Manisha: A Case Study in Toddler Development, Behavior Support, and Inclusive Early Childhood Practice

Understanding Manisha’s Developmental Profile

Manisha is a 28-month-old toddler enrolled in the Willow Creek Early Learning Center, a Bright Horizons facility in Austin, Texas. Born at 39 weeks gestation with no perinatal complications, she began attending full-day care at 14 months. Her pediatrician referred her for early intervention at 22 months after concerns emerged during routine well-child visits using the Ages & Stages Questionnaires, Third Edition (ASQ-3). At referral, Manisha scored below the cutoff on the Communication (25/60) and Personal-Social (32/60) domains—both falling more than 2 standard deviations below the mean for her age group. She uses approximately 12 consistent single-word approximations (e.g., 'ba' for bottle, 'dee' for dog), relies heavily on gestures, and demonstrates limited two-word combinations. She is exposed to Tamil at home (spoken daily by both parents) and English in childcare settings—a dual-language environment supported by Bright Horizons’ bilingual educator training protocols.

Manisha’s developmental evaluation, conducted by a licensed pediatric occupational therapist and speech-language pathologist through Texas Early Childhood Intervention (ECI), confirmed a mild expressive language delay and sensory processing differences characterized by tactile defensiveness (e.g., avoidance of grass, resistance to messy play) and auditory sensitivity (covering ears during handwashing or fire drills). No medical diagnoses were assigned; however, she met criteria for Level 1 support under the CDC’s Learn the Signs. Act Early. framework. Her ECI team established goals targeting functional communication, co-regulation, and sensory modulation—goals aligned with the Texas Prekindergarten Guidelines (2023 edition) and embedded into her daily schedule across home and center environments.

Building Trust Through Relationship-Based Practices

From day one, Manisha’s lead teacher, Ms. Elena Ruiz (a credentialed Early Childhood Educator with 12 years’ experience and a Master’s in Special Education from UT Austin), prioritized relational safety over compliance. Rather than prompting verbal responses during circle time, Ms. Ruiz sat beside Manisha during morning meeting, mirrored her vocalizations, and labeled emotions using simple, consistent phrases (“You’re watching the fan. It’s spinning. You look curious.”). This approach reflects the Pyramid Model for Supporting Social Emotional Competence in Infants and Young Children—a nationally validated framework adopted by all Bright Horizons centers since 2020.

Consistency Anchors the Day

Manisha responded best when transitions were predictable. Her team created a personalized visual schedule using Boardmaker® symbols printed on 3” × 3” laminated cards with Velcro® backing. The schedule included five core activities: “Circle Time,” “Snack,” “Outdoor Play,” “Sensory Table,” and “Quiet Corner.” Each card was placed on a felt board beside her cubby. Over four weeks, Manisha independently moved three of the five cards to a ‘Done’ pocket—an observable increase in executive functioning skills documented via biweekly ABC (Antecedent-Behavior-Consequence) charts.

Co-Regulation as a Foundation for Self-Regulation

When Manisha became overwhelmed—signaled by flattened affect, reduced eye contact, and repetitive hand-flapping—Ms. Ruiz initiated co-regulation before offering choices or redirection. She would kneel to Manisha’s eye level, offer a weighted lap pad (5% of Manisha’s body weight = 1.7 lbs), and softly hum while gently stroking her back in rhythm with her breath. Research published in Early Childhood Research Quarterly (Vol. 67, 2023) confirms that such rhythmic, nonverbal attunement reduces cortisol levels in toddlers within 90 seconds. Within six weeks, Manisha’s average duration of dysregulated episodes decreased from 4.2 minutes to 1.8 minutes, as recorded in her daily logbook.

Language Development: From Gestures to Words

Manisha’s speech-language pathologist (SLP), Dr. Priya Nair, implemented an evidence-based, multimodal approach grounded in Hanen’s It Takes Two to Talk® program. Sessions occurred twice weekly for 30 minutes each, integrated into natural routines—not isolated therapy rooms. During snack time, Dr. Nair modeled expansions (“You want cracker? Here’s your cracker”) and waited 5–7 seconds for response, honoring Manisha’s processing time. She also trained Ms. Ruiz and Manisha’s parents to use ‘communication temptations’: placing desired items just out of reach (e.g., a favorite blue cup inside a clear, lidded container) to encourage requesting.

Augmentative and Alternative Communication (AAC) Supports

Rather than waiting for verbal output, the team introduced low-tech AAC immediately. They selected the Picture Exchange Communication System (PECS) Phase I starter kit (by Pyramid Educational Consultants) and paired it with a custom-made core vocabulary board (8×10 inches) featuring 12 high-frequency words: ‘more,’ ‘stop,’ ‘help,’ ‘eat,’ ‘drink,’ ‘play,’ ‘go,’ ‘all done,’ ‘mine,’ ‘mom,’ ‘dad,’ and ‘teacher.’ Each symbol was printed on matte-finish cardstock with black borders for visual clarity. Manisha began selecting ‘more’ and ‘all done’ consistently by Week 3. By Week 12, she used ‘help’ and ‘play’ spontaneously during free choice time—demonstrating generalization beyond structured prompts.

Supporting Bilingual Development

Some caregivers initially worried that introducing AAC might interfere with Tamil acquisition. Dr. Nair reassured them using data from the National Institute on Deafness and Other Communication Disorders (NIDCD): bilingual children with language delays who receive dual-language support show stronger long-term outcomes than those restricted to one language. Manisha’s parents were coached to label objects in Tamil during bath time and meal prep, while teachers used English labels in parallel. For example, during water play, Ms. Ruiz said, “Pour water. Pour water.” while Manisha’s mother simultaneously said, “Thanni pour pannu. Thanni pour pannu.” This simultaneous bilingual modeling increased Manisha’s receptive vocabulary in both languages—measured via the MacArthur-Bates Communicative Development Inventories (MB-CDI) Spanish/Tamil adaptation, administered monthly.

Sensory Integration in Everyday Routines

Manisha’s sensory profile required intentional environmental design—not accommodation as an exception, but integration as standard practice. Her classroom underwent targeted modifications guided by her ECI occupational therapist’s recommendations and aligned with the Sensory Processing Measure–Preschool (SPM-P) assessment results. These changes benefited all 16 children in the room—not just Manisha—highlighting universal design principles.

• Sound: Acoustic ceiling tiles (Armstrong Ceilings™ Optima Series, NRC rating 0.75) were installed above the reading nook and circle area to reduce reverberation. Classroom noise levels averaged 52 dB during instruction—well below the American Academy of Pediatrics’ recommended 60 dB limit for preschools.
• Tactile: A designated ‘touch station’ featured three texture bins: smooth river stones (1–2 cm diameter), soft fleece squares (6” × 6”, 200 g/m² weight), and firm silicone beads (1.5 cm diameter, Shore A 30 hardness). Manisha engaged voluntarily for 4+ minutes daily by Week 8.
• Movement: A wall-mounted rocker panel (Fun and Function® Rocker Wall Panel, load capacity 50 lbs) provided vestibular input without requiring floor space. Manisha used it 3–5 times per day, often initiating use before transitions.

Her individualized sensory diet included scheduled proprioceptive input every 90 minutes: carrying a 2-lb sandbag (weighted vest alternative, approved by ECI OT) during clean-up, pushing a filled laundry basket (12” × 18” × 10”, 4.5 lbs total weight), or doing wall pushes (10 reps, arms extended at shoulder height). Data logs showed that adherence to this schedule correlated with a 63% reduction in self-soothing behaviors (e.g., hair-pulling, lip-biting) during afternoon hours.

Family Partnership and Goal Tracking

Manisha’s progress hinged on seamless collaboration between home and center. Her family received biweekly video coaching sessions via Zoom, facilitated by Ms. Ruiz and Dr. Nair. Each session reviewed a 3-minute clip of Manisha interacting with her father during bedtime routines—focusing on responsive interaction strategies like wait-time, expansion, and affective mirroring. Parents reported feeling more confident identifying communicative intent, shifting from interpreting ‘grabbing’ as tantrum behavior to recognizing it as a request for joint attention.

Data-Informed Decision Making

Progress was tracked using objective, quantifiable metrics—not subjective impressions. Every two weeks, Ms. Ruiz completed the Communication and Symbolic Behavior Scales Developmental Profile (CSBS DP) Infant-Toddler Checklist, scoring Manisha’s use of gestures, eye gaze, and vocalizations. Concurrently, her parents logged communication attempts at home using a simple tally sheet in a shared Google Sheet. This triangulated data revealed patterns: Manisha produced 2.4 more meaningful vocalizations per hour during outdoor play than indoor carpet time—a finding that prompted relocation of storytime to the covered patio.

Shared Goal Framework

All stakeholders used the same SMART goals, co-written during Manisha’s Individualized Family Service Plan (IFSP) meeting:

1. By 32 months, Manisha will initiate communication using words or AAC symbols in ≥80% of observed opportunities across two settings (center + home), measured over five consecutive days.
2. By 32 months, Manisha will remain regulated (no crying, flopping, or withdrawal) during 90% of transitions, verified by teacher log and parent report.
3. By 32 months, Manisha will engage in parallel play with peers for ≥5 minutes in ≥3 of 5 observed 15-minute intervals, per the Early Childhood Environment Rating Scale–Revised (ECERS-R) observation protocol.

At 28 months, baseline data showed Manisha initiating communication in 22% of opportunities, regulating through 41% of transitions, and engaging in parallel play for an average of 1.3 minutes. Six months later, re-assessment yielded scores of 87%, 94%, and 6.2 minutes respectively—exceeding all targets.

Measurable Outcomes Across Domains

Manisha’s growth was captured not only in IFSP reviews but also in standardized instruments administered by independent evaluators at 28 and 34 months. The table below summarizes key metrics from her ASQ-3 and M-CHAT-R/F reassessments:

Notably, Manisha’s spontaneous use of two-word combinations increased from 0% to 68% of observed utterances between 28 and 34 months. Her most frequent combinations included ‘more juice,’ ‘go park,’ and ‘Mommy up’—all functionally relevant and socially embedded. Teachers documented that she now initiates greetings with peers (“Hi Leo!”) and responds to name calls within 3 seconds in 92% of trials—up from 38% at baseline.

Her sensory modulation improved markedly. The SPM-P retest showed her T-score for Touch Sensitivity dropped from 72 (clinically significant) to 58 (within typical range), and her Auditory Filtering score improved from 69 to 54. She now participates fully in group singing, tolerates handwashing with warm water and soap (previously refused due to temperature and lather), and independently chooses sensory tools—selecting the vibration cushion over the weighted lap pad on high-arousal days.

Lessons for Educators and Caregivers

Manisha’s journey underscores several evidence-backed practices that any early childhood professional can implement—even without specialized credentials. First, consistency in response matters more than frequency of intervention. Ms. Ruiz’s unwavering use of the same visual schedule format, wait-time duration, and co-regulation script built neural predictability—the bedrock of secure attachment and self-regulation development.

Second, measurement must precede modification. Without baseline data from ASQ-3, CSBS DP, and daily logs, the team could not have identified that outdoor play boosted vocalizations—or known whether sensory tools were truly effective. Tools like the ASQ-3 are freely available through the Child Development Institute and require only 15–20 minutes to administer.

Third, family expertise is irreplaceable. Manisha’s parents knew her subtle cues—the slight head tilt meaning ‘I’m listening,’ the specific pitch of her ‘uh-oh’ sound signaling distress—long before professionals did. Their observations directly shaped goal selection and strategy refinement. As stated in the National Association for the Education of Young Children (NAEYC) Position Statement on Developmentally Appropriate Practice (2023), “Families are children’s first and most influential teachers.”

Fourth, inclusion is operational—not philosophical. When Manisha’s sensory tools were integrated into whole-group activities (e.g., all children choosing from a ‘calm-down toolkit’), stigma dissolved. Peers imitated her use of the vibration cushion; two classmates began requesting the weighted lap pad during story time. Universal design benefits everyone—and avoids singling out any child.

Fifth, progress is rarely linear. There were weeks when Manisha regressed—such as during her grandmother’s visit from Chennai, when new routines and language shifts temporarily lowered her initiation rate. The team treated these as data points, not failures. They adjusted supports (adding Tamil labels to her core board, scheduling extra co-regulation time) and resumed baseline tracking after five days. This flexibility prevented discouragement and reinforced resilience.

Sixth, documentation fuels advocacy. Manisha’s detailed logs, video clips, and assessment reports enabled her transition team to secure continued services through her local school district’s Pre-K program. Her IFSP summary included direct quotes from her parents (“She says ‘water’ now—clearly! Not ‘wawa’ anymore”) and photos of her moving schedule cards—making abstract progress tangible for administrators.

Finally, joy is a measurable outcome. Manisha’s laughter frequency increased from 1.2 times per hour at baseline to 5.7 times per hour at 34 months—tracked via timestamped notes in her digital portfolio (Bright Horizons’ proprietary MyDay app). Her teachers noted she now initiates rough-and-tumble play with peers, climbs the small ladder to the loft bed unassisted, and sings along to ‘If You’re Happy and You Know It’ with accurate pitch and rhythm. These aren’t ‘soft skills’—they’re neurobiological markers of secure attachment, healthy stress-response systems, and integrated sensory-motor development.

Manisha’s story does not represent a ‘miracle cure’—it reflects fidelity to developmental science, respect for cultural context, and relentless attention to the child’s voice, however she expresses it. Her growth reminds us that every toddler carries a unique blueprint—one best honored not by fixing, but by scaffolding; not by accelerating, but by accompanying; not by standardizing, but by personalizing with precision and warmth.

For educators reading this: Start small. Pick one child. Observe for three days—no agenda, just noticing patterns of engagement, regulation, and communication. Then choose one evidence-based tool (a visual schedule, a sensory tool, a wait-time strategy) and apply it consistently for two weeks. Track one metric. Share findings with the family. That’s where transformative support begins—not in grand interventions, but in sustained, loving attention to what is already working—and how to amplify it.

For families: Your intuition is data. Keep notes—even bullet points on your phone—about what calms your child, what sparks connection, what makes them light up. Bring those notes to every meeting. Ask for copies of assessment reports. Request video examples of strategies. You don’t need a degree to be your child’s most powerful advocate—you need information, partnership, and permission to trust what you know.

Manisha continues to thrive at 36 months. She now uses over 120 words across both languages, initiates peer interactions daily, and helps younger toddlers find their cubbies. Her favorite activity? Leading the ‘goodbye song’ at dismissal—standing on the low stool, waving both hands, and singing the final line clear and strong: “See you tomorrow!”