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Explore specialized continuing education for speech-language pathologists focusing on school-age stuttering and fluency enhancement techniques. Leading Change in Continuing Education SLP NERDCAST We’re like a conference—in your car, gym, laundry room… wherever! Customer ReviewS Nina was knowledgeable about stuttering and provided the information in a positive, engaging, and informative manner. I walked away with so many tools that I can already start using. Lisa This was everything I needed to hear about fluency and more. Practical information and ready to implement strategies. It was also a non-intimidating introduction to reframing my thinking about fluency and the first step towards unlearning what I learned in grad school over a decade ago. Lauren This course gave me a new perspective on how to treat school-age students with fluency issues!! It's not about a "cure", but about strategies that make communication easier!! Jane Choose the Membership that's Right for You Options that save you time and fit your budget Learn More Basic Unlimited Access to Courses & Content Experts All Access Unlimited Courses, Content Experts, & Therapy Resources Business Great for groups, departments, and organizations Meet Your Instructors Podcast Course: School-Age Stuttering Therapy: I'm So Confused About the Strategies! This course is offered for .1 ASHA CEUs (Introductory Level, Professional Area). "Thank you for making this excellent, research-based learning opportunity that is both extremely accessible and affordable. This is the best kind of PD: it’s one hour at a time so I can learn and then have time to synthesize and apply. It provides information I can apply to my practice immediately; and I can listen and learn while I drive, fold laundry, etc. thanks for the research and resources!" -Johanna H. Get this course and more with an SLP Nerdcast Membership MEMBERSHIP INCLUDES: Unlimited access to 100+ courses for ASHA CEUs: All SLP Nerdcast Memberships get you unlimited access to courses for ASHA CEUs that go in your ASHA Registry and can count towards an ACE Award. Access to conferences, live events and exclusive content All SLP Nerdcast Memberships get access to live events and exclusive content, including two annual conferences, SLP Linked and LEAHP. Unlimited Access to our Resource Library Upgrade to our All Access Membership and get unlimited access to our Resource Library that includes therapy materials, course handouts, and resources you need to save time. Introductory 60 min Offered for .1 ASHA CEU (1 Hour of PD) Podcast Course Watch the course for free below or listen on your favorite podcast player Post-test included in SLP Nerdcast Membership What's Inside: Course & Instructions Podcast Course & Instructions: School-Age Stuttering Therapy: I’m So Confused About the Strategies Post-Test Self Assessment, Course Evaluation, and Feedback Learning Objectives After participating in this session participants will be able to: List 3 techniques for helping children reduce the severity and frequency of stuttering behaviors. Describe how integrating communication skills into stuttering therapy can enhance therapy outcomes List 3 techniques for helping children enhance their observable speech fluency Time Order Agenda: 10 MIN: Introductions and Disclosures 15 MIN: Review of techniques for helping children reduce the severity and frequency of stuttering behaviors 15 MIN: Review of techniques for helping children enhance their observable speech fluency 15 MIN: Review of integrating communication skills into stuttering therapy can enhance therapy outcomes 5 MIN: Closing, Discussion and Questions Course Description: If you’re like me, you left grad school crossing your fingers that you could avoid clinically working with fluency so the world would never know how much you don’t know. Or maybe you’re not like me, and fluency is your jam (thank you!). Either way, this episode has something for every SLP, calling out some really big elephants in the room, including how to avoid bad goal writing that leads to ineffective therapy. Nina Reeves is back with her no-nonsense approach, sharing current, evidence-based intervention strategies to help school-aged children who stutter. If you haven’t already listened, pop back to the previous Nerdcast with Nina to set a strong foundation of principles and attitudes that puts these techniques into perspective. Nina’s got some tough love for you and me, but don’t worry, as Kate assures “Nobody’s hitting anybody with a stick” (it will makes sense when you listen, trust me). There’s plenty of grace, humor, and solid how-to in this info-packed episode as Nina empties your bucket of the “cr@p” and loads it full of fluency intervention gold to start your journey towards comfort, competence, and confidence with students who stutter. Tune in and learn about the nuts and bolts alongside the incredible role of social-emotional experience in effective stuttering intervention. Nina Reeves, M.S. CCC-SLP, BCS-F is a board-certified specialist in fluency disorders and the co-founder of StutteringTherapy Resources, Inc. Summary Written by Tanna Neufeld, MS, CCC-SLP, Contributing Editor Speaker Disclosures Kate Grandbois Financial Disclosures Kate is the owner / founder of Grandbois Therapy + Consulting, LLC and co-founder of SLP Nerdcast. Amy Wonkka Financial Disclosures Amy is an employee of a public school system and co-founder for SLP Nerdcast Nina Reeves Financial Disclosures Author and Co-owner: Stuttering Therapy Resources, Inc. Royalties and Ownership Interest, Intellectual property. Kate Grandbois Non-Financial Disclosures Kate is a member of ASHA, SIG 12, and serves on the AAC Advisory Group for Massachusetts Advocates for Children. She is also a member of the Berkshire Association for Behavior Analysis and Therapy (BABAT), MassABA, the Association for Behavior Analysis International (ABAI) and the corresponding Speech Pathology and Applied Behavior Analysis SIG. Amy Wonkka Non-Financial Disclosures Amy is a member of ASHA, SIG 12, and serves on the AAC Advisory Group for Massachusetts Advocates for Children. Nina Reeves Non-Financial Disclosures Past volunteer for both National Stuttering Association and Stuttering Foundation of America References & Resources Van Riper, C. (1971). The Nature of Stuttering. Englewood Cliffs, NJ: Prentice Hall Van Riper, C. (1973). The treatment of stuttering. Englewood Cliffs, NJ: Prentice Hall. SISSKIN: Avoidance Reduction Therapy (ARTS): https://www.stutteringhelp.org/training/avoidance-reduction-therapy-group-setting https://leader.pubs.asha.org/do/10.1044/avoidance-reduction-therapy-a-success-story/full/ https://www.sisskinstutteringcenter.com/arts Nina Reeves’ Website: www.NinaReeves.com Stuttering Therapy Resources Website: https://www.stutteringtherapyresources.com Stuttering Therapy Resources Online Contacts and Resources: Instagram: https://www.instagram.com/stutteringtherapyresources/ or @stutteringtherapyresources Facebook: https://www.facebook.com/StutteringTherapyResources/ YouTube: https://www.youtube.com/user/StutteringTherapyRes Twitter: https://twitter.com/StutterResource Course Details Where Listen to this course on your favorite podcast player, on our YouTube channel, or using the video above. Course Number ABJE0047 Transcript Available A transcript may be available for this course. Click here to visit our blog and read the transcript. Email ceu@slpnerdcast.com for transcript help or accessibility needs. Available on demand When Course Disclosure Financial and In-Kind support was not provided for this course. Learn more about corporate sponsorship opportunities at www.slpnerdcast.com/corporate-sponsorship Disclaimer The contents of this course are not meant to replace clinical advice. SLP Nerdcast hosts and guests do not endorse specific products or procedures unless otherwise specified. READ MORE COURSE POLICIES Additional Information All certificates of attendance and course completion dates are processed using Coordinated Universal Time (UTC). UTC is 5 hours ahead of Eastern Standard Time (EST) and 8 hours ahead of Pacific Time (PT). If you are using SLP Nerdcast courses to meet a deadline (such as the ASHA Certification Maintenance deadline) please be aware of this time difference. Your certificates and course completion dates will reflect UTC not your personal time zone. Closed captioning and transcripts are available for all courses. If you need additional course accommodations please email ceu@slpnerdcast.com Refunds are not offered for digital products, downloads, or services Certificates of attendance are only awarded to participants who complete course requirements Please email ceu@slpnerdcast.com for course complaints Thank you to our Contributing Editors Episode Summary provided by Tanna Neufeld, MS, CCC-SLP, Contributing Editor Audio File Editing provided by Caitlin Akier, MA, CCC-SLP/L, Contributing Editor Promotional Contribution provided by Paige Biglin, MS, CCC-SLP, Contributing Editor Web Editing provided by Sinead Rogazzo, MS, CCC-SLP, Contributing Editor Nina Reeves, M.S. CCC-SLP, BCS-F, ASHA Fellow Nina Reeves, M.S. CCC-SLP, BCS-F, ASHA Fellow is a board-certified specialist in fluency disorders. Nina is staff fluency specialist for Frisco ISD and fluency specialist consultant for San Diego Unified Schools. Nina is a nationally recognized workshop presenter in the area of fluency disorders and is an author of clinically based materials. She is co-owner of Stuttering Therapy Resources. Nina is a recipient of numerous awards, including the ASH-F Van Hattum Award for outstanding contributions to public schools, and recently was awarded the 2019 ASHA Certificate of Recognition for Special Contributions in Preschool-Grade 12 Education Settings. Kate Grandbois (she/her) & Amy Wonkka (she/her) SLP/BCBA; SLP Kate and Amy are co-founders of SLP Nerdcast. Kate is a dually certified SLP/BCBA who works primarily as an "AAC Specialist". She owns a private practice with a focus on interdisciplinary collaboration, argumentative alternative communication intervention and assessment, and consultation. Amy is an SLP who also works as an "AAC Specialist" in a public school setting. Amy's primary interests are AAC, typical language development, motor speech, phonology, data collection, collaboration, coaching, and communication partner training and support.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Sponsor 1 Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are here today to talk about a topic that is very new to Amy and I, uh, we are here with Neshifa Hudamoman to talk about feeding in the ICU. Welcome [00:02:00]  Neshifa. Hi Kate and Amy. I am so thrilled to be chatting with you guys today. Thank you for having me on. Now Neshifa,  Amy Wonkka:  you are here to discuss early feeding and developmental care in a cardiac ICU, which is. a really specific topic, but as we were discussing before we hit the record button, actually applies to so many of us who are working in the field of speech language pathology. Um, before we get started, can you please tell us a little bit about yourself? Sure.  Nashifa Hooda Momin:  Um, so as you guys mentioned, my name is Nishifa, and I've been a practicing speech I've been a speech language pathologist for about 11 years. I currently work in an acute inpatient children's hospital and work primarily with pediatric feeding and swallowing and pediatric dysphagia. My passion is working with infants and children with congenital heart disease. More specifically, single ventricle physiology, and I work primarily in the cardiac intensive care unit and our step down unit, which is called the CACU. Um, and I recently stepped into a new role as [00:03:00]  an allied health research scientist, so I get to support, um, evidence based practice, quality improvement, and research in my institution. And then finally, I'm wrapping up my doctorate in speech language pathology from MGH Institute of Health Professions. We'll be finishing this August. So super excited about that. Outside of the realm of speech language pathology, I like to run and I like to read. And that's about me.  Kate Grandbois:  So many things. So that's very, that's very exciting. Um, your role sounds really interesting and I feel like I could talk to you for a thousand years about the doctorate, but that's not why we're here.  Let's move on to read our learning objectives and disclosures, and then we will jump right in to learn more about feeding in, uh, infants. Learning objective number one, participants will be able to identify three reasons for the importance of neurodevelopmental care in the cardiac ICU. Learning objective number two, participants will demonstrate the ability to accurately [00:04:00]  identify a minimum of three feeding problems commonly observed in infants with congenital heart disease. Learning objective number three, participants will be able to identify three strategies to improve culture and education on PO feeding in a cardiac unit. Disclosures, Neshifa's financial disclosures, Neshifa Neshifa is an employee of Children's Healthcare of Atlanta. Neshifa also received an honorarium for participating in this course. Nishifa's non financial disclosures, Nishifa has no non financial relationships to disclose. My financial disclosures, I'm Kate, I am the owner of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and I serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy.  Amy Wonkka:  Amy's disclosures. That's me. My financial disclosures are that I'm an employee of a public school system and co [00:05:00]  founder of SLP Nerdcast. And my non financial disclosures are that I am a member of ASHA Special Interest Group 12, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, let's get started. Uh, Neshifa, why don't you start us off just telling us a little bit about congenital heart disease? What What is it? What is the definition? Yeah,  Nashifa Hooda Momin:  absolutely. And I think that's a great place to start because before we dive into neurodevelopment, I think it's good to just understand our foundation. So when we talk about congenital heart disease, it's any type of structural abnormality in the heart that's present at birth. And these defects can widely vary based on their severity and impact in heart function. And the way that I like to Um, categorize them, or the easiest way to think about them is acyanotic defects and cyanotic defects. So when you have an acyanotic defect, it's often an abnormality in the structure, which may be like a hole between the chambers, like the ventricles or the atriums. And, um, some examples of this could be like a [00:06:00]  ventricular septal defect, which is essentially a hole between the two ventricles, or an atrial septal defect, which is a hole between the atriums. And what ends up happening is that, uh, When the blood is being circulated through the heart, what the blood that is already oxygenated goes back from the left side of the heart to the right side of the heart to re oxygenate. So these babies, clinically, will often be, have increased work of breathing, they'll have, um, endurance issues, they may, like I said, they'll have tachypnea. Um, but again, this is one of those things where it's like an inefficient system, um, and once they have surgery, they generally will do well. The other type of defect is a cyanotic defect. And what a cyanotic defect is when you have insufficient oxygenation going to the rest of your body. And this is, this is a little bit more serious, right? And so what ends up happening is that blood that's from the right side, that's not oxygenated yet. It hasn't gone to the lungs. will cross over to the left side and then that blood will get circulated to the rest of the body. So when we see these kids clinically [00:07:00]  before any type of repair, any type of surgical repair, you'll see that these babies often may have like blue fingers and toes because remember that our fingers and toes are the furthest away from our heart. So it's usually a telltale sign like when you see these infants, um, at bedside. Um, and then these kids are often similarly going to have work or breathing issues, endurance issues, um, and then they'll need some type of surgical repair. So congenital heart disease can impact one in 120 in the United States. It's a relatively and actually the most common birth defect that we often see with, um, infants. Kate Grandbois:  Okay. I have a follow up question. I, first of all, I feel like I need a refresher on the structures and function of the heart. Absolutely. , so I want to say something back to you to make sure I've understood it  and I'm going to use a word that prior to this recording, I'm not even sure I could pronounce. Essentially, what you're saying is infants who are born with congenital heart disease can fall generally into two [00:08:00]  categories. One is a cyanotic and the other is cyanotic.  Nashifa Hooda Momin:  Is that  Kate Grandbois:  correct? I'm getting, I'm giving myself all the A pluses for pronunciation. Um, and of, and of those two, of those two categories, the cyanotic category is um, Would you say more severe or has a larger impact on the child's body and oxygenation overall?  Nashifa Hooda Momin:  Absolutely. right on it.  Kate Grandbois:  Hooray. I'm so glad I got it.  Nashifa Hooda Momin:  You brought up a great point. I think we could talk a little bit, just very, very simplistically in terms of blood circulation, right? So when we have blood circulation in our body, we have deoxygenated blood that comes in from our, I'm not going to get too particular. It comes to the, right side of our heart, and it goes into our right atrium, and then it goes into a valve, and then it goes to our right ventricle. From there, it'll go in through, into our pulmonary artery, and then it'll [00:09:00]  go into our lungs to get oxygenated. Then that oxygenated blood will return through our pulmonary vein, and go to the left side of the heart, so now we have oxygenated blood. blood and it'll go to the left atrium through a valve through the left ventricle and then that left ventricle will send it to the aorta for systemic blood flow. So that's why when you have blood that goes from the right to the left side without any oxygenation without it all going to the lungs, um, That's when we can have a cyanotic defect. Now I will say as a disclaimer, it's not that the whole full 100 percent of the blood is going from the right side to the left side with no oxygenation. Um, we could talk more about structural, um, anatomy and that would take us, uh, onto a different path, but I, I, there are mechanisms in place in terms of the structure of the heart to have a little bit of that blood flow going to the lungs. It's not just like a one way street.  Kate Grandbois:  What's amazing about this is that you're a speech pathologist. Yeah, and we are here to talk about speech pathology, and I can't wait to make [00:10:00]  this connection. So, so keep keep going. Tell us more.  Nashifa Hooda Momin:  So, so to then kind of switch into neurodevelopment, right? So we were just talking about cyanotic defects, right? When, think about when the baby is in utero. So when the baby is in utero, the same thing is happening at that point. If they have a cyanotic defect, then oftentimes that blood that is being passed is not all of that is not going to be going to our brain. So when these babies are born, especially with critical CHD, and we can talk about some of the diagnoses that you see as critical CHD being like Tetralogy of Low, Transposition of the Great Artery, Hypoplastic Left Heart Syndrome, Hypoplastic Right Heart Syndrome. Those are more synodic defects. We often see a lot of neurodevelopmental issues. So that's kind of what I wanted to talk a lot about today, is that you know, why is this such a hot topic for infants with congenital heart disease? It's, and it's often because it's something that we're not always thinking about. Um, now I will say a lot of the research and we'll talk through a lot of the research, [00:11:00]  um, is now this is at the forefront. Um, but yeah, is that, yeah, that's, that's just a little bit about, you know, congenital heart disease and neurodevelopment.  Amy Wonkka:  And just, just to go back to the, what you were saying about having a cyanotic, um, form of congenital heart disease and the fact that that is also happening in utero, um, I wonder if you can, and I know you're going to talk about neurodevelopment, but just talk about the importance of oxygen when we're thinking about, um, the development of a brain. Nashifa Hooda Momin:  Yeah, exactly. So imagine, um, well, when, when we'll talk a little bit about this later, when we talk about like neurological insults and whatnot that happened, it perioperatively postoperatively, even what we see preoperatively, but when you aren't getting adequate oxygenation to the brain. That's obviously going to cause changes in your brain function, but also the brain is what controls the rest of our body. So there's just a lot, uh, we need to have a hundred percent oxygenation right now. If we were to go, [00:12:00]  um, to the doctor and they put a pulse ox on us, we would have a hundred percent oxygenation. The cyanotic babies. If we, right after birth, if we were to check their pulse ox, it would not be at 100%. It would be around 75 to 85%. Um, again, it'll depend on the type of structural abnormality, but that's not considered what we would say normal or typical, right? Um, so it's definitely a concern and definitely something that we have to address pretty quickly after they're born.  Kate Grandbois:  And for everyone listening who is kind of, you know, either working in a medical space or even in a school. And thinking this is, you know, the first time that we're the first time that they're hearing about congenital heart disease in its intersection with speech language pathology. You had mentioned before we hit the record button that this is a relatively new field. Is that true?  Nashifa Hooda Momin:  That is true. So that's the interesting thing about it, right? So, um, so much has changed in the field of congenital heart disease and the management of congenital heart disease. So much [00:13:00]  has even changed in, um, how we take care of kids in the ICU. There's been surgical advancements, there's been ICU advancements, there's just knowledge advancements. advancements in congenital heart disease. There's knowledge about neuro development at this point, and so with all of this information with specifically the surgical ICU advancements, the mortality rates among the Children with CHD born with CHD has decreased. But there's a lot At the same cost that we've seen an increase and, um, more neuro, uh, neurological abnormalities and neurodevelopmental impairments. Um, and so we have to remember that yes, cardiac intensive care is life saving. Um, and it's, it's so big for a caregiver who has an infant with congenital heart disease, but it does come with a lot of environmental and tactile stress, um, that is placed on the infant in an ICU setting. And that's why we're talking about neurodevelopment. Amy Wonkka:  And for those of us who haven't been in that environment, either, you know, in our personal life or in our professional life, can you, can you give us just a little window into [00:14:00]  what the cardiac NICU looks like, what that intensive care environment sounds like and looks like?  Nashifa Hooda Momin:  Yeah, absolutely. Um, so it's interesting cause I, um, I guess being in the field for now, I, 11 years, um, and working in the ICU, I have so many new graduate students. Students that when they, um, meet like a medical SLP, they their goal is I want to work in the NICU setting and I think that's fantastic because I, but I think that's because also many people don't know that you can work in a cardiac ICU and it's, um, equally fun, um, at least in my perspective. And so what a cardiac ICU is, essentially we can have babies that are, um, we can have neonates and we can also have full term babies. But it's any baby that, that, specifically in my institution will come to our institution when they likely need some type of intervention, whether that is a surgical intervention in the operating room or whether that could be a cath intervention or whether that's just, Hey, let's bring them in. Let's do a full workup and see if we can [00:15:00]  manage this as an outpatient, um, and then get them home and then bring them back when they're bigger and healthier to do that surgical intervention. But these are the kids that are going to likely need some type of cardiac intervention because Because of their congenital heart defect for me. Um, specifically, I work in an ICU setting and like I mentioned in a step down unit as well. And so A typical day is, um, oftentimes if a baby is transferred over into our unit, we'll all often do like a pre op or pre op feeding before they have any type of surgical intervention. I'll see them post operatively after any type of surgical intervention. And then especially these kids that may require multiple interventions, I'll follow them along and make sure that I'm supporting them in their feeding. Because keep in mind, You know, similar to a NICU baby when they're born, they're gonna need all that support to, to feed, right? But now add that component and then add the surgical component to it with them having surgery quite early on. Um, and it, it is a really stressful environment and they need [00:16:00]  all the support from a speech language pathologist, even a PT and an ot, really like a multidisciplinary team.  Kate Grandbois:  As you're talking, I'm making these frowny faces because I mean, it's just, you know, thinking about these tiny little human beings in this very experiencing this trauma. Um, and, and being in, I don't know, I'm imagining, I'm imagining an ICU. There's bright lights, lots of beeping. I mean, tell us a little bit about what these tiny little humans experience on a day in day out basis.  Nashifa Hooda Momin:  So if you think about, um, in an NICU setting or an ICU setting, specifically the cardiac, um, ICU setting, you have, say the baby is born, right? And say the baby has congenital heart disease. It's a cyanotic defect and say it's a single ventricle, um, defect. That patient is going to require pretty quick intervention and our hospital is not a birthing hospital. So the first thing that's going to happen is the baby is going to be separated from their mom [00:17:00]  quite early on and they're going to come into our ICU setting. At that point, They're going to likely get some type of echo. They're going to get lines placed. Um, they're going to have, um, the medical team is going to come and kind of look at their echo and look at, you know, kind of what their, like the, what their blood work is. Um, oftentimes we may initiate PO feeding, but the first couple of days, especially before any intervention for a high risk infant is pretty chaotic. There's a lot going on. There's a lot of, um, Healthcare providers trying to get in and kind of do their assessments prior to any type of intervention. So I hope that is that answering kind of generally what  Kate Grandbois:  it does and I you know, I'm just thinking about what impact These experiences will have on on the infant, uh, i'm just you know, looking at some of your talking points about about what they experience in terms of procedures, interactions. These are brand new babies been, who have been separated from their moms. I mean, this is like a, this is [00:18:00]  huge. This is very layered.  Nashifa Hooda Momin:  So it's interesting if you look at the, um, European research, um, based NICU studies, specifically NICU, not cardiac ICU. They have found that an infant can have in a day in the hospital can have anywhere between zero to 14 type of procedures. And another study by Cruz and colleagues that was done in 2016, they found that infants in a typical day were having anywhere between seven to 17 procedures. And these would include, um, He'll, um, like a heel touch to get blood, um, nasal endotracheal suctioning, any type of placement of peripheral venous catheters. And so the interesting part about all of this is that once a child reaches that threshold of pain, all non Non painful experiences will be perceived as pain, um, and the infant will often shut down. And interestingly, only 5 percent of the touch in a hospital setting is considered positive. All that 95 percent of the rest of that is considered either medical or, [00:19:00]  uh, or painful.  Just putting it into perspective of kind of like what an infant goes through.  Kate Grandbois:  I have to imagine that this has a massive impact on their nervous system.  Nashifa Hooda Momin:  Mm hmm.  Kate Grandbois:  And I wondered, what does it mean when an infant shuts down? Nashifa Hooda Momin:  So oftentimes you'll see like a baby, well, uh, I see this quite a bit with PO feeding. Um, and PO feeding, I mean by, is per oral specifically, so eating by mouth. Um, if I'm feeding a baby that is generally having like, uh, it's stressful for them. They're tachypneic. Um, it doesn't feel good. Potentially they aspirate or maybe they're just a, a preterm infant and they're just It's super overstimulated. Shutting down will often be that they look sleepy, right? Their eyes will close, they'll kind of disengage. Their body, their body like tone will change. Um, and you kind of, a lot of times it can be perceived as Oh, they got sleepy, right? Um, but they really truly just shut down. They're like, they can't take anymore. And so you'll see this kind of like, um, stagnant or no response. Um, and, and [00:20:00]  not in a. serious way, but in a way of like, Hey, I'm not going to engage in this activity. I'm not going to engage in this for the next step. I'm not going to PO feed. And so a lot of times, um, you'll often see that. And I feel like, I mean, outside of the world of NICU and babies, I think we're similar in the same way, right? When we're overstimulated to some level, we like to back down our nervous system. Well, like wants to get that. And so I, I, it makes sense, right?  Amy Wonkka:  Yeah. Sort of just having that self preservation mechanism to just be like, this is too much. Yeah. I've got to take a little break here. Yeah. Yeah. Yeah. In your talking points, you also had some information just about brain volume. And so thinking, thinking about all the things, right, thinking about the oxygenation piece that we talked about earlier with the cyanotic babies, thinking about nutrition and how much it might just be a struggle to get adequate nutrition. All of those things together are obviously important for development. Um, yeah. [00:21:00]  Can you talk to us just a little bit  Nashifa Hooda Momin:  about that piece? Absolutely. Um, so interestingly, there was a study done by Scotting in 2021, and they found that infants with CHD had smaller brain volumes than a typically developing infant. So what they looked at specifically was 10 infants with the postmenstrual age of, uh, 39 to 54 weeks, and then they compared it, um, and those were the typically developing infants with, um, 10 infants with CHD, um, and what they ended up finding was that the infants with CHD had a smaller, had smaller brain volumes, and so some of the inclusion inclusion criteria. And what I mean by, um, inclusion is that what types of infants we're talking about with CHD. These were the more critical CHD, so Tetralogy of Fallot, Transposition of the Great Arteries, Coarctation uh, uh, Hypoplastic Left Heart Ventricle, Hypoplastic Right, um, Ventricle. So again, are more, uh, critical CHD. And then in another study, um, by Litsch et al. in 2009, They also looked at infants [00:22:00]  with critical LCHD, and they looked at 29 infants with hypoplastic left heart syndrome and 13 with transposition of the great arteries. And they found a one month structural difference in brain development. And so then what does that mean? Right? And so I, I always, I love the study because it really puts into perspective as a healthcare provider on how, what does it mean? How do I, what do I take with this information? Right? So an infant, imagine an infant born at 38 weeks with hypoplastic left heart syndrome, their brain is going to be similar to that of a 34 weeker, right? So to take that one step further, how do you suppose that the infant's development and maturation is at that stage? Given that it says 38 weeks versus what our perception and actual development support the infant is actually getting, um, and so when we think about just to kind of think about in utero development and the milestones that the baby is kind of achieving in gestation around 34, um, To 36 weeks is when that non [00:23:00]  neutral to suck on a pacifier really matures. And that sucks while a breed coordination for PO feeding that matures around 37 to 44 weeks. So now if we add that layer on, then what, what are we, what are we expecting from the baby versus what? We should be expecting from the baby. Um, so I, I like to talk about this because it puts into perspective how we, when we work with this particular population, we really kind of have to take a step back, look at what their existing research. We have to look at the patient in general. We have to look at their cues. We have to put it all together before we just have these like unrealistic expectations and almost like push the baby too hard. And we're kind of heading in that wrong direction neurodevelopmentally. Kate Grandbois:  And I know we're going to get to this at some point, but I can't, I can't help but think about the long term implications of all of this across all the variables we've talked about the trauma and separation from the mom at birth, the lack of nutrition or risk of lower nutrition, the neurodevelopmental [00:24:00]  changes. I, I wonder if maybe this is a dumb question, but Are there guidelines for adjusted age when you're talking about brain volume like we do for preemies?  Nashifa Hooda Momin:  No, because I don't think it's consistent across all babies with CHD, right? I think, um, and I think this is still something that we're learning more and more. I think in general, we can all agree that infants with cyanotic lesions are just at a higher risk because we know in utero, they were also not getting the best oxygenation, right? But. Um, I don't think there's any guidelines in specific to be like, Hey, these particular infants, we're going to do it this way. I think in general, we know that critical CHD is just a higher risk population. Um, but it's interesting because, um, another point that I kind of wanted to bring up is really when we think about these kids and we think about, we were talking about interventions when a baby goes to, um, has any type of intervention, they get put on maybe Bypass, for [00:25:00]  example, cardiopulmonary bypass. And a lot of times as speech language pathologists, and I'll say I'm guilty of this, like, our assumption is that, oh, well, you know, now that we're kind of going under cardiopulmonary bypass, and then they're likely going to have any type of neurological insult on top of everything that's going on, and post operatively, we might see an insult. But interestingly, one thing that I also found, um, interesting about our specific population is that, um, There's actually preoperative concerns as well, like we've been talking about, right? And so in a study that they looked at in 2019, they looked at 70 newborn infants with critical or serious CHD, and they did an MRI prior to surgery. And what they ended up finding was that 39 percent had some type of cerebral lesions, with white matter injury being the most prominent lesion. Um, and there were a few cases of arterial ischemic stroke. And so again, like, why am I bringing this up? Because I think when we think about neurological insults with populations in general, with babies or adults, we always tend to think [00:26:00]  about, you know, During surgery, like perioperatively and postoperatively, and oftentimes we're not even thinking preoperatively. Um, and I, I can say that I've done that myself, and I still do, because I think it's when you don't see it, when you can't visualize, um, something, then it's hard for us to, like, take that into consideration.  Kate Grandbois:  And I have to assume, just as a clinician, Your consideration of where the patient is at baseline is a really important component of the interventions you choose post op, right? And what you're talking about is, is evidence related to what that baseline looks like in terms of potential lesions or, or other, of all the things, all the exposures, all of the, you know, traumatic experiences that this tiny little baby has gone through.  Nashifa Hooda Momin:  Yeah, absolutely. And we really, as a clinician, like you mentioned, we have to look at the whole continuum. We have to look at them [00:27:00]  from intrinsically when the baby was in utero. We have to look at it preoperatively, how clinically they present. perioperatively, postoperatively, and then to take it one step further, we also have to think about outpatient. I think one of the areas where I feel like the disconnect often happens is between a hospital setting and an outpatient because as a healthcare provider, I, and I'm, I'm trying to be better about this, but like, how do we make sure that caregivers realize that this is something that we need to be thinking about even as they get home? And even if the, the CHD may be repaired, That there are some other considerations we have to continue to think about and then how do we make sure that they get plugged into outpatient and they take it seriously because again, when you can't visualize something, it's hard to take it seriously. Sometimes it's hard to think about like, okay, well, you know, I had my Heart defect is done. And now, you know, the speech therapist might be saying or the, um, the healthcare provider is saying that I need to do all this outpatient testing and yada, yada, yada. And I have to go to the cardiologist appointment and I have a PCP appointment. I have three [00:28:00]  other kids. Like it sometimes becomes less important, but I think we have to emphasize the importance of it because there are, uh, considerations we need to be thinking as, as they, as these children start to grow. And to, to that point, um, the American Academy of Pediatrics found that infants who needed heart surgery, specifically cyanotic lesions, um, and those cyanotic lesions that had comorbidities such as prematurity or prolonged hospitalization were at a higher risk for developmental disabilities. And there's also research showing that, um, The more critical the CHD, the more, um, sorry, the more severe the cognitive impairment that we may, we may see with this particular populations and so a lot of these challenges that we see these in the challenges that these infants have won't often be seen. Um, and I think that's a of times kids are being seen or teased out to school age. And so is it? Is it that they develop in school age? Or is it just that they were missed until that moment, right? And I think it's because I think they're just missed until that moment because the child isn't going to be pushed. [00:29:00]   In a school setting until their school age, right? They may it may. They may just make it right by they may. It may not be concerned concern, but some of the challenges that we often see is exactly that. Decade of function challenges, attention, fine motor and gross motor, academic struggles and behavioral issues. But again, it's not that these issues just, you know, showed up at the age of five or six. I think it's just the fact that nothing, nobody was like really testing 'em. They might not have been pushed until they were integrated into a school setting.  Kate Grandbois:  So I am wondering now that I know this is a relatively new field, and it sounds like there's a lot of emerging evidence or a lot of, you know, in the last few years, a lot of evidence that these kids, these babies are at higher risk, are there any standard screening procedures in place or standard screening Um, protocols in place to catch some of these deficits so that we can provide the critical period of early [00:30:00]  intervention. Nashifa Hooda Momin:  Yeah, so, um, I can't speak 100 percent to how other institutions are doing this, but I will say at our institution, we do have a neuropsychologist who, um, will try to plug them in with the, with her, um, and she will often do these assessments, uh, to kind of see where they are in terms of, in terms of neuropsych, and she follows them up to the age of two, and I know she's looking specifically at our more high risk population again, um, but I think it's something that truly is needed everywhere. And I'm, I'm hoping that as we, you know, we're learning about all of this and I, I hope this then becomes like regular standard care practice for a lot of our critical CHD babies.  Amy Wonkka:  So, I mean, I don't want to lose the, the, the piece about this is life saving care for so many of these infants. So even though it is, you know, in a stressful environment and they're experiencing challenges and they may experience prolonged challenges, it's also, um, [00:31:00]  It's also potentially it's life saving. Um, are there, are there any, um, strategies or is there any research around things that can be done when they're still in the NICU or in the step down unit, um, that might just help facilitate  Nashifa Hooda Momin:  positive outcomes? Yeah. And I think that's a great point. So that's the thing, like we've talked about all this research, right? So then what, we know all of this, what are we doing about it? Right. So interestingly, there is now research about looking at neurodevelopment in CHD. And what they found is they thought there was a study by Peterson or a paper by Peterson in 2018. Um, and some of the strategies they talked about for specifically for our CHD babies that do kind of overlap with our NICU population is massage, uh, skin to skin kangaroo care, which, um, again, that's definitely something that we use in the NICU, developmentally supportive positioning. Now, um, I want to say this is more specific to, you know, when the patient is intubated or that when the [00:32:00]  patient is in ECMO, like, we can still do developmentally supportive positioning in these critical time periods. Q based feeding and PO feeding, and I'm, we'll talk a little bit about the importance of PO feeding and the PO feeding project that we did at our institution, pain management and procedural support, and what I mean by that is that We don't want to over sedate our population because then we're missing these developmental critical windows where we need to be involved and working with this particular population. Um, so yeah, that's kind of like what's going on currently.  Kate Grandbois:  I have to assume, I have to assume that there is a lot of coordination of care that is happening to be able to provide the supports that we know are going to try and counterbalance all of the negative experiences. So everything from educating other staff members, collaborating with parents, you've already mentioned collaborating with a neuropsych for follow up. This has to, I guess All of that collaboration really has to be built [00:33:00]  upon some foundation of infrastructure within your within your workplace. And I have to imagine that if that's not there, all of these pieces are not going to be executed well. Nashifa Hooda Momin:  Yes. So I agree. And I think that one of the great things I feel like at least what I at least what I feel at our institution, everyone there wants to be there. Everybody is so, uh, eager to support these infants, and I think that's what's making that difference. And I, and this isn't, this is, I'm sure, all across the United States, like, when you work with this particular population, you are passionate about change, you're passionate about patient outcomes. But at our, um, institution, there's a couple things that we're doing, um, structure, or like, I, I don't know if it's structurally, I don't know if that's the word, um, that we're doing, um, to help support neurodevelopmental care. One of them is, uh, neurodevelopmental rounds. And so neurodevelopmental rounds, it was actually created by our child psychologist. And, um, what it is is it's a what it's once a week rounds and we round on four patients. So about four patients for the hour. It has a [00:34:00]  physician champion. The primary nurse for that patient will be on the rounds. And then our rehabilitation staff, PT, OT, and speech will be in rounds. Um, This is currently being revamped with like, you know, COVID obviously kind of shifted a lot of things, but we're kind of revamping it at this point. But what we're talking about is these are the patients that often, um, we're not, we want to bring neurodevelopment into the lens, right? So we're like, Hey, This patient is a high risk patient that is going to be here for a long period of time because they're waiting for a heart, um, and, or this patient has a VAD and they're going to, they're waiting for a heart, or this patient is a single ventricle baby who is too, uh, fragile to go home, so they're going to stay here in the interstage period, or this patient sustains some type of neurological insult and they're going to be in this institution for a period of time. At that point, And it really at any point when the patient is there, we have to start thinking about development, right? Is the patient getting tummy time? Are we doing cycled lighting? Are we doing the things that you would be doing in a home setting that [00:35:00]  we don't do in a hospital setting? Because it is important for brain development. We know that if we took CHD in hospital out, we know there's all this research that this, these are the things that we need to be working on in a, for a typically developing infant. But sometimes that gets put on the back burner. And so we're trying to bring light to that when they're inpatient. Um, The second thing we have is a neuroprotective care council. Um, It was created in 2018. It's supported by a physician champion and the team includes a PTOT speech, a pediatric psychologist, um, and nursing. And we have quarterly meetings and quarterly goals. And so some of the things that we've worked on so far that have been, um, super interesting have been mobilizing patients. And I mean, intubated patients, intubated babies, like getting them out of the bed into the mom's arms for skin care. kangaroo care. And we've had kangaroo thons, um, neonatal temp management. So thinking about the importance of temp management, because that can really change our vitals and put the baby in a crisis, uh, promoting oral feeding. We'll [00:36:00]  talk more about that. And then, um, incorporating parent feedback into our practice. Cause what are we, if we aren't really putting the parent Um, giving them a chair, a seat at the table. Sorry, I said that wrong, a seat at the table. Um, because it is important. At the end of it, we can think we're doing all the right things, but we have to have that perspective from the caregiver as well. Amy Wonkka:  Can you talk to us a little bit more about the feeding piece? Just how many, how many of the babies in general are able to do PO feeds when they come to you? And what does that process look like as you're working with them over a prolonged period of time? Sure.  Nashifa Hooda Momin:  Yeah, absolutely. So, um, if we, if the patient comes to the hospital, um, and they are medically stable, we are going to try to PO feed the baby, uh, preoperatively. The only thing I would say we're probably not going to PO feed is if they're intubated, obviously. And, um, if they are, um, on ECMO or something, if they're really, truly stable. There is not an option to PO feed. Otherwise, we're going to have [00:37:00]  some type of involvement, whether that would be, um, offering a pacifier, pacifier dips or oral feeding, and we will try to oral feed as much as we can, and as, um, when the medical team says, says we get clearance for them. Um, so the project that we did to kind of emphasize this PO feeding was, um, in 2019, we had done an internal survey with our CICU nurses. Um. Just about neurodevelopmental care and interestingly, the knowledge deficit we found was all around feeding. Um, it was about how to feed a baby, like what position to use. There's so many nipples, what's appropriate. Um, what is like the speech therapist is always talking about signs of aspiration. What is the sign of aspiration? Like how, what feeding, feeding related deficits, right? Um, knowledge deficit. Um, so the purpose of our project really was to get CICU nurses, uh, you know, give them the strategies and kind of. address this deficit. Um, and so I will say it's so important because as [00:38:00]  a speech language pathologist, yes, if we're consulted, I'll go feed the patient, but I'm not feeding the patient around the clock. I'm not there at night. And so the nurses really, truly are the core of promoting feeding in a unit. Um, so knowing that is important. So what we ended up doing is two speech language pathologists, one of them being me, myself, um, educated two nurses that were our nurse champions for PO feeding. And then all four of us together kind of came up with, well, had this project. So two nurses, um, and specifically were kind of like the support when the nurses had any questions. And then as the speech language pathologist, we were involved in doing didactic teaching with the nurses and new nurses, and then also doing hands on teaching. So the purpose of the project was to educate CICU nurses on the strategies of bottle feeding, given the knowledge deficit, and the way that we set this up was that we had To speak to speech language pathologists that were primarily in the cardiac units, and we worked with two nurses that then became our P. O. Champions, [00:39:00]  and we educated them on strategies and everything that we would be telling the nurses. And then the speech language pathologist worked on a two part system. One was doing didactic education to the nurses. Um, and then the second part was a hands on course or hands on practice. So So the didactic part was where the nurses would come and new nurses would be on board and it was part of their onboarding education. They would meet with a speech language pathologist and we would talk about topics like CHD and medical complications, feeding difficulties in infants with CHD. Like what are, what do we anticipate with this particular population? What are the feeding strategies? When to appropriately use these strategies? And this included positioning the different types of nipples in the, um, in our system. the use of pacing, and then we talked about the importance of developmentally, developmental feeding, and signs of aspiration. Then, they had two to four weeks where they would be clinically practicing in the ICU or step down unit, and then we would meet again for hands on practice. And the reason I loved this kind of model was [00:40:00]  because they got to take the didactic teaching and apply it and then see if What, what wasn't making sense or where they needed more clarification. And then the hands on practice, they would come with the speech language pathologist and observe us feeding, like, two to three patients for an hour. Um, and then they would ask questions, and we would kind of have this, like, open dialogue of, Hey, like, this, I have a question about this nipple. Why did you do this? And it was great because I felt like you got the, the didactic education, then you have a little bit of hands on practice and you can fill in all the holes in the, in, in between. Um, and so. With that, the nurses that I mentioned that were educated, they were also there to support these nurses when we weren't even around. So, like, say you're clinically seeing a patient as a nurse, and then you're feeding a patient, and you're obviously not able to get the speech language pathologist. Obviously, we always tell them, call us if you have any questions. But say they see the PO Champion nurse, they can easily go to them and be like, hey, I have a question about this. And so there's a little bit of that support in the unit as well. And so what we ended up finding is that nurses [00:41:00]  reported an increased confidence in their ability to recognize early signs of aspiration and feel empowered to reach out to speech language pathologists. And we saw, um, an increase in speech consults within that unit, as well as appropriate use of swallow studies with that particular population. And then some other wins that we saw was that we kind of changed a little bit of that culture that I had mentioned in one of my learning objectives, and that we changed the supply. So in our unit, Previously we had standard flow nipples and slow flow nipples and realistically with our population and with the amount of infants that we see, we really weren't using standard flow nipples and having an inappropriate nipple for these for this population ends up causing the safety issue because what if you are unaware, then you're just going to grab it and use it. And we really didn't need that. Right. So we ended up Switching, taking the standard flow nipples out and then replacing them with preemie or extra slow flow nipples because that's usually our go to for this population. Um, we continued this [00:42:00]  education model where now every nurse that enters, um, into the ICU units has this like, um, hands on teaching or has the didactic teaching and the hands on with speech language pathologists. And this started a long time ago and we're still doing this. And, um, we've started, we've created some more feeding guidelines so that We're promoting PO feeding in our units and including collaboration with our providers. And then now we also have automatic orders for all infants under three months. And we're actually expanding that hopefully soon to include maybe up to six months or even up to a year. Um, so there's been a lot of wins out of this project. Um, Yeah, that's a little bit about the PO feeding project.  Amy Wonkka:  That sounds awesome. It does sound awesome on multiple levels. I think it's great that you incorporated like multiple stakeholders into the initial planning with the two champion nurses. Um, but then I feel like also just the fact that it was ongoing and multilayered, uh, how big were your trainings usually? How many nurses are you training at once?  Nashifa Hooda Momin:  So back, [00:43:00]  uh, like I guess a while ago, we would have about 10 to 15, but, um, our, we are transitioning to a new hospital. So recently we've had 15, 20 nurses at a time now. Um, and we've been doing them quite frequently, but yeah, this, it, I think it could vary. Sometimes we've had like five and sometimes we've had more. It just depends on who's being onboarded into our system.  Kate Grandbois:  It sounds like a tremendous win. I know you use the word win a couple of times, but just to not only make other stakeholders feel empowered and confident, but engaged and also elevate the evidence based practice in your, in the whole, within that department, within that unit, that is a tremendous win. That's a tremendous success. Um, and I am hoping that anyone listening who is working, maybe not even in a similar workplace environment, takes away those suggestions for how to really elevate and shift [00:44:00]  culture if you see need for improvement across some implementation from evidence based practice. I just, I think that's a really wonderful example of how we can, as speech pathologists, implement change. shift our workplace culture to better embrace EBP. And then hopefully the outcome of that is elevated outcomes, better outcomes for our patients. Cause that's the whole point, right?  Nashifa Hooda Momin:  Yeah. And I will say with this pro, uh, project, we have seen a dramatic increase in P. U. Pio feeding since 2016, specifically with their single ventricle population. And I feel like it's important to say that because that's our critical population, right? So we've shifted the culture in the unit, but we've also shifted our mindset that we can do this with our, with our critical CHD patients. And then it also kind of highlights how it's not just like a lot of times when we think about like our speech pathologists or OTs are doing beating, but that's not really the case at the end of it. Our caregivers need to be empowered, [00:45:00]  our nurses need to be empowered. We all have to have that same goal. Um, and I will say one of the things that I reiterate to caregivers, nurses, and to anyone that really is in the, in cardiac is that when you have a baby, what the common things that a baby does is they poop, they sleep, and they eat. And when you're in a critical environment like the CICU or a step down unit, especially as a caregiver, you don't have that much control. What if we were to empower you? What if we could give you a little bit of that control back and let you P. O. feed and have a little bit of that Normalcy., right?  Um, so I think it's, it's. I, I think there's a lot of interest around this. I think that, and I think that's why it was so successful because everybody wants to support this population, nurses, physicians, um, caregivers, speech language pathologists, OTs, PTs, the neurodevelopmental care team, like everybody is invested. And I think that's why we got to see this change. So it was cool. Like you mentioned, stakeholder, having stakeholder buy in is extremely important. [00:46:00]   Kate Grandbois:  I wonder if you could talk to us a little bit about the parents, because as all of this is happening, You know, and you've talked a lot about the importance of forward thinking, uh, developmental impact, discharge, carryover. The parents are going to be the ones doing all of that. Not only that, but many of these parents may be experiencing trauma of their own. You know, being separated from their babies, complicated, perhaps they, the mother experienced a complicated birth, perhaps, et cetera, et cetera. I wonder if you could talk to us about what the role is of the speech pathologist in terms of supporting the parents and centering the parents throughout this experience. Nashifa Hooda Momin:  Yeah, absolutely. So as a speech language pathologist, um, when we get to bedside and are working with this particular population, oftentimes maybe the first, it depends really, Previously I would say that the first feed was always done by the speech language pathologist, but ever since I've [00:47:00]  become a mom, I've realized that's a big thing, right? That's a huge thing to take away from somebody. Um, and so I will do my very, very best if I can, if the caregiver is there to try to, if, And if they're interested in doing the oral feed to support them to do the oral feed now, I will be probably all over them and helping them position and kind of holding the bottle and like hands on with the parent. But I, I think that that's where it starts. That's where our relationship will usually start. And then usually after the 1st or 2nd feed. It is really like, hey, like, if the caregiver is there, I want you to feed and I will support. I will, you know, usually be crouched on my knees or, um, hovering over the parent, feeling for signs of aspiration, watching the vitals, like explaining and providing strategies, maybe some hand over hand, like, hey, we're going to pace the baby now. Hey, let's remove the bottle. Cause I see this, but really our relationship starts really early on. from the beginning. It's, hey, let's empower you to do this because the great part about this and usually how I end sessions is, hey, I'm, [00:48:00]  you know, we're, it was great working together and, you know, we were going to change the plan this way, but I want you to know, you know, I'm here and this happened this way, but I can guarantee you, it's not always going to happen this way. So when I come back tomorrow, I want you to tell me like everything that happened, how much they ate. You know, where you struggle, what came up, um, if it like, what questions you have, because you have to let that marinate a little bit. And then let's, let's just keep this going. And the great part about that is that by the time they get ready for discharge, I feel like they are pretty confident about feeding their infant. Oftentimes I think it, like it shifts, right? They're like, no, like, I know you're saying that this is happening, but I feel this way. And a lot of times I'm like, you know, your baby and I believe you, right? Like, um, And so I do think that that's a huge thing is empowering the, of the, the caregiver. But the other thing about just the caregiver in a, um, in working with an infant with CHD and thinking about neuroprotective care is we, something that was really eye opening for me was that we, when one of our neuroprotective care [00:49:00]  meetings, we had a parent who came and spoke about, their experience. Um, and I will say that this, um, mom, their child, she took her child home on palliative care and the patient ended up passing away, but she came and kind of talked to the neuroprotective care team about just kind of her experience and what was considered normal in the ICU and what was considered normal in the CACU unit, right? And it was so eye opening to see, like. There's, there's a lot that a caregiver is going through that we often just don't really process. Um, and so I think after kind of hearing that perspective, it's really just emphasize that we have to have to have to have a caregiver at the center of the care, right? We have to put bring the caregiver in. We have to get their perspectives, because one, we get a holistic understanding of the patient's needs. There's more patient advocacy, because remember, we're not always there, right? The caregiver may be there watching what's going on with the patient and can advocate for, hey, like, I'm noticing every time they feed, they have a [00:50:00]  desaturation event. I know you're saying there's no clinical signs of aspiration, but why does this happen, right? Um, it could be, like, thinking about enhanced parent care management. And then another huge thing is, like, you have to start thinking about the social determinants of health for the patient. So when the patient goes home, is the plan that we're recommending feasible? If we're recommending follow up every week, um, They live two hours away, they have, they rely on Medicaid transport, or say there's only one car with eight people in the house, is it feasible? What if we're recommending thickening, right? Is it, in, in, in terms of financially, like, that might not be an option. So, really, really, really, we have to have these, like, ongoing conversations with a caregiver to make sure that the plans that we're recommending are feasible and we're understanding what their perspective truly is. And then like I mentioned empowerment and then, um, I think all of this truly fosters a collaborative environment. So yeah, that's, that's kind of my little tidbit on the importance of having a caregiver in involved in care.  Kate Grandbois:  I also wanted to ask [00:51:00]  just in that same, through that same lens, what role counseling plays in all of this? Because in your first few days of supporting a parent, I have to assume that there has to be counseling has to be at the forefront to just kind of make space for their experience everything from their own healing if they gave birth to fear for their baby's life to I mean, there are some really big emotions in that room. And I have to assume that if you go in with, Well, we're going to use the slow flow nipple and this is how you pace a baby like none of that's going to land because of all of the stress and, and all just all those feelings. What can you tell us about the role of counseling in these, in these environments? Nashifa Hooda Momin:  Absolutely. Um, I think that it's as a speech language pathologist, it's a skill that you definitely need. Um, and it's something that you learn that kind of reading the moment, right? There's been times where I've come in, [00:52:00]  um, in communicating with the team, right? So I've come in after the nurses told me that they've gotten some news, perhaps that there's like, uh, confirmed genetic involvement on top of their speech. And then I'm supposed to feed this baby and sometimes you just have to gauge like, is it an appropriate time or do I just need to have a moment to be there for the caregiver? Or do I need to reschedule? Do I need to take a moment and let them have their moment before I come in saying, Hey, let's feed your baby. Let's do XYZ. So I think it's a huge skill for the speech language pathologist to have. Um, there's been times I will say that I've had to completely pivot my session and just, um, Just talk, talk to the caregiver and just listen, just listen, right? Um, and then come back at a different time and do therapy, because I think that it's important for them to have their moment and to express how they're feeling. The second thing I'll say that I'm super thankful about is having social services, like social services with this particular population is involved very, very early on and they are incredible. Um, and so a lot of times. There's things that might come out during [00:53:00]  my session, uh, that may, may not be, like, public knowledge, and a lot of times I'll, like, can, can, uh, communicate with the, you know, the caregiver that, hey, is it okay if I pass this along? It seems like you're dealing with a lot here, and I can easily pull in social work and fill them in on what I know, but a lot of times they already know because they're excellent at their job, uh, but it is a huge, like you said, it's very, uh, emotional, and, you know, We need to have that support there. And I do believe that we try really hard to make sure that caregivers are getting that support. Now, do I think that there's no room for improvement? No, I think there's always going to be room for improvement. It's just a high risk population that needs a lot.  Amy Wonkka:  So at some point, um, hopefully the treatment has gone successfully. And the babies are going to be discharged. What does that, what does that process look like for you as a speech language pathologist? What does that look like for the families? What might that look like for if the baby's going to need to continue receiving some sort of outpatient services? Can you just talk us through that [00:54:00]  process  Nashifa Hooda Momin:  a little bit? Absolutely. Um, so it can vary depending on the patient. So if we have a patient that is doing well, PO feeding, maybe it's an asianotic defect. Maybe they were the kid that, um, got diagnosed at birth and then went home and just had, you know, cuddles and love and, um, and then like required the surgical intervention. And then they come to the, they come to get their surgical intervention, intervention. They meet the medical team and speech language pathology and rehab. And Um, maybe for them, it could be as easy as just, Hey, like, we're going to recommend outpatient services should you need it, but you're fully PO feeding, you're doing fantastic. Um, and then, you know, giving that information and they may just go, go home. I think general practice for most of us as rehab is to make sure that you still have plugged in, even if you may not need it, because you never know what's going to happen, right? But then if you have the example of a cyanotic baby who is likely going to require more support, I [00:55:00]  may or may not, but I would imagine so, um, like I said, standard practices that we're going to try to get them plugged into all different types of therapy, outpatient, PT, OT, and speech. Um, and then the other component of that is like, say you have a family, like we talked a little bit about the social determinants of health. Like we're not. They're not going to be able to attend these appointments. It's going to be a lot. They need to have service at home. Well, social work and, um, has a way, uh, for at least in Georgia, it's called babies can't wait. And I'm sure it's different for every, um, state, but essentially it's a way for therapy to be in the home setting. I will say it's a great option. Um, it does, it just depends on the availability of a, of a therapist that can go and, um, See these patients at home. So that's definitely something to consider. But I will say that having therapy is having therapy and versus not having therapy, right? Especially when you need it. And we have to think about what's feasible for the caregivers. Um, and then you can also have the super critical [00:56:00]  infants with a single ventricle physiology. who require three different pallet palliation surgeries. Um, and that particular population, we do set up outpatient, but we have a dedicated single ventricle clinic, um, where we'll be following up with them outpatient as well. So there are a couple of things that are in place, but it does, I will say that it's, it's a lot to consider because PCP, right? Your pediatrician, you're still going to have outpatient services. Um, You're probably going to have, like, a cardiology follow up appointment, um, and then if you're more critical, you may require more, more things, right? Um, it is a lot on the caregiver, so it's, it's, we always want to make sure that it's feasible, so we try to provide options and try to see where the caregiver is and what their, um, needs are and try to meet those needs. Amy Wonkka:  And in terms of the babies who have more complex feeding needs, do you typically get enough opportunities while the baby is in your NICU or in [00:57:00]  your step down unit to work with the families to where they're feeling comfortable with the feeding before they go home?  Nashifa Hooda Momin:  Yeah, so oftentimes it, I will say that it does depend if you have a critical CHD baby, like someone with single ventricle physiology, those patients, I do feel like generally we get a little bit more time because they're a little bit high risk and we're not going to discharge them right away. Um, so I do get that time. Does that mean that they all go home full PO feeding? No. And so a lot of times. These kids may go home with enteral support, like an NG tube and maybe taking some by mouth, um, and not in general, just in CHD in general, that could be the case, that could be the case for a cyanotic lesion as well, where we worked on it, um, we weren't able to get to full PO feeding because perhaps there's a genetic comorbidity, and so they may be going home with enteral support, um, and then with the goal of hopefully getting to full PO feeds. Kate Grandbois:  You've shared so much information with us today and I, I feel smarter [00:58:00]  and I, I, I, I mean, I'm serious. There's been so much that's been new to me personally. One of my takeaways from this conversation is that this relatively new field, even though the vast majority of the field of speech pathology in general does not work in a cardiac ICU, it sounds like this has implications for all of us, especially for You know, working in early intervention, um, in all of pediatrics, looking at that medical history, being a little bit more aware of the long term impact of a congenital heart defect. Um, I wonder if there's anything else that you'd like to share with our audience that we haven't gone over yet. Nashifa Hooda Momin:  Yeah, I think one, one thing I'll say as a speech language pathologist is that I love how we all can do such different things and then take different parts of our lives to do other things and learn about it. I will say if you're in the world of, um, I guess in a hospital setting, um, I feel like you probably can echo this, but it's so [00:59:00]  important for multidisciplinary communication, um, and collaboration with this particular pop, especially this particular population. I will say that I practicing for 11 years and I say this all the time and, uh, learning. I love learning and there you're always going to learn and always keep yourself open minded to opportunities to knowledge. Um, and. You know, there's there's no end. And I think that's the one fantastic thing about speech is that even being in my doctorate program right now, um, that I've had the opportunity to meet such different speech language pathologist with vast knowledge on different areas that I have no idea about. And it's. It's so interesting to just collaborate and learn from them because I think there's still so much overlap between us, right? Like you, uh, you guys all mentioned when we were before we recorded like offline, just thinking about like, how does this, how does this come into effect as the patient, um, is, well, not the patient as a child is five, six years old in a school setting, right? [01:00:00]  Like, so And the only way we're going to know that is to talk to each other and collaborate and learn from each other. Um, so I think it's, I guess my take home message is keep learning, have an open mind, collaborate. Um, because there's so much that we can learn and grow and, uh, contribute to the world of speech language pathology. Amy Wonkka:  I totally agree with you. I mean, I feel like, I've learned to echo Kate. I've learned so much just in our like hour long conversation here. But I do think, you know, as somebody who works in a really different environment than, than a NICU, um, I am still seeing students in my case who are coming in and I might read in their history that they have these like medical conditions as part of their medical history. And I think just having a better understanding of what that actually very helpful as the person who's treating them much later on, um, in their course of development. And so we have so much to learn from each other as speech language pathologists, but we also have so [01:01:00]  much to learn, like you had said, from other disciplines where, where we work closely together. Uh, we didn't really talk about it too much today, but I'd imagine, you know, for instance, you're working really closely with OT and PT to think about, you know, positioning and all of those pieces. Um, so yeah, I think having an open and collaborative mindset is so important. I totally agree with you.  Nashifa Hooda Momin:  I agree. Um,  Kate Grandbois:  thank you so much for being here with us. This was really wonderful. We're so grateful for your time. To anyone listening, whether you're in a hospital setting, working as a med SLP, working in a school, working in pediatrics, whatever it is you're doing, we hope that you found some value in this conversation because it does touch so many of us in the field. Nashifa, again, thank you so much for your time. All of the references mentioned will be in the show notes and you can use this episode for ASHA CEUs. Everything you need is in the show notes. Thank you again so much for being here.  Nashifa Hooda Momin:  Of course. Thank you for having me. It was great chatting. Thanks so [01:02:00]  much. Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Sponsor 1 Announcer:  Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes This episode is brought to you in part by listeners like you and by our corporate sponsor, Ventris Learning. Ventris Learning's culturally and linguistically responsive teaching resources help speech language pathologists, reading specialists, and teachers more effectively meet the assessment and instructional needs of [00:02:00]  all students, including those who tend to become underserved in language and or literacy. To learn more, visit www.ventrislearning.com .  Episode   Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are here with a fellow speech nerd, Ali Sherman. Welcome, Hallie. We're so excited to talk to you today about Tier 2 vocabulary. Thank you so much for  Amy Wonkka:  having me. Now, Hallie, before we get started, can you please tell us just a little bit about yourself?  Hallie Sherman:  Sure. So, my name is Hallie Sherman, and I'm a licensed speech language pathologist from New York. If you cannot tell by my thick Long Island accent, I will probably be hitting myself in my head with my hands because I talk with my hands. But, I worked in the schools for 16, 17 years, working primarily with 5th, And upper grades and early on in my career, I realized I had no idea what I was doing. Um, I'm five foot tall. These students were taller than me. I received goals that I did [00:03:00]  not understand and had to figure it out all on my own. And first school placement jobs that I had, it was almost like you were pledging a sorority. Like you can't ask questions like that's just like not, you're not, You can't appear like you don't know what you're doing. So I had to figure it out all on my own and there was nothing out there. There was no resources for older students. And I made a lot of mistakes. Um, I just pulled any ELA worksheet to work on some of these comprehension goals. And I realized early on in my career that I'm going to either get burnt out, or I'm going to need to get out of working with this age group if I'm going to survive. Um, and then I had a kind of aha moment, and realized, wow, if I teach these kids, um, a little bit differently, Then I get different results and we're actually having fun here and we're actually making progress and they're actually excited to come to speech and that was when 12 years ago, I started my [00:04:00]  blog speech time fun because I wanted to be able to. ShareIt was working with my speech students, with others, because it's what I needed. I wish I had someone to go to. I once had a student who finally got the R sound, and I ran into the hallway to share it with someone, and I had no one to share it with. And I ran back into my room. So, I wanted to be able to create a space for SLPs working with older students to not feel alone. And people, sure enough, found my blog and read it and was sharing it on Pinterest and things like that. And that's when I realized I needed to create the resources that I needed. So, more than just sharing what was working, strategies, what I was finding. I wasn't finding enough, so I started creating my own resources, putting them on Teachers Pay Teachers, and it was really resources for students that were older, but reading at lower reading levels. And it was embedding the different aspects of how to teach it differently so they can grasp it. They're already getting access to main idea in the [00:05:00]  classroom. They're already taught how to summarize. It's not sticking. And here I am, the SLP, pulling them out of art and music and all the fun things, working on it again, that's not fun. But I can teach it in a different spin, incorporating their interests, using their reading levels. And that's when I started creating my own resources, and that's when I wanted to be able to do more than just that. Give someone a PDF that they can use. I wanted to be able to share how I was doing it. And so I started doing professional development. That's when I started my podcast, SLP Coffee Talk, so that I can just help inspire other SLPs as much as possible, working with older speech students and getting the access to the materials and support and training that they warrant and deserve. And that's when I started in 2021, I believe, um, my membership SLP Elevate, because I wanted, again, just to. Combine the resources and support for SLPs working with older speech students because I call us the weird, crazy stepchild [00:06:00]  sometimes. We're not the ones working with the little itty bitties. We're not the ones working with the geriatrics. We're the ones in that crazy middle that no one understands and I want SLPs to not feel alone. So that's a little bit about me.  Kate Grandbois:  Well, thank you for sharing. Uh, I know that one of the things that we're going to be talking about today is resources for SLPs. And that's one of the things that we're very passionate about is open access information, clinicians being able to get what they need when they need it, because we already have enough barriers working against us in our workplace settings. Um, before we jump into everything, I do need to read our learning objectives and financial and non financial disclosures. I will get through that as quickly as possible. Todd. Here we go.  Learning objective number one, describe the benefits of working on vocabulary with your older speech students. Learning objective number two, list at least two resources available to SLPs for quick vocabulary activities. And learning objective number three, describe how to make vocabulary activities meaningful and fun for your older speech students. [00:07:00]  Disclosures. Hallie's Financial Disclosures. Haley is the owner of Speech Time Fund Incorporated and the SLP Elevate membership where she provides materials and support for SLPs working with grades 4 through 12. Haley also received an honorarium for participating in this course. Hallie's non financial disclosures. Hallie has no non financial relationships to disclose. Kate, that's me. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures. I'm a member of ASHA SIG 12 and I serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy.  Amy Wonkka:  Amy's financial disclosures. Uh, I am an employee of a public school system and co founder of SLP Nerdcast and my non financial disclosures are that I'm a member of ASHA Special Interest Group 12 and I also participate in the AAC Advisory Group for Massachusetts Advocates for Children. Kate Grandbois:  So one of the things we talked about before we hit the record button is kind of the general [00:08:00]  backdrop of this conversation is tier two vocabulary. And while Amy and I were prepping for this episode, I very honestly said that I didn't know what that was. And I, I feel like I, I shouldn't be ashamed or I should be ashamed to say it, but the fact is I've never worked in a school for some reason that piece of graduate school from 20 years ago is just no longer in my brain. So maybe you could start off by telling us a little bit about what tier two vocabulary is and why we should care about it.  Hallie Sherman:  Sure, so there are three tiers of vocabulary. Don't worry, I didn't learn about it in graduate school either. I learned it from a book, Bringing Words to Life, the Robust Vocabulary Instruction by Isabel Beck, Margaret McGowan, and Linda Kukan. It's a really great resource if you want to dive deeper in what is Tier 2 vocabulary and the different tiers. So basically Tier 1 is that common vocabulary words that students are developing naturally. Dog, house, cat, sky, Rainbow, all those fun things that might not need to be explicitly [00:09:00]  taught. Now granted, we do know some of our students that do need that. But let's think about students in general. Those students, those words are typically just developed. I'm going to skip to Tier 3. Tier 3 is those curriculum based vocabulary words, words that your students are learning about in science, in social studies. They're studying them for a test, and then we forget them. Do you remember every single cranial nerve? Because I don't. Disclosure. So, those are Tier 3 vocabulary words. We study them once. We recall them, we need to know them when we need to know them, but then we forget them. So, a lot of times SLP is like, I want to help my students with curriculum, I'm going to focus on mitochondria and the parts of the cell, those three branches of government. But guess what? We often have times students working in different classrooms at different times. We can't always know what subjects they're working on and that's not really helping them when they get to that next chapter, right? There are strategies and we can discuss that, like there are frameworks that we can teach them on what consists of a good definition. [00:10:00]   But is it really benefiting them is how to define? When are we ever really defining words in our life? Unless you're working for a dictionary, you're not really. You might need to just know how to use it and understand it when you're coming across it. But those tier two vocabulary words are those words found across various curriculum and subject areas. Those words like increase, predict, convey, um, oh my goodness, I can't even think off the top of my head, um, convince, persuade. All those things that could be found in a social studies textbook or an essay could be found in an ELA something, but it can be found anywhere. And we need to teach our students what to do when they come across those words that they might not be familiar with, that can be helping them in any subject area, versus just an arbitrary subject area. Thank you. vocabulary list given by a science teacher for unit three. Amy Wonkka:  And I think that's super, that's a super helpful framework for us to think about going into this conversation [00:11:00]  because we're, those of us who are working in schools are working with students who may have varying language needs, um, and it can be hard to think about where your starting point is, right? So should, and I think one thing to think about is do you have one of those students where that tier one vocabulary does seem pretty essential? Um, and knowing that you can drill down into that tier two vocabulary, whether that, um, I think the big piece of a tier two vocabulary is also that it's higher frequency use, right? So maybe that student does need to know mitochondria and they do need to know all of those parts of the cell and maybe you help them a little bit with some of that. Um, But your bigger bang for the buck is going to be those two or two words that they're going to be able to use across their day and across their school career  Hallie Sherman:  and having those academic conversations throughout their school day is going to impact them. They're going to be hearing these from the teachers when they're readings, and they need to know what to do when those words come across that they don't know. So one question I get asked often is. How do you know what words, even tier two words, to pick from? [00:12:00]  Like, I, I named you like ten of them. That was going to be my question. There's  Kate Grandbois:  just so many.  Hallie Sherman:  And just like anything, we can't just pick arbitrary word lists because we don't know what words our students are going to come across. Now you can Google, and I'm going to give you a site so you don't even have to Google it, but Vocabulary does have tier two vocabulary word lists by grade. It's a great starting point if you're not familiar with. What's your two vocabularies words are and how they might get more complex as the grade level goes up now I'm going to put a disclaimer just because your student is in third grade Doesn't mean you should only be looking at that third grade word list because that doesn't mean that they have that Grade one grade two words mastered and they might still come across a fifth grade word And they need to know what to do when that word comes up Across their way, so it's a good starting point of I don't know what your 2 words are. I don't know what's your 2 words. My students [00:13:00]  might be exposed to, but another good place. If you're not familiar with this site or whatever, but you can also look at your students curriculum apps. A lot of times the scope and sequences that the teachers are utilizing has those tier two words embedded that they're expected to utilize in their classroom instruction, that they're expected to ask their students questions. And that can give you a starting point of, I know my students are being exposed to the word compare and contrast because that's part of the scope and sequence of ELA in the third marking period. So, again, it's doing a little detective work. It's not a exact science. That's the downfall. Sometimes of being an SLP is we don't have a curriculum, but almost the fun of it is we get to use anything that can benefit our students. So using a site like vocabulary, it's a great starting point gives you a whole bunch of words, but. It's a matter of teaching our students how to identify these words and what to do when they come across them and they don't know [00:14:00]  what to do with it.  Amy Wonkka:  Well, and Hallie, I feel like you bring up such a good point too in terms of talking to the resources in your building. We talk a lot on this podcast about the importance of collaboration and how it's so much better when you're able to work with other people and sort of meld your expertise. Um, I don't know if you have any tips for Perhaps classroom teachers working with classroom teachers, or if you're in a district that has like a curriculum specialist, um, and sort of how SLPs might be able to utilize those resources within their school building. Hallie Sherman:  It goes also the flip side of many school resources don't know how to utilize us. Because often we are referred to as the speech teacher and they think we're working on the R sound or we're stuttering all day. And they are shocked to find out that we are actually working on language. And I'm like, well, we are the speech language pathologists and sometimes just having your door open sometimes so people can hear what's going on in your speech room, that it's more than just saying sounds can go a long way. I actually happened to one time, um, [00:15:00]  borrow a, the literacy, like specialist office because someone needed to use my office and he was shocked to hear. He was like, wait a minute, you're teaching summarizing? I'm like, yes. Anyway, but we can also advocate for our students that in order to be a successful reader. They need to have adequate language comprehension skills and vocabulary is one of those aspects. So we can share with teachers, Hey, I am a resource. If your students are struggling with reading and this and that, because I can help provide you with strategies to help improve on their vocabulary. So not only can we provide the teachers with strategies, but we can also show them that we are available and then asking them, Hey, where are my students struggling? What are some things you're working on in your classroom? How can I help? Support you. And more that we open ourselves up for asking those questions, the more people, you know, not everyone's going to jump and say, Hey, help me, but some, some might. So we're all in it together to help our students. [00:16:00]   Kate Grandbois:  I also have to assume that and forgive me if this is a stupid question being so very new to the concept of tier two vocabulary, but. Because these words are so high frequency, I would also have to assume that one of the benefits of working on them in your sessions is generalization versus some other like tier three vocabulary where you're gonna see the word mitochondria in this context and then presumably that's why your long term memory is not capturing that, capturing that, but I have to assume that it. Focusing on generalization when tier two vocabulary is in play is a key component.  Hallie Sherman:  Yes, we want to make sure that our sessions are relevant. We're pulling students out of class. Yes, it's least restrictive environment, but we want to make sure our students are getting exactly what they need in the time frame that we're giving them. And by using arbitrary words, mitochondria is not arbitrary, but it's not necessarily helping them every single day of their life. I don't know. I'm not using mitochondria all the time. [00:17:00]  So, They're not using it in math, unless maybe that math teacher is like a science person. I don't know, but the chances are not as great. And we want to always show our students how what we're doing in our speech closets are going to help them in whatever subject they're in. And by using these vocabulary words and saying, Hey, you might've heard your teacher utilize this. And even, and if you have that opportunity of knowing how they are using it, Hey, when so and so said, please compare and contrast these two characters that you're reading in whatever novel you're working in. Oh, I did hear that. That was hard for me because I didn't really know what she was asking me to do. Oh, let me think about the context of how it was asked. Oh, okay. These two characters have a lot of things that are similar and different. Oh, that's how we're, um, that's what she's asking me to do. So we can help them show them how what we're doing and practicing in our speech room can be beneficial outside of the speech room when it is more obvious of what it's, when they are seeing it more often. Amy Wonkka:  Well, I think you're really getting at sort of that first learning [00:18:00]  objective about the benefits of working on vocabulary with our older students, right? I think we want to make sure that everybody has a solid foundation in their vocabulary and then you're building on that foundation. But I think something that you're able to do probably more often with older students compared to very, very young students is have more of those explicit conversations about how the work that you're doing together is going to benefit them outside of the therapy room. Um, I didn't know if you, if you could share with us just a little bit more about some of those benefits on explicitly working on vocabulary with that age group of students.  Hallie Sherman:  Sure. So there is actually tons of evidence that shows that working explicitly on vocabulary can impact their academic success. There's research that shows that working on top, uh, working, that working on vocabulary knowledge will help with academic attainment. That also, um, there's also evidence that children with lower levels of vocabulary are more likely to, [00:19:00]  are less likely to acquire vocabulary successfully. On their own. So they need to be explicitly taught it, and that's why they're coming to us, right? We have to assume they've been exposed to these words in the classroom, just like those tier one words they've been exposed to. There's evidence that our students with language difficulties need more exposures. They need to be explicitly taught how to figure it out and more often, and get more practice. And they need those meaningful exposures on how to, on how to learn these vocabulary words. So showing them one, how, how they're utilizing it, where they might have heard it. And how it's going to benefit them and then also having those meaningful exposures to it and just more repetition by using a word once is not going to be enough. Kate Grandbois:  I also have to assume because these students are older, in some cases, they likely have some metacognitive skills, right? They can reflect on themselves, their own experiences, and facilitate some of that generalization and maybe reflect on how it is helping them or making class feel a [00:20:00]  little bit easier or more accessible. Do you find that that's the case? Totally. Our  Hallie Sherman:  older students, the K 2 students, they're still learning to read. And yes, they still need vocabulary. In order to decode a word, they need to have that schema of that word. You can't decode a word that you've never seen before. It's like if I was thrown into a different language, it would be much harder for me to decode a word that I've never heard in that language. If I was like an alien or whatever. But our three, grades three and up, they're not learning to read anymore. They're expected to read to learn. Now, we do know that some of our speech and language students are still working on those decoding skills and phonological awareness skills, so they're still boosting and working on that, but they're also expected to read, to develop for an article and write a document based question essay and, and refer back and especially with like Bloom's taxonomy, they're expected to like, create and illustrate and do all these fancy things. But if they don't have a general, if they can't, they're not gonna be able to recall, they're [00:21:00]  not gonna be able to understand if they don't have the vocabulary. And that's where we come in, is that we can help impact their overall comprehension. If we can help get that foundation and what to do when they come across those words that they don't know. Amy Wonkka:  Okay. I think we're sold. Vocabulary intervention is important for students. I wonder if you can talk to us a little bit just about, like, what does that look like? What does that look like when you are in your speech office? You're having a session with a one on one with a student or in a small group. How are you doing things differently? And in your example, when you first started in your career, right? How does that, how do your sessions look different? differently now that you have this focus on vocabulary intervention.  Hallie Sherman:  So, like I said, I don't like using arbitrary word lists. I like to teach my vocabulary in a contextual manner, and there's tons of evidence that shows that students learn better when words are in a context. So, how do I do that? I like to start with words that they do know, and I like to make them [00:22:00]  nonsense words. So, I like to do tier one words to teach how to use context clues to figure out meanings of unknown words. So, I like to use the word blah. So, I'll say, The boy sharpened his blah. And started working on his homework, writing his homework. Okay, the students were like, I know it's a pencil, Mr. Sherman, I know it's a pencil. I'm like, okay, I know, but how did you know? Let's look at the sentence. I see writing. I see sharpened. I see homework. The only, I can tell that it's a noun in there. We can talk about parts of speech, how it is used. And it shows them, okay, these are the different clues I can use when a word I don't know. I can try to predict the parts of speech by understanding the sentence structure. I can guess what the sentence is about even without understanding what that word is. By understanding the gist, the main idea of the sentence, I can get an idea. Maybe I might not know that exact word. Maybe I know a synonym to that word. Maybe I know an antonym to that word. That's those word [00:23:00]  relationships we can pull back in. Now that we know you might have mastered those in, you know, the younger grades. But these later grades, we might not need to utilize that to kind of figure it out. So I start with the words that they do know to show them, one, to build, it builds them that confidence, like, oh, wait, I got this. This is easy. Two, shows them, how do you know? And then we work up from there. Then I'll do some more, maybe emotions, more, more challenging vocabulary words. And again, how did you know, teaching them to look for examples in the sentence, maybe abbreviations that will give them a clue. Maybe there's some illustrations on the page that will help them. And I model my thinking about my thinking. One of the hardest things that was, that I realized was so essential when working with older students was teaching them how I did things, things that we do innately. We don't even realize the self talk that we are doing when we come across something challenging. Or it might not even be that challenging for us, but we're just naturally doing it. [00:24:00]  And by that self talk, it's actually language. So we can give them a conversational script. Oh, I don't know what this word is. I think it could mean this. Let me plug that in. Oh, what's going on here. Okay. I see this word. It could be. I think it's a noun. It's right next to a verb and modeling that and then having giving them that script and then doing it together and tons and tons of practice. Our students need that explicit instruction, tons of modeling and those scripts, make it visual, give them that step by step on how to do it and show them them one, they can be successful and to how this is also going to help them will also when things get challenging, they're not going to give up. Kate Grandbois:  I also love the suggestion of using language in the framework of problem solving and self talk, because that can be utilized across all of life. Right? You know, identifying what you do know, it's, it's making me think of when you were like, um, Looking at the SAT in [00:25:00]  your future or whatever standardized test and like, okay, when you have a multiple choice, you know, you had to learn how to problem solve through, um, through a difficult moment and you're right. We do so much internal self talk for self regulation for problem solving. And I love the idea of modeling that explicitly and slowly. To only because it creates a foundation that can be replicated over and over and over again.  Hallie Sherman:  And I also model for my students, like what would happen if you just skipped over that word? So I'll even take like a song lyric and black out some words. And like, are we going to get the same effect if we don't know every single word in that song? Like, can Taylor Swift be as successful if we like, Just skip over half of her songs. We might not know what she's referring to. You might, you might guess wrong. And that's what can, our students can, what can happen to our students if they just, a lot of times they'll just skip over [00:26:00]  it. Amy Wonkka:  What other types of, you've given some really nice examples of using strategies to attack the A lack of comprehension within a sentence. Are there other things similar to that? Whether it's like activities, you mentioned vocabulary. Are there other resources if you're a speech language pathologist who's thinking about, okay, I would like to do more with tier two vocabulary, sort of where can I get started? Where can I get some examples of how it might look in my session?  Hallie Sherman:  Sure. So one of my favorite tools and it is free is vocab grabber. There is, if you go to this, if you type in vocab grabber by visual thesaurus, it may say to log in. You don't need to log into anything. You can enter in any text. So say you go to Readworks, News ELA, any of these sites where has free articles, Wanderopolis. You can, a lot of those sites have vocabulary words bolded, but it might not always be the words you might think of. If you [00:27:00]  copy and paste any text, or if you want to be wild and crazy and type in the novel that your students are reading, and you click vocabulary, you click go, whatever the word is, there's a whole bunch of different buttons. If you unclick all and you click the vocabulary one only, those are two, two vocabulary words that they pull out for you. And they also show you by a visual. view, which word was used more often in that text. And then if you click any of those words, it shows you where it was in the text, the sentence it was in, the definition, the parts of speech. All that fun stuff. So if you're, okay, my student is reading this in class, I want to help them prepare for when they come across words they don't know. We might not have that time to maybe pre read it ourselves, or have that time to self analyze, we're busy. So if you can just. Put it into this site, it will pull out the words for you, and this way you can prepare ahead of time those words that your students might not know. So you could do some [00:28:00]  pre reading strategies with them, like hey, I like to call it, um, Acquaintance Stranger, Stranger Acquaintance Friend. So it's a little like, like a KWL, what do you know, what do you want to know chart, like, what, like a background knowledge assessment. So I'll read, read the words out that might be in that text that they might not be familiar with, or I'm not sure if they are. Are you, are you a stranger? Have you never heard it before? Are you an acquaintance? I've kind of heard it, but I have no idea what it means. I couldn't buy it a birthday gift. I wouldn't know what to do with that. Or are they your friend? Like, I can use this, I use it all the time. I'm texting my best friend using that word. That kind of thing. And this way you can go ahead, like, why waste your time with those friend words? And I like to start with those acquaintance words first. Let's build their confidence up. Let's go. Okay. So you've heard this word before. Now we're going to give it to you in a context. Let's look at it. What parts of speech is it? What does that tell us? Maybe think of another word that can be utilized in the place of that. And then we can teach them what to do with Senate with the unknown [00:29:00]  words. And it might need to be a building up their background knowledge, a little bit of it, and maybe explicitly teaching it, but it's giving you ahead of time. That prep of. Hmm, I don't need to teach every single word, but what word to focus on? And just because that article might have told me four words to focus on, those might not have been the best four words. Or maybe those are too challenging words for our students, and we need to take it a little bit easier for them. Amy Wonkka:  The other thing I love about that example you just gave is also that you're still helping the students to develop those self assessment skills. as well. So hopefully if that's a strategy that you're using often in your session where they're identifying, okay, is this a stranger? Is this an acquaintance? Is this my friend word? Um, then hopefully they can then start to internalize that. So perhaps when they're in a class and they're facing a word that they're not so sure about, instead of just skipping it and being like, ah, I I'll deal with that later. Maybe they ask themselves and go through that little inventory. Um, and, and that helps them better attack the situation as well. [00:30:00]  Are there any other suggestions? I love that suggestion. Any other suggestions that we could use, um, as we're trying to incorporate more of this tier two vocabulary instruction?  Hallie Sherman:  Oh my goodness. I have so many. Um, I love utilizing YouTube videos to teach, um, using context without reading. I'm all about taking the reading piece out and changing things up when my students don't know what is coming of me. So taking any Pixar short, like for example, snack attack. I don't even think it's a picture. It's a YouTube video. And it's a three to four minute video of this woman who buys snacks. Someone else tries to take it. I don't want to like give, um, this, uh, the, uh, spoiler alert. You can pause at many different points and embed a sentence that you create. The man is sitting adjacent to the lady. They can use what they see in front of them, they don't have to read, they can read the sentence you're providing, and try to guess what those unknown words are. And there's more opportunities to [00:31:00]  practice in a fun and engaging way, where they don't realize they're learning, but the more opportunities to practice, the more opportunities they get to, the more confident they will feel when they come across those words that they don't know. And again, always modeling, again, how you are thinking about your thinking, what you are doing, and showing them like you, us too, have to do thinking to be successful. We don't know every single word. And that's okay. And I even, I even use like vocabulary of Fortnite. Like, I'm like, I don't know what a skin is, and a, and a, I don't, and I, I'm like, tell me, tell me everything you know about Fortnite. And like, these words are foreign to me. I'm gonna use my context of what you're telling me to figure out what these words mean. And they're like, and they're like, they wanna just tell me the answer. I'm like, no, no, no, no, no, I'm gonna figure it out by what you're telling me. And showing them that we, too, have to use these same strategies when we come across something we're not familiar with. So, I've had students make me Fortnite dictionaries [00:32:00]  so that they can, like, teach me vocabulary words. Um, anything that allows our students to teach us is a teachable moment for them. And it shows, it builds their confidence and shows them how they can use the same strategies on something they do already know.  Kate Grandbois:  I love that. I love anything that is approaching therapy with humility and bringing humanity into the room and the reason I say that is because you're showing in modeling a student how you deal with problems because all humans have problems. We all, we all approach things that we don't know. Nobody knows everything. I think that's like the second time today I've said that. Um, I, I really just love that. What other, what other bags of tricks you got up your sleeve over there?  Hallie Sherman:  Just like I like using Pixar shorts and wordless videos, you can do the same thing with wordless picture books. The best part about wordless picture books is there's no words, so we can pretend there are words there. So whether you're reading Pancakes for Breakfast and the lady is distraught [00:33:00]  that the Animals destroyed her kitchen, the word distraught is not there, but we can put it there, you can take a sticky note and put there so pretend it's like a word, and they have to use the picture, they have to use what they see what's happening in the text, what they see in the, and it's not just so text based, and it allows them to be a little bit more successful and we can, and we can show them like, again, What are some other words that can fit into that blank? What words that don't fit into this blank? Is she, like, let's look at her body language. There's a lot of social inferencing also that can be, uh, incorporated. There's other skills that all, that all are intertwined in order to be successful. So we can tap into our students strengths if they are visual learners. If there was, we can use what they are strong with to help, um, build a vocabulary in a fun and meaningful way.  Kate Grandbois:  That was going to be my next question was about fun. I know like two teenagers. And their idea of fun is not my idea of fun. Well, my idea of fun is not many [00:34:00]  people's idea of fun, but, but in, but in reality, I mean, what in your experience, what is the approach when you're working with an older student who doesn't want to be in your therapy room? I mean, how do you, how do you make that fun?  Hallie Sherman:  One, you have to get them those quick wins by showing them that they can be successful. By starting with those. Acquaintance words by starting with those tier one words like duh, mr. Sherman. What do you what? I know that it's a pencil I'm okay throw rocks me. Yes a duh, but how did you know? And showing them, look, you can do this and building up from there and not starting at the hardest level. Let's start, let's start where they're at and show them, look, you got this and building that confidence and also building that safe, comfortable environment. It is so essential, especially the older students that you take the time to build rapport, get to know them. Let them get to know you, like before, I make mistakes too, [00:35:00]  I need, I, I cannot draw to save my life, you give me a soccer ball, I'm going to hit my head with the ball, like I don't know what to do. And oftentimes my students are like, I can teach you how to play soccer, I'm like, see, you can teach me something, I'm going to teach you something, and by the end of this year, we're both going to be good at something new. And showing them everyone has different strengths and weaknesses. Everyone has different learning styles and taking those times to have those conversations. There's free sites online where you can have students take some learning style quizzes so they can see for themselves, Oh, I do need frequent breaks. Oh, I do need things broken up into smaller pieces. Oh, I do like things read to me versus when it's whatever. For them to see for themselves, like there's nothing wrong with you. We just all learn differently and that's okay. And also having those conversations about what do you, what do you want to get out of coming to speech? What do you want to get out of coming to school? What do you want to be when you grow up? Maybe their goal for the year is to make the soccer team, to ask a girl out on a date, to get a job at the movie theater, whatever the, whatever it might [00:36:00]  be. We can incorporate that while working on these various goals. So if a student told me soccer, I will find some YouTube videos on soccer. I'll find some articles on soccer that have some tier two words embedded. And if not, I will create them and work on these skills while incorporating their personal goals and their interests. And also. Showing them, in my speech room, it's not a matter of getting things right or wrong. You're always going to get it right. It's a matter of when. And it's okay.  Amy Wonkka:  I think incorporating student interests is just so important and being able to identify that they're an active participant in this whole process. Do you find that you often talk to students about their IEP goals explicitly? Hallie Sherman:  Definitely, definitely as they get older, even more, I know many often, especially in the high school age, students are expected to go to the IEP meeting and be a part of the conversation. And you don't [00:37:00]  want that meeting to be the first time they're hearing, I have a language disability. Oh, that's why I'm here. Like, we don't want to have those conversations. So a lot of times in the beginning of the year, I like to go through like, what are their goals? Even their accommodations and modifications. Let them be self, like, how can they advocate for themselves that I need more time? My test should be read. Why? Sometimes these, the other teachers that they might be working with don't have that time to go through it all. We can, and the more we can take the time to be like, okay, everyone's here for a different reason. Everyone has different strengths and weaknesses, but this is what we're going to get out of coming to school, this is what we're going to get out of coming to speech. And if you want to graduate from speech, this is what you have to do as well. And that's okay, but having those conversations. Obviously, when they're a little younger, you want, might want to get parent permission if it needed, but often like they might not know they have an autism diagnosis or whatever it might, they might not be aware of certain things and you might want the permission from a parent, but as [00:38:00]  they get older, you can still have those conversations about just learning is different and that's okay. Kate Grandbois:  I also think that ties really closely to some social emotional concepts like self acceptance and, uh, self esteem and empowerment. So, making sure that there is that close relationship between their confidence and competence to advocate for themselves in accepting who they are and what accommodations they need. And I, I think that's something that I know adults that struggle with that. I mean, it's a really, you know, it's hard emotional work to, to get there. And I love the idea of wrapping language around that for empowerment purposes. I think that's awesome.  Hallie Sherman:  Yeah, definitely. Especially students that need things read, you know, repetition. I need to hear it again. They should not be in fear of asking for that. And I always say to them, if anyone gives you a hard time, you tell me, you come straight to me. Kate Grandbois:  So knowing how strapped SLPs are, how we are constantly [00:39:00]  fighting for resources and time, what are some quick tips that you have for getting some of these resources at our fingertips? Hallie Sherman:  There are so many free resources out there that you don't need to reinvent the wheel such as one of my favorite sites is Bamboozle all you need is a free login and if you type in Context clues or tier 2 vocabulary a bunch of activities will show up. So for example, I typed in context clues and I'm gonna click one of these here And it pops up different passages with pictures and it gives you four choices. So I looked at the plans for your new house. This is earthquake county. You need to fortify the frame or you'll have a disaster with the first tremor. The word fortify means, and it has a picture of a house shaking. So I, okay, what do I see? I see a house shaking. I see things moving. I see, I know, I see the word earthquake. Okay. What do I know about an [00:40:00]  earthquake? Okay, well, things shake. So my choices here are destroy, shake, strengthen, or build. Okay, this earthquake, this earthquake county, you need to fortify the frame, or you'll, okay, we have to use our clues to figure out, it's just an example here, what to do with that word. And there's a lot, this is not the best choice because there's a lot of words here that might be difficult, but that's why sometimes you need to like preview it. I'm going to give you another example, Pam and Gia are sisters, and they're very different. They just look at how they are, uh, Just look at how they are dressed. Pam doesn't care what she wears or how outdated her clothes are. Gia, on the other hand, is quite chic. And it's a picture of the two, uh, Olsen twin sisters and one's not, it's more trendier than the other. Poor Pam. I feel bad  Kate Grandbois:  for her. That was,  Hallie Sherman:  I know, I know. Or whatever her name was. And then you can work on any other goals. Like what, what would you say to Pam? But here's just an example of how you can take [00:41:00]  pictures and have some passages, and you can find things at different levels, whether it's a sentence level, at the paragraph level, with pictures, without pictures, and using whatever level your students are at to practice the skill over and over and over again. And this site is great for its quick, easy data, because your students are each taking turns picking a card from the, whether it's a, this one is, this cards. So that's, if you have a group of two, you get 12 opportunities each. Um, so, and if it's an odd number, I like to do teams and things like that. But Bamboozle is a great tool that you can find a plethora of games. At different levels, um, work on vocabulary and isolation, and it could be that you might want to work on reviewing synonyms and antonyms, looking at teaching parts of speech, working on, uh, root words and prefixes and suffixes, all those things you can do right on Bamboozle by just typing in the search bar. Um, so that's just [00:42:00]  one tool that I love to utilize. Just as similarly, another fan favorite in my speech room is Bluket. If you're familiar with Kahoot, it's a similar tool that, like, the students do need their own devices, where Bamboozle, you, uh, it's the only, you're the only one who needs a device, but you can, every, you have, you're the host, and there's tons of games right on there, so you can search, and I'm going to give you, I created one with GIFs, you the link so that you can access the GIFs and the sentences ready to go with the tier two words that I made, um, to utilize with my students, um, But you can find if you just type in context, there's a whole in the search in the discover tab, a bunch of games show up. The best part is there's different game modes. So a lot of the students like gold quest. Which is when, when they get their word right, when they get the answer correct, they get three different treasure chests to pick from, they don't know what's inside of it, it could be gold, it can be stealing gold, it can be [00:43:00]  losing gold, and us as the SLP, as the host, we can decide is it gonna be a five minute game, a seven minute game. We're going to play a certain amount of rounds. The negative of this one is because they're all on their devices and they're all doing different words at the exact same time. It's not great for like data and teaching, teachable moments, but it's a great way to practice once they're finally grasping the concept. So Kahoot is a little better because it allows you to have like pausing after each question to like, let's discuss how we know. Dambouzle the same way like let's discuss it once they're ready to do it more on their own and practice and just to have fun. Look, it is a great fun tool. All you need is a free log in Gmail account or any email account to log in. And the best part is students are familiar with these sites, especially your older ones. The classroom teachers are using the blue. They might not be using bamboozled, but they're using blue kit and Kahoot. And [00:44:00]  there, those are 2 easy ways, and I'm going to show you, I have a tier 2 word game on Kahoot as well. I'll give you the link to that one as well that I created, which has pictures. I have one with non sent words, so they can like, like the block, um, right in there, so they can play that with their students to practice that using, using picture clues as well. Um, so. Look at Bamboozle Kahoot. If you go to, um, like some sites like readworks.org that you can search certain articles based on skill. So you can search by vocabulary and context clue. So it's other opportunities to just practice even further. Um, but like I said earlier, I do love using YouTube videos. So I love the site ed puzzle, which allows you to embed some of these sentences already into the videos where if the video pauses, a sentence pops up. And it allows you to go through what's going on in the video. Um, so I have already ones, and I will give you the, if you type [00:45:00]  in, if you type into Ed puzzle again, all you need is a. Login information, I type in just context clues, a whole bunch of videos already made by other educators might not be speech pathologists show up with teaching either teaching you how to use context clues or different videos on using context clues. I literally am seeing a whole bunch here. Um, a bunch of Simon's cat videos. Storybooks that are on YouTube, you're incorporating context, clues, and you can preview it. I recommend previewing everything ahead of time. And the best part about Edpuzzle is you can edit someone else's work. So either you can create your own video with embedding the Tier 2 words. Go into Flocabulary, get some inspiration over there of what tier 2 vocabulary words, you know, your students should, should not know, and then pause at various points, create your own sentences as if you were the narrator, or take something that's already done, and say you don't agree with what that person made ahead of time, [00:46:00]  you can edit their work, and they won't know, it's really okay, so that's the best part, you're not offending anyone that the whole gist of Edpuzzle is educators supporting educators there and creating different videos with quizzes embedded. Teachers are using it for like a homework assignment, especially during COVID times. They're like assigning it via Google Classroom. I don't have students write anything in because I don't know how to delete it. I just had them verbally tell me out loud what their answers are. And the best part is The video pauses, you don't have to remember, 2 minutes 38 seconds, I need to remember to pause here, give them this sentence, you can set it once and have it for life, and the best part is, you get to choose when you go on to the next, the next clip. So say they need more assistance, there is actually a rewatch button, so it teaches our students those self advocacy skills, like, I need to see that again. And it's right there embedded. Let's click. Let's click rewatch and we can [00:47:00]  watch it again. What model, what I'm going to do this time. You can give it, you can make it a multiple choice. You can give them picture symbols. You can throw in some board makers or whatever symbol systems are in there that they're utilizing. You can embed pictures into the questions and the answer choices into Edpuzzle. So whatever your students need, it might take a little bit of work up front. Not if you find one that's already made, but if you find if you need to make your own, you have it then for life and videos are so motivating. We can find ones on their interest. You can find something on video games. You can find I have glued is a great YouTube video. If you if your students are obsessed with video games. Um, there's if your students are into science, this preheated where the boy gets access to his dad's science experiments. There's there's snack attack. I said, that is a really great 1 coin operated is a boy who wants to go to the moon. There are so many things already out [00:48:00]  there that you don't need to reinvent the wheel. It's motivating and you can embed all those strategies built in. So that's a puzzle is a great, great tool. It is free. Um, and you don't even need to save it to your account. You can just stream it. Um, and it's super easy. You can share it with each other, create them with a colleague, and there's a share button so you can share it with them. You can share it with, if you want to send it for home practice, you can do that as well. Um, there's so many possibilities. It is a great tool if you like using YouTube videos in your speech room. Having Edpuzzle is a great, um, a great tool to use. Do that in a more organized manner and if there are any YouTube videos that you find that are not on Edpuzzle There is actually a Chrome extension for Edpuzzle that you can go into YouTube If you have the Chrome extension downloaded, there will be a button on that YouTube video. Just click it And it opens up Edpuzzle and brings it in there.  Kate Grandbois:  That is awesome. [00:49:00]  That sounds like such a great resource. And to anybody who's listening and driving or folding laundry or whatever, we're, Hallie's going to send us all of these links. They will be in the show notes, um, for just to have at your fingertips when you need them so you don't have to write anything down. Hallie, thank you so much for sharing all of this with us. In our last couple of minutes, do you have anything else that you would like to share with our audience?  Hallie Sherman:  If you got anything out of this episode, I hope it is that we can make learning fun, that we can make learning meaningful. And one way to do that is utilizing tier two vocabulary words and doing it in a contextual way. And it doesn't always have to be a paper and pencil activity. So if you have fun, they will too. And I, hopefully you got a bunch of ideas here that you can change things up, keep students on their toes and always keep learning fun.  Kate Grandbois:  This was great. Thank you so much.  Amy Wonkka:  You're so welcome. Thank you so much for having me. Yes. Thank you so much for sharing your time.  Sponsor 2   Thank you again to our [00:50:00]  corporate sponsor Ventris Learning, publisher of the Assessment of Literacy and Language, or ALL, and the Diagnostic Evaluation of Language Variation, or the DELV. SLPs, school psychologists, and reading specialists use the ALL to diagnose developmental language disorder and to assess for emergent literacy skills, including dyslexia, for children ages 4 through 6. The DELV is appropriate for students ages 4 through 9 who speak all varieties of English. To learn more, visit www. ventresslearning. com. Outro   Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the [00:51:00]  episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Kate Grandbois:  Welcome everyone to SLP Nerdcast. We are really excited for another edition of SLP On Demand. For those of you listening for the first time, SLP On Demand is a series that we put out occasionally where we answer [00:02:00]  questions from our audience. So if you are a member and you have a clinical question you can write in and our doctor of speech language pathology who is here with us Dr. Ana Paula Moomy will answer your question. Welcome Ana Paula. Thank you. I'm very excited for today's question. It touches something that I do for a living. I was really excited to kind of catch up with you before we hit the record button and learn a little bit more about what the research says, because that's always fun for me. Before we read our clinical question aloud, I am going to quickly review our learning objectives for today's discussion. Learning objective number one, identify the relationship between data collection, target selection, and goal writing. And learning objective number two, identify at least two different types of data collection that can be used when working with AAC users. Uh, anyone who is listening can also find information about, uh, our financial [00:03:00]  and non financial disclosures in the show notes. And Apollo, why don't you get us started by reading aloud our listener's question?  Ana Paula Mumy:  Sure. So the question relates to resources for data collection for AAC users. And Andy, um, who wrote in. Um, stated that her mentee has 14 life skills elementary students on her caseload, and she's looking for ways to help her efficiently track device use throughout her student's day. So that's a  Kate Grandbois:  really big question.  Ana Paula Mumy:  Yes. And I think we just have to first acknowledge, like, this is a big question that's hard to answer, um, because there is so much that we don't know about these particular students. And there's also. Um, we don't know specifics about what devices they're using. What does that look like? And so, um, I would say just in general, this is gonna be a little bit difficult to, to touch on, but, um, also acknowledging that I would say data collection is tricky regardless, [00:04:00]  right? It's strictly tricky whether, um, we're working on articulation or language or it doesn't really matter, right? All of these areas. Um, especially. Tracking, um, data or taking data without sacrificing genuine engagement with the person that's in front of you, right? So that's the big thing. I think, um, I work a lot with grad students and I think about how sometimes they're so attuned to the data collection process that they forget, like, oh, wait, but there's a person in front of me and I should be engaging and just really building that relationship and the rapport. So, yeah. Um, I just wanted to acknowledge those, uh, setbacks in a sense, right, um, related to data collection.  Kate Grandbois:  And to kind of piggyback on that, obviously this episode is likely, you know, it's under an hour long. Uh, we are not going to be able to cover everything about data collection in this short amount of time. Uh, anyone who is listening who would like [00:05:00]  to learn more about data collection, either while you're listening to this episode or after this episode is over. We do have three or maybe even four episodes specifically on Monitoring progress and data collection, including probe data or discontinuous data, which I know we're going to talk a little bit about today, uh, that is a very complex topic. So if you are listening and you know already that that's something that you'd want to learn more about, check out the show notes. We will link, um, we will put links to all of those episodes in the show notes for  Ana Paula Mumy:  you. So I wanted to focus on one article in just my research and really just admitting, first of all, that. I am not an expert on AAC. And so it's an area that is a stretch for me. And so, um, as I looked through some of the research, um, I found one helpful article, um, on data collection and monitoring AAC intervention in the schools, um, by Katya Hill, um, in 2009 in the [00:06:00]  perspectives on AAC, a journal. And I appreciated how they talked about, um, collecting the data, To collect, depending on the design and the targets of the intervention program. So, in other words, really thinking about, like, what are we actually tracking in relation to device use? And, um, they divide up 2, uh, areas or talk through 2 different areas. Um, performance data and outcomes data. So with performance data, um, representing really the quantification of specific language targets. So things like, uh, spontaneous or novel utterances, um, communication rate potentially, or any word based measures, um, that might include things like. Uh, total number of words used, or maybe it's percentage of core vocabulary that's used, um, or mean length of utterance, um, even diversity of words. So is there, um, a [00:07:00]  mixture, right, of are they using nouns, verbs, adjectives, and so on? So just looking at these word based measures and other types of performance, um, data. And then the other Area was outcomes data really representing the results of intervention that's related to things like quality of life and satisfaction and functionality. So, um, that was helpful to me to categorize, um, and make that distinction. Um, and because our goal. And this is what they talk through is to optimize communication in a student's daily environment. Um, then we really should have both performance data that's collected in those environments and then also outcome measures, um, that report, you know, perceptions or satisfaction of performance by, um, Those closest to the student. So that could be teachers, of course, caregivers. Um, but then, of course, the student him or herself, right? And so [00:08:00]  I did wonder, Kate, if you would just touch on, um, examples of those, the performance data that might be tied to or, or more appropriate for complex learners, because this might be easier for a child who, um, Um, is maybe more verbal, but not one that is, um, where, where there's just more complex, um, profiles. So if you wanted to talk about that for a little bit, I would love to hear your input.  Kate Grandbois:  Sure. So, I mean, anyone who's listening to this podcast knows that, or has been listening for a while, that this is my jam. This is the, this is my clinical wheelhouse. I'm very fortunate to have worked in AAC for the last almost 20 years now. Uh, not quite 20 years, but over 15, not that we're counting. Um, and this particular profile, complex learners, emergent learners, early language learners, is what I, what I love to do. Um, I really appreciate the way that you've described, at least from this article, these two different categories of data [00:09:00]  collection, um, that you've Because I think often when people think of data collection, they think of tally notes scribbled on a sticky, right? You know, we're going back to your point of not wanting to sacrifice connection. We grab what we have, and we, oh gosh, I've got this, I've got this goal on whatever it is, and so we, we, we scribble our tally notes, and we think that that's our data collection, and yes, that is data collection. Uh, is it quality data collection? Perhaps not. Um, and I, I really just wanted to take a second to, um, to think to at least appreciate the different qualifiers when it comes to the kind of data that you are collecting. That is a really important first thought to kind of zoom back to this learner's question or this member's question about what recommendations they can make to their mentor. And I think the first recommendation based on that article from what I'm hearing from you is really reflecting on your purpose. What are you taking data about? Is it outcomes related? [00:10:00]  Is it performance related? Is it aligned with our EBP model in terms of considering clinician's perspective, client's perspectives and values? Um, I think when you keep that as a lens, it's a lot easier to then zoom in a little bit further. Um, and think about what data collection methods are most appropriate, uh, to your next step or to the targets that you're, that you're trying to work towards. Now, I know that I just went really off topic, but to answer your question about an example for a more, a complex learner or an emergent learner, um, I think that when you're, first of all, every child is unique. Every learner is unique. There is no, I have, I have big feelings when I hear things like, well, this is the way it's done or this is what we do here or no, you are always customizing your AAC intervention to your learner, especially if that learner has a complex profile. So a number one, um, you're always making data driven decisions, person driven decisions, [00:11:00]  patient centered decisions. Um, particularly when there is complexity involved. And a lot of com, when you're working with complex learners, often your first objectives are related to teaching symbolic exchange, teaching the use of symbolic, uh, language. Now, when I say symbolic exchange, I'm not talking about pecs before anybody gets a little grouchy thinking about pecs and all of the grouchy feelings that we've developed about pecs. We are talking about moving through a developmental lens to teach a person how to use symbols to communicate. Um, and I think, you know, that can look like a lot of different things that can, when you're talking about AAC, depending on your learner, that could look like point selecting icons in a sequence. It could look like scanning a visual field to select an icon and make a purposeful choice. It could look like sequencing two icons. together to produce voice output, [00:12:00]  uh, it could, it could be producing one symbol for a function that isn't just requesting or perhaps they are an emergent learner and they're, you know, in developmentally making requests and making basic wants and needs known is a main goal. So you want them to produce a single symbol to get their wants and needs met and then everybody's throwing a party, right? So it really will depend, um, So much on who the learner is in terms of choosing that those targets and choosing that data collection strategy for performance. If anyone is listening wants to learn more about, um, the lens of AAC and going back to basics, we did a great interview with Dr. Kathy Binger, um, and Dr. Ken, Jennifer Kent Walsh called AAC back to basics that really specifically takes a good look at what. Um, the intersection of AAC and language development and how we can better integrate those two things. Did I answer your question? I know I [00:13:00]  went on like four tangents. No, you did. Ana Paula Mumy:  And  Kate Grandbois:  thank you. That's  Ana Paula Mumy:  perfect. I appreciate it. Um, that makes it, uh, a lot clearer and, um, for sure, Just having those tangible examples are super helpful. Um, another recommendation that I found in the initial stages of device use, which kind of goes back to a little bit of what you were saying, um, was to actually take data on what the SLP or the communication partner is doing. So, um, there were some really helpful questions, um, Again, for me, because this is not my area, um, that helped me think through like, okay, so what does that mean? Exactly. So things like how often does the student have access to their system throughout the day? That is a pretty important question, right? And then how many opportunities did the student have to actually use their device? Um, another question, how often are adults modeling on the device? And so that modeling component being huge, and maybe you could [00:14:00]  speak to that a little bit more.  Kate Grandbois:  I was going to  Ana Paula Mumy:  say, I've got a great example for that, but keep going. Yes, so I have one more here. Um, how often is the student attending to the modeling that's provided? So again, this isn't necessarily looking at the output from the child. It's really more talking about the input, right? What is happening? Um, with the individuals around that child who are doing something or providing access or providing that modeling and so on. So yes, please give me examples.  Kate Grandbois:  I was going to say, I was like jumping in my seat because I have such a great example for this. So backing up really quickly. Back to our sticky note with tally marks on it, right? We think that that is frequency data. So frequency data collection strategies would be, you know, marking every single instance of the target behavior that happened. And again, we're not going to get into this in detail. We will list additional references or episodes in the show notes. Unpacks a lot more of different kinds of strategies of data collection. Frequency is one of them. [00:15:00]  Percentage, who doesn't love a good percentage? I think we over rely on them out of 80 percent of opportunities, right? Everybody knows how to take percentage data Um and rates how many times you do things in a certain period of time Those are a pretty common data collection strategies in speech pathology. One of the less common ones that I love, and I swear I'm going to answer your question, is trials to criterion. Trials to criterion is a data collection strategy where you're looking at the number of opportunities or the number of trials, trials to criterion, that a person needs to achieve a certain outcome. Threshold or to achieve a predetermined set of mastery. The reason that I love trials to criterion is because I have applied it to measuring the behavior of communication partners. And this is my story. I consult to a wide variety of. of programs in in Massachusetts area. Uh, because I'm a BCBA, don't anybody hate me. I'm not evil. Because I'm a [00:16:00]  BCBA, I work a lot with behavioral programs. I work a lot with BCBAs, um, and trying to integrate some of this speech pathology. research, knowledge, best practice, person centered care in some of these programs. And in that work, we have one, one program in particular, we did a lot of patient education, a lot of teacher education around the importance of modeling, around the importance of language bombardment, around the importance of making a, making someone's, um, program linguistically rich. And what we did was To kind of flip the script, we said, okay, how many trials does this one particular complex learner need to produce a word? How many models do they need? And what's nice about this is that we switch from asking the question, what does a student know, to how do they learn? Once you know how a complex student learns, rinse, repeat, you've got the recipe, [00:17:00]  let's make all the cookies, let's make all the words, let's, let's do this again and again and again, but when you really flip your thinking to thinking about asking questions and taking data to learn about how they learn instead of what they know, you can really apply that to the entire environment. So in this particular example, we took trials to criterion data on the number of models that were provided in a day. And to learn how many times did this one kiddo need to get exposed to this one word for them to be able to produce it. And the answer was hundreds. What's amazing is that he was able to get hundreds of exposures in a short period of time because the staff got super competitive and they, and you know, they started becoming more aware of their own behavior and their own roles and responsibilities as communication partners. Um, so. So another tangent, I guess that's my, my function and my role here today is to go off on these tangents, but it's the different data collection [00:18:00]  strategies you choose can really help you shift the way you're thinking about where that, where the quality data comes from because it's not just your communication. It's not just, it's not just your student. It's not just your client. You could be looking at data about the environment. You could be looking at data about the communication partners. We're really talking about a whole. a whole human and a whole microcosm, a whole environment, a whole set of variables that we need to consider for AAC success. I hope I answered your question again.  Ana Paula Mumy:  Yes. Thank you. One more thing that I wanted to touch on before I'm going to pose another question to you, Kate, is I found just a variety of data collection sheets that were downloadable for free. And again, for me, it was helpful just to think through, like, how are they structured and, you know, just in different ways and organized. And so there were some that were goal based versus prompt based data collection. And so one example was, um, data collection that was based on, um, [00:19:00]  modeled words. So you select a word and then show, of course, the child, you know, what happens when you select that word. And so having that, um, sequence of modeling and then seeing, um, Or giving them a taste of what does that produce, right? Or what's the outcome after that happens? Um, and then, uh, the, Um, it was also, uh, a word selected by the child after a prompt was provided, um, and then a word selected spontaneously by the child without any prompting. So they had essentially like an MPS format where you were tracking modeled words, words that were prompted, and then words that were spontaneous. So MPS, um, was one way that it was structured. Um, another one, um, another example was, um, Based on a variety of language functions like requesting protesting are they commenting [00:20:00]  describing negotiating and so on so there was lots of different options to think through because I, um. I feel like so often we get stuck on just requesting, right? It's just a request a button. It's just and that's like the only thing that counts or that really is being monitored when there's so much more right that we can look for when it comes to language usage beyond just number of words. So. Those were really helpful for me to look through, just in terms of thinking about, you know, efficiently tracking usage, um, with different parameters. Do you have anything to add, um, in relation to, to that?  Kate Grandbois:  I, I  Ana Paula Mumy:  think,  Kate Grandbois:  you know, everybody wants a good data sheet. You know, data sheets are better than your sticky note with Scratch with, with tally marks. I think something that you bring up that's really important to think about is the relationship between data collection and goal writing. Uh, we, again, this is a whole other, [00:21:00]  this is a whole episode that we can link that we've done on the importance of measurement target selection. Uh, we will link that in the show notes as well. Um, the short CliffsNotes version is We think of data collection and goal writing as something that happens in a sequence. So first we write our goal, then we take our data. And that's absolutely not the case. We need to be thinking that these are two things that happen in tandem. They influence one another. Uh, we want to be thinking, before we write our goal, we want to be thinking about what kind of, what's the data collection going to look like? Is it reasonable? Is it doable? Who's collecting the data? How often is it going to get collected? Um, you also want to think about your target when you're writing your goal and how your target's going to get measured. Is it a target skill that's really fleeting and you have to be watching the entire time? Is it a target skill that is prolonged? Um, is it something that's low frequency? So you're going to be lucky if it happens once a day, or is it high frequency where it's potentially happening multiple times in a half hour? Um, all of [00:22:00]  these things are really important to consider when you are thinking about your data collection. Uh, and when it comes to recording your data, There are a lot of different ways in AAC to do that. I think the way that the best way is the one that works for you, that keeps your hands free, that keeps your attention on your client. Um, there are two strategies that I think are, um, there are a handful that I think could be considered that I think are worth considering. The first is maybe a tally counter or a golf counter. I don't know why it's called a golf counter, but you know, they're like little clicker. They're like bouncers. You see them at like the, at the clubs, uh, you know, uh, clicking for, for capacity in a, in a, you know, in a bar or whatever. Um, those are nice to kind of hang on your belt with a carabiner. You could do one on each side. And then, uh, Um, if you're doing percentage data, one, your right side [00:23:00]  is for successful trials. Your left side, left side is for unsuccessful trials. At the end of the session, you've got a total percentage. Um, you didn't have to do any sticky notes. Um, another consideration would be, um, another consideration would be probe data. So probe data is really complex. Um, we have a whole episode on probe data. The short version of the story is that any data collection system that you have, you want your data collection to be. accurate, reliable and valid. If you are not measuring accurately, then you're not going to be able to inform your goals and you're not gonna be able to measure progress. It's impossible to, in a lot of instances, track every single instance of an occurrence. That is when you get into this trouble of not being able to engage with your client and have a nice connected session. Um, a potential answer to this problem is probe data where you're only recording predetermined, a predetermined set. of a certain number of trials. The problem with probe data is that it can be really [00:24:00]  inaccurate. It can violate that, you know, ideal standard of data collection that's accurate, reliable, and valid. The way to mitigate and take probe data in a way that is better is to take more, the more probes you take, the more accurate. And if you add a qualifier to that, so let's say you're recording the first three trials, but you're also recording whether or not it was prompted, you're also recording how long it, you know, the duration, you're, you're adding some qualifier onto the probe, the more probes you take, and the more qualifiers you add, the more accurate it is. And again, we have an entire hour long episode that reviews the research. Not that any, it's very dry. I know it sounds boring, but we really liked it. Um, so there are a lot of different ways that you can make your probe data more accurate, reliable and valid. I think another problem with AAC in particular with data collection is that it feels cumbersome because you've got this extra device. So you're like, but I got the device and I've got the student and now I have these golf counters and a pen and a sticky note and there's all these things. Um, [00:25:00]  it can feel really overwhelming. And I think there is often in a lot of. A lot of instances, a big temptation to use the internal tracking system. So a lot of our devices come with internal data collecting data collection trackers where you can toggle it on and it will record every instance of a target behavior or every instance of a target communications or every instance of an icon selection rather. Those are really tempting, but they are very, they have a lot of limitations. So the first major, major limitation is ethics. We have heard from the AAC community that these mechanisms feel very much like spying. Imagine if there was someone walking around with you all day, following you around, listening to every single thing you said. But didn't tell you that they were listening. Uh, we need to be, if we're going to use these mechanisms, we need to be extremely careful about turning them on and off and doing it with informed consent. And that's informed consent for the AAC user and potentially their families, depending on their age and all these [00:26:00]  other kinds of things. The other thing that we really need to think about with these internal data collection systems is the law. So, we could, depending on your state, there is a potential that you are violating a privacy law, uh, by taking this data and storing it in a cloud. Um, that is not part of your district. It could be a violation of FAPE here in Massachusetts. We have to be very careful about that. And we have families sign additional permissions, some schools and some programs I work with won't even do it because it is too close to some violations. So check with your administrators, check with your state and make sure that use of these is even within the provision of what would be considered. Um, Uh, secure storage of data as part of an educational file. So that's another consideration there. Um, the other and last limitation of these internal tracking systems is that they are going to track everything. This, these little tiny robots and say, these machines don't know if it's you that selected the button or the child that's or the student that selected the button. So if you [00:27:00]  are using them for short periods of time, because we know we have to turn them off so that we're not theoretically, you know, following someone around listening to what they say all day. While it is on, you want to make sure that you're only capturing what it is that you're measuring. So if you're capturing models for a communication partner, you want to make sure that the student doesn't select a device, doesn't select an icon, or conversely, if you're using it to measure independent student productions, you have to make sure you're not providing any prompting, that you're not providing any modeling on the device, that the tally mark that you're getting is actually independent productions of the student. So there are a lot of limitations to those. Uh, and those are all really important things to consider.  Ana Paula Mumy:  Absolutely. Yeah. I hadn't thought about that. Um, for sure. And it really, I think in some ways that almost defeats the purpose of, um, the therapy strategy of modeling. Right. So if, if your goal is to model a [00:28:00]  ton and to really see that growth through modeling, then you almost would be shooting yourself in the foot if you used it. Right. Like, yeah. Yeah, well, I want to just ask a follow up question to just, um, in relation to the gold writing. So you kind of already answered the initial question that I had. So I'm just going to add on to the question. Um, just because again, thinking about our member who's mentoring someone, um, And really just understanding that relationship between goal writing and data collection. How might she help her mentee with goal writing to help with better data collection? Does that make sense?  Kate Grandbois:  Yeah. And I think, you know, again, this is a really great question. And like you said, at the beginning of the episode, to really answer this question, well, we need a lot more information, right? Because we don't know if this individual is a complex learner, we don't know what their goals are. And the goals and [00:29:00]  targets are going to have a significant impact on how progress is monitored, because again, Data collection and goal writing are BFFs. They cannot be separated. You cannot do one without the other. They don't happen in a sequence. They happen in tandem, and they influence each other, influence each other continually. Because as you're monitoring progress, theoretically, if they're making progress, the goal may need to be adjusted, right? That's why we have annual IEP meetings, because we're rewriting goals based on progress. Um, I think when you're working with a mentee, And you're trying to unpack some of these concepts, I would go back to the goal first and I would go back to the target and think about what it is that you're measuring and all the variables that will influence how that measurement is taken. Um, that might include all of the things that we've already mentioned, but the environment, the communication partners, how fleeting the communication [00:30:00]  target is. Um, and I also think it's important to have a little bit of forward thinking. And I know where this is a question about a school environment. Um, so theoretically you have an entire year under the IEP to take that, to take that data collection. But having a really good baseline measurement is also really important because if you don't know where you started, How do you know where you're going? And for some, particularly complex learners, really small steps are really huge deals and we don't want to miss them. Uh, we don't want to not give credit where it's due for our students who are working so hard and the paraprofessionals who are working so hard and the teachers who are working so hard and the whole team who was working so hard. Right. So taking those, I would also be really asking a lot of questions about where the student is currently and taking really good baseline measurement. So that you have a strong foundation off of which to judge what progress was made to begin with. Did I answer your question? [00:31:00]   Ana Paula Mumy:  Yes. Okay. So do you want to talk a little bit? Do we have time to just touch on, um, do you have like favorite ways to, um, measure baseline or recommendations or strategies that you, like your go to, um, options, you know, for baseline? Oh, that's a really, it's a  Kate Grandbois:  really good question. Um, I think not as a standard because it is going to be influenced so much by the learner and the environment. Um, I think in a perfect universe, we would take enough baseline measurement to have a solid understanding that this is exactly where the student is and not just a bad day. Um, particularly for more complex learners who might be, you know, presenting with sleep disturbances or, you know, there might be other things going on in the child's life that make that one day that you took baseline measurement, not the best day for baseline measurement. So in a perfect world, we would have a decent amount of baseline. A decent amount of measurement at the beginning of treatment to have a good understanding of where [00:32:00]  we are, so we can decide where we're going. Um, I also think that designing data collection systems that feel achievable and doable is really important because if it's not achievable and doable, then the data that you collect is going to be. Inaccurate. Uh, in one of our data collection courses, we talk about this a little bit in a little bit more depth, but there's an expression, garbage in, garbage out. So if your data collection is inaccurate, that's going to inform your progress. In an inaccurate way, which is going to lead to inaccurate decision making and clinical reflection, um, and potentially poor choices for implementation and intervention. So, really making sure that we hold data collection strategies that are, um, Accurate, reliable, and valid at the center is really, really important. And there's really no gold standard because it's such a customized experience. We also have a, we have a handout on our website that I will include in the show notes as well [00:33:00]  on what accurate, reliable, and valid data means. Um, and again, referring people back to our original, you know, some of our previous work in data collection, just because I recognize that this is a very, a very nuanced, very nuanced conversation.  Ana Paula Mumy:  Yes, well, and just, you know, one takeaway for me, just as you were talking is to really think about representative samples, right? And when we think about this, whether it's a speech sample for an Arctic kid or language sample for a child with a developmental delay. I mean, it doesn't matter what the. Uh, situation is we have to make sure that we are doing what we can to make sure that we are sampling, um, their speech, their device usage, whatever in the best way possible, but also yielding the most representative sample possible. And so. It might take more than one trial, right, to get there. And because, like you said, there's so many variables that could impact that individual's willingness [00:34:00]  to participate or willingness to show what they do know or what they are capable of doing. So, um, so, yeah, that's important. I think sometimes, you know, with AAC, we, we tend to maybe think, um, differently, or, or we don't use sometimes like just the basic knowledge that we already have about like, yeah, in the same way that this applies to X, Y, Z, it's going to also apply for our AAC users. Um, there's maybe, like you said, nuances or different things that we have to take into consideration, but it's still, there's some basics that. Are just foundational, right?  Kate Grandbois:  Totally agree. Totally agree. So, I mean, I think, I think I really appreciate the literature that you brought to the table. I know I shared quite a bit, but I couldn't help myself because this is my area. This is my clinical area. I love  Ana Paula Mumy:  learning from you.  Kate Grandbois:  So great. Um, we will link every all of the additional resources in the show notes and Apollo. Was there anything else that you wanted to [00:35:00]  share?  Ana Paula Mumy:  No, that's it. That's all I had for today.  Kate Grandbois:  And to the listener who wrote in this question, thank you so much for writing in. We hope we did it justice, um, on, you know, in terms of what you shared. Anyone out there who's listening, if you have a question for us and you're a member, Please write in, we would love to read your questions and do a little literature search for you and discuss your clinical case on the air. Um, Dr. Anupama Moomy, thank you so much for being here. This was really wonderful and we look forward to the next iteration of SLPD On Demand.  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, [00:36:00]   www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.