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Early Interventions for Children with Speech and Language Developmental Delays

Diagnosis is a critical element of clinical psychology. Working in a clinical environment day in and out exposes one to a multitude of disorders across all age groups. Quite often in my clinical work I find myself wishing that a certain patient had approached a psychologist for help at an early age so that the problem would not have intensified. Unfortunately in spite of the data available for psychological practice in Pakistan, most parents consider it a huge stigma to bring a child to a psychiatrist or psychologist. Many schedule their visits at times when others are at work or school, especially in a joint family setting and issues are avoided rather than addressed. In short, we relive the vestiges of the ostrich syndrome again and again until the issue at hand becomes severe enough for school authorities to take note and call in the parents. It is at that time that psychologists are frantically urged, pushed and rushed into giving ‘reports’ and providing that elusive diagnosis.

Here, I have outlined some basic points for parents to consider in cases where they either suspect a developmental delay or where their child has been diagnosed with a disorder such as Down’s syndrome, Mental retardation or has Autistic features. It is by no means a complete review and if you want details and help,you will need to contact a qualified psychologist.


In cases where a child shows developmental delay in his speech and motor functions. The early intervention plan formulated for him includes aspects from these areas.

Developmental delay means that a child has not attained developmental milestones expected for the child’s age in one or more of the following areas of development: cognitive, physical (including vision and hearing), communication, social-emotional, or adaptive development.

Clinically, a developmental delay is a delay that has been measured using clinical opinion, appropriate diagnostic procedures, and documented as a 12-month delay in one functional area; or a 33% delay in one functional area or a 25% delay in each of two areas.

As children change from “toddlers” to a “preschoolers,” they are “transitioning” from the early intervention process to a process more suitable for preschoolers and a revision is usually needed as they turn 4 years old and beyond.

The Concept of Reward:

Do you remember your childhood? Do the words, ‘gift’ and ‘surprise’ ring a bell? if they do, and the memory is pleasurable, it is probable that you were rewarded appropriately by your parents and they did not overindulge you. Rewards given appropriately and not as bribes or given far in extnet of the behaviour expected, work. When parents complain about rewards not working I have frequently observed that this is usually due to the fact that the so called reward has no value in child’s eyes – it is something that he can get in anycase if he screams loudly enough, throws a tantrum or if his parents really want him to be quiet. ‘If you listen to me you will get a choclate…. okay … you will get two chocolates… okay three… and finally *slap* and *drag*… parental guilt attack and a few more chocolates later… a heavy sigh with ‘these children are just uncontrollable’ …’.

For a child’s progress it will be necessary to reward him when he manages to perform an activity successfully. For most cases of developmental delay related to speech (if no physical reason is found) such as correctly voicing his needs etc, the procedure of the reward can be as follows:

  1. Select a behavior for which the reward will be given.
  2. Select a suitable rewardsuch as it can be a favorite toy or simply clapping by the parents – anything that makes him happy will do. Keep in mind that the reward needs to be valued by him for any effect to take place and it must be given immediately.
  3. When working towards any goal in your mind, start off with rewarding every single time he makes the slightest push towards the desired behavior, and then later increase the level of response expected by the child before he gets the reward. Make sure that non performance does not get that reward any longer. For e.g. in order to help him get what he needs, for the first four days, reward for a behaviour already being followed so he may be rewarded whenever he points towards an object he wants, then reward for the next four days whenever he makes some articulate sound while pointing (not merely screaming), then for another four days reward when he imitates or makes some attempt to imitate you as you name the object (do not be strict about accent and pronunciation) and so on, until he starts naming the object on his own. After the first four times, vary the reward that is, you do not need to provide the reward each time but instead provide it randomly and eventually stop. You can give a bigger reward as a closure for an older child and tell him that this ‘game’ has now ended.
  4. Patience is the key here and the parents will need to show the child exactly what response will get him the reward several times before he even starts imitating them.


As a parent you need to set up both short and long term goals based on an understanding of your child’s needs, strengths and weaknesses. A psychological counselor can help you in this process.

 Long term goals are important as the child nears the preschool or school age. These describe the expected growth in the child’s skills and knowledge over the next year as a result of the special education that he receives. Goals should be positive, measurable and achievable. This will help understand the child’s level of growth from year to year.

 A good goal can be made by asking these four simple questions:

  • WHERE? : The setting or under certain conditions
  • WHAT WILL BE ACHIEVED? : Skill(s) or specific behavior. This part begins by asking yourself what the child can currently do and then making markers based upon achieving a specific skill in a specific period of time.  Be REALISTIC and research well before setting up a goal that involves a child being perfectly potty trained at age 1! You are raising a human being, not a robot. And yes, I have come across people who have expected that.
  • HOW? : To what extent and in what manner?
  • WHEN? : At what point. Specify the time and age level of your child when the aforementioned will be made possible.

N.B: Regularly matching the progress report provided by school teachers with your short and long terms goals worksheet will help you in this process. Six monthly meetings with your child’s teachers are also essential for updating yourself.


Information and checklists provided herein are to be used as a guideline and not for final diagnostic evaluation. Interventions are provided at the end and are meant to be used by the parents at home.

Articulation problems: A child may have difficulty in articulation. This is a difficulty with pronouncing sounds to make words. There are many reasons children have difficulty in making sounds. These include hearing problems, poor muscle control, cleft palate and lip or learning problems.

The checklist below shows the age at which native English speaking children use a sound correctly. Marking your child’s age, with a pencil, after every few months in the area on the left, will give you an idea of his progress in his level of articulation.

Your child’s age Age Sounds Acquired
3 m,n,h,w,p
4 b,t,d,k,g,f
5—6 v,j,s,1,r
7 z,ch,sh,th

 As a rough guide, a normal child’s speech can be understood by a stranger:

• 25 per cent by age one,

• 50 per cent by age two,

• 75 per cent by age three, and

• 90 per cent or greater by age four.

Interventions for articulation problems:

As children usually respond very well to sounds and music, they can be taught to articulate using a variety of techniques involving visual and auditory stimuli:

  •     Certain toys available in the market produce sounds when buttons are pressed. Your child can be encouraged to play using toys that call out the alphabet phonetically. The parents need to say the letter aloud in the same manner and encourage the child to repeat. Initially this may yield no result but do not give up.
  •   While producing a sound, proceed systematically starting from ‘A’ and going till ‘Z’. Stick to one sound for some days before progressing.
  •   Certain sounds such as ‘o’ involve very obvious lip movements and the child can be taught by making him place his fingers on the parent’s lips and tracing the shape while the sound is being produced.
  •   For sounds such as ‘t’ and ‘d’ or ‘b’ and ‘p’ that have similar lip movements, these should be exaggerated in front of the child to make it easier for him to imitate.
  •   Another idea is to place a mirror in front of the child reflecting both the parents and the child while the sound is being produced.
  •   The correct behavior should be rewarded.
  •   Do not get upset if the sound produced is less than perfect. For most children, articulation becomes better after age 4.

Language problems: In addition to articulation, some children also has difficulty in expressive language skills and show developmental delay. Please bear in mind that a child who has a speech, language, or listening problem upon entering kindergarten will be at a distinct disadvantage for learning and participating in class. In kindergarten, children are expected to follow verbal directions,f ollow stories, learn and remember new concepts,  answer questions, mimic the sounds and words shared in class, and recount information using speech that is understandable to others. Some children may need regular speech therapy in order to be able to follow these basics.

Checklist for early speech and language milestones:

Place a tick mark in front of each statement if true, every 4 months, in order to obtain an idea of how your child is developing.

By age 3 to 4, usually children:

use sentences of 4 to 6 words ____

comprehend and answer simple w – questions (who, what, where, when) ____

show an interest in how and why things happen and how people feel ____

ask questions, usually who or what questions ____

follow concrete, two to three-step directions (e.g., “get your shoes, put them on and then come here”) ____

talk easily about daily activities, especially what they are doing, just did or will just do (e.g., what they did with friends / during the day) ____

talk to themselves and mostly their toys while playing ____

tell a basic story or sing a song ____

give directions like “fix this” ____

Interventions for language problems:

The following can be used to give a child some of the basics and prepare him for all that is to come in the preschool environment.

Book reading:

  •   Indulge in book reading with your child. Make a bedtime story a regular habit before putting him down to sleep. This increases vocabulary and helps with parental bonding. It also reduces the incidence of not wanting to go to sleep with most children falling asleep before half the story is done!
  •   Place him beside you with your face at his eye level and make sure that his attention remains on the book if you are reading from one. Initially, the child may not be able to pay attention for more than 1 minute. Start off with a short 1 -2 minute story and increase the time slowly as he starts responding. Normally, a 3 years old child is able to listen to a story / poetry for approximately 5 minutes.
  •   Go slow and pronounce each word loudly and clearly. Vary your tone where necessary.
  •   When he gets distracted, tap twice on the picture in the book to get his attention towards it.
  •   Make sure books with big pictures are used that are familiar to him.
  •   Point to each picture using the child’s finger(s) / hand and let him trace it as you say out its name.


  •   Make a habit of talking to the child, whether it is in the bath, at mealtime or on an outing.
  •   Keep in mind that he will learn more from being talked to directly rather than hearing two people talk to each other as happens in cartoons.
  •   As before, reward him every time he makes an attempt to answer back using sounds. Later he may be rewarded upon imitation of the word spoken by you.

Please note that all the points mentioned above are meant to be used as guidelines only and are not an alternative for proper psychological guidance.

Its all in the Hat – The Seussian Magic

The Cat in the Hat

Dr Seuss – the name conjures up specifically Seussian images: a cheeky looking cat with a hat, a green Grinch with evil red eyes, and of course, the Lorax. Harnessing a potential inculcated by the rhythmic pie-chants of his mother and inspired by an admiring comment on his ‘doodles’ in his Oxford class by his then classmate and later wife, ‘Ted’ Seuss went on to carve his own niche simultaneously in the art world and children’s literature. His art lies between the surrealist movement of the 20th century and whimsical doodling of a man who claimed that he had never really learnt to draw!


Though Seuss enjoyed writing books that would encourage children to read, his books have symbolic elements meant for adult comprehension – the irresponsibility of ‘once-ler’ in the Lorax in using truffula trees to fuel his ambitiousness, or the controversial butter-battle book with its oblique reference to the growing threat of arms build-up and nuclear war heightened by its highly disconcerting blank page ending. Even his playful change of title in Marvin K. Mooney, will you please go now!,  as Richard M. Nixon in friend Art Buchwald’s column with Nixon resigning the next day aroused much notice.


Dr Seuss

As Dr Seuss wanted and envisaged, his books have been used for several decades as a medium for the teaching of English language, and as a means of encouraging children to read. His dream was realized to a great extent for even at the time of his death on September 24, 1991, his works had been translated into 15 different languages and over 200 million copies sold worldwide with 6 posthumous publications. The cat in the hat – intended as a children’s primer with the inclusion of 220 new-reader vocabulary words remains popular to date both in and out of schools.


He wrote 44 children’s books, over 400 World War II political cartoons and countless advertisements and editorials. Animated renditions of his nearly 30 of his books like the Butter Battle book, Gerald Mcboing-boing (1951), How the Grinch stole Christmas, and Horton hears a Who! (1971) among others, brought him further fame, prestige, one Oscar, two Emmys, a Pulitzer and a Peabody among others.


Dr Seuss enlivened many hearts and minds with his particular brand of fun and infectious optimism – “you’re off to great places! Today is your day! Your mountain is waiting. So . . . Get on your way!” Teaching above all, the message of tolerance to young minds, Dr Seuss gave it all in his swan slogan shortly before his death -: “the best slogan I can think of to leave with the U.S.A. would be: ‘we can . . . And we’ve got to . . . Do better than this.” Needless to say, we agree.

Pictures courtesy:



Of Inattention and Hyperactivity

 Seven years old Ali* was rushing around the school playground pretending to be a rocket. The harassed looking teacher tried to explain to his mother how he never seemed to concentrate in class or sit still, always fidgeting and distracting others. His mother seemed equally helpless and soon after giving Ali a box on the ear, dragged him away, scolding him harshly.

Four years old Shafia* was known to her parents as a stubborn child. They had started despairing of ever getting her into a reputable school. She could not focus on one thing at a time and appeared to get bored of her toys, alphabets, letters and other educational and play material in less than a few seconds. While her mother tried to coach her in remembering colors and letters, she found she could not do so without hitting her daughter after every few minutes. Ultimately she decided to send her to a preparatory centre for getting admission later in the most elite school in Karachi. The headmistress on the first day said that they had special methods for such stubborn kids but they would have to agree for corporal punishment for their child so the centre could ‘mould’ her properly. Soon enough, the centre also gave up as their methods had only succeeded in developing a fear of studies in the little girl who now quaked at the sight of a pencil and a copy, refusing to touch it at all.

IPP. PN Shifa

Quite often many such cases pass by undiagnosed, where inattention or hyperactivity and impulsivity are the main symptoms. More often than not, they are dismissed as being just kids, or labeled as naughty and punished accordingly. Parents blame teachers for not making the subjects interesting and teachers blame parents for not handling their offspring in a better manner. At the end of it all, it is the child who suffers.

 ADHD or attention deficit hyperactivity disorder is a disorder characterized by a combination of lack of attention with features of hyperactivity and impulsivity. Psychologists use criteria provided in the Diagnostic and Statistical Manual for Mental Disorders (DSM IV TR) to see if a patient fulfils the minimum six symptoms requirement of either inattention or hyperactivity and impulsivity or both. In case the latter is missing, the diagnosis may be of ADD or attention deficit disorder only where a child is able to sit in one place for more than a few minutes but is not able to focus on his work continuously, loses necessary work items frequently, fails to carry out instructions and even fails to listen when spoken to directly. The diagnosis of hyperactivity/impulsivity disorder seems imminent when a child is always on the go, fidgets a lot, is unable to sit when situations demand it and interrupts or intrudes or has difficulty awaiting his turn.

 The ‘cure’ for a child with ADHD does not lie in harsh parenting. Correct diagnosis is the key to more than half the problem. Detailed clinical interviews along with certain pen and paper tests taken from the child and the parents help in diagnosis. Psychologists and remedial teachers alike can provide help through structured programs for parents and children. Exercises and games are conducted with children in individual settings that help them in focusing, reducing impulsivity and gaining a greater degree of control on their actions. Psychiatric help is necessary in establishing a correct dosage of methylphenidate (Ritalin) as the growing child requires medical support to help him focus. Controversy surrounds the idea of drug administration to children yet researches suggest that the benefits far outweigh parental concerns of dependency.

 Psychological help can also be provided in cases of ADHD. In fact many psychologists stress on reducing dependency on drugs and on utilizing a behavior based approach to reduce problem behaviors. In Pakistan, Applied Behavior Analysis or ABA is a relatively new phenomenon. This approach involves utilization of behavior principles such as rewards and different types of plans for focusing on different problems. For e.g. with a child who has a mild level of inattention during class, one of the ABA approaches may be to establish a baseline for the number of times he looks up during his work and then applying a reward system for the swiftness with which he manages to complete his work and then allowing him an early break. Eventually, the premise is that he will be able to develop inner controls and a post intervention analysis will reveal a change in behavior when compared to the baseline.

Institutes such as the Institute of Professional Psychology at Bahria University, Karachi, have initiated the teaching of ABA as a subject in Pakistan. The theses and projects produced by the students here show a strong link between the control of symptoms of ADHD and the application of ABA principles. Young patients are treated at the Institute’s PN Shifa outpatient department using behavior principles and parental guidance sessions are carried alongside to ensure the usage of these at home.

Child's play haven at IPP, PN Shifa, Karachi.

*Names and symptoms have been completely changed and adapted to suit the article. Yet, they are based on true accounts and observations of patients at my workplace.

IPP: Contacts: +92-21-99204889 , +92-21-99205065