamine, opioids and oxy-tocin being produced. This is addictive, so the more it happens , the more the baby craves it. The parent is rewarded by the baby's reactions so will do it more and more. The parent-baby interaction is set up and the path to social communication is well underway.

Children who are non-nuero-typical/have ASD do not have this response. The area of the brain is not lit up by human contact but other areas may show sparks  for certain objects which appeal to them. 

 We call this the social motivation models of ASD. This believes that early differences in social attention set up developmental processes that ultimately deprive the child with ASD of adequate social learning experiences. This causes an imbalance in attending to social and non-social stimuli which further disrupts social skill and social cognition development. So, if a child is not motivated to seek out the social attachments his skills will diminish due to lack of experience and practice. If they are motivated, the skills are practised and reinforced.

By 6 months of age, a typically developing child, begins to follow eye gaze and can recognise when they have lost a caregiver’s attention.  A neuro-typical infant may show distress when a caregiver’s eyes avert. The 'still face experiment' is a good example of this, where the infant seeks out his mother's eye contact and when she doesn't get it, she works really hard to try to make it happen before becoming distressed when it doesn't.

By 10 months of age, a child begins to shift gaze from a caregiver to objects of reference to predict and anticipate the actions of others.

By 12 months of age, a child will initiate shared attention on desired items or items that are of interest to the child. 

This means that a neuro-typical child:

• is drawn toward social vs. non-social stimuli,
• derives pleasure from this engagement,
• notices attention shifts of others,
• initiates bids for engagement, actions, and objects of interest
• Practices ways of getting more social attention and indeed, they become very skilled.

Children with Autism Spectrum Disorder (ASD) show limited neural sensitivity to social stimuli and tend not to look toward people’s faces. They will  miss gaze shifts between people and objects and will have difficulty predicting actions and initiating bids for engagement.

Another difficulty is picking out speech from background noise:  when a neuro-typical child hears speech sounds, the sounds are processed as social or intentional stimuli, while children with ASD may just  hear sounds.

Plus, MRI scans have shown that children with ASD may use a different area of the brain to process  social stimuli (e.g., faces, speech sounds). This area is the same as we all use  to process images and sounds that are non-biological.  This makes predictions of actions, intentions, and emotions less efficient and more intellectual. 

So what does that mean for therapy?

We need to respect these differences and early intervention is the key. We must work hard to make them see the point in social interaction for themselves. Hanen's More Than Words is a research lead, evidence based approach which shows how we can develop this, by thinking about how we set up and structure interaction. Later we like social thinking approach to take this further

The theory underlying the approach in the More Than Words programme proposes two key factors:

1. Learning to communicate is a very social process and that children learn to communicate from birth within everyday interactions with their parents.
2. Parents foster their child's communication development by responding to it promptly and building on what the child is communicating about. This applies to all children, including those with autism. However, it has been shown that children with autism also benefit from some very specific ways of responding to them.
   

We need to responsive, which means:

1. Responding promptly (within a few  seconds of a child doing or saying something).
2. Responding  positively – responding in a way that shows the child the parent is really interested in what she or he is saying.
3. Sticking with what the child is “talking” about and interested in – this means not trying to direct his attention to something else when he is already focused on something or someone. We can use his interests as the basis for communication.

Being responsive involves Following the Child’s Lead, which takes advantage of what the child is currently interested in and attending to. We can, therefore, capitalise on the child’s current focus of attention. This is thought to increase the child’s ability to learn from the language he hears since his attention is already 'captured'. This is in contrast to us directing the child’s attention away from what he is interested in to something else, which can be challenging for the child.

It's so exciting: the more we know, the more we can understand and then the more effective we can be!