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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:  Welcome to SLP Nerdcast. We're so excited for our topic today. We are here to talk about something that is under discussed in the field of speech language pathology, and yet at the same time, something that is critically important [00:02:00]  for every single thing we do as speech language pathologists. We're here to talk about counseling, and we have two content experts here with us to make the conversation even better. We're very excited to welcome Dr. Corrie Clark and Kate Mellillo. Welcome Kate and Corrie. Hello. Yeah. Thanks for having us. We're very excited to be here. I was thinking why I listened to this podcast. Amy Wonkka:  We're so happy to have you here. Thank you so much for sharing your time with us today. Um, like Kate mentioned, you're here to discuss counseling with a focus on children and adolescents and executive functioning and relationships. But before we get started, can you please tell us a little bit about yourselves? Kate Melillo:  Sure. I'll go first. Okay. So, um, I'm Kate also. Um, I am a speech pathologist in North Carolina. Um, Cori and I co own Be a Problem Solver Services, which is our private practice. [00:03:00]  Um, and my focus is on executive functioning and social skill building. Um, and our practice is actually both mental health. and speech services. So it's a little bit of a unique combination. You don't see that a lot. Um, and I'm, I also write a lot of social emotional learning content as my other job. So I'm, I'm in this world all the time. And I'm Dr. Corey Clark. I am, um, a licensed clinical mental health counselor. Um, I specialize in working with, uh, children and adolescents and, um, I also teach, uh, a, a clinical mental health counseling program, uh, called the Chicago School and I, I am also the president elect of the Association for Child and Adolescent Counseling, um, and so a lot of my focus is on, you know, the unique work with, uh, counseling children and teenagers. Oh, and we're also married. [00:04:00]  We are also together. So if you hear us having a marital argument, that's great. That's what podcasting is the perfect platform for side chatter. Um, so that's, that's wonderful. And I, I want to circle back. I were tickled that you listened to this podcast. It's always funny for Amy and I to hear that kind of thing because we hang out in a zoom room and then we send these off into the ether. Kate Grandbois:  So it's, it's always nice to hear that. Um, and we're, as I already mentioned, we're so excited to have this conversation, it, you know, counseling touches everything we do, and your practice is unique, and it sounds wonderful blending these two areas of competency, um, and we're very excited to get started. I do need to read our learning objectives and disclosures. I will try and do that as quickly as possible. Learning objective number one. Describe key knowledge areas, attributes, and skills of child counselors To incorporate into speech sessions as they [00:05:00]  intersect from the competencies for counseling children and adolescents. Learning objective number two, describe three relationship based counseling strategies that can be easily included in speech sessions. And learning objective number three, Identify how the mental health strategies discussed intersect with executive functioning treatment in the relationship based model of executive functioning. Disclosures, Corey's financial disclosures. Corey is the co owner of Be A Problem Solver. Corey is the co owner of Be A Problem Solver Services, PLLC, which is a mental health and speech therapy practice, and Be A Problem Solver Education, LLC, a parent education service where Corey received a salary for a speaking fee. Corey is a faculty member at the Chicago school where he receives a salary. Corey is non financial disclosures. Corey is president elect of the association of child and adolescent counseling. Kate's financial disclosures. Kate is the co owner of be a problem solver [00:06:00]  services, PLLC and be a problem solver education, LLC, where she receives a salary and a speaking fee. Kate is a research strategist at 3C Institute where she receives a salary. Kate's non financial disclosures. Kate has no non financial relationships to disclose. Kate, that's me, Kate Granbois. I am the owner and founder of Granbois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and 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, that's me. My financial disclosures are that I'm an employee of a public school system and co founder of SLP Nerdcast, and my non financial disclosures are that I am a member of ASHA Special Interest Group 12, which is AAC, and I also participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, we've made it through the disclosures and the learning objectives. On to the actual content. Um, [00:07:00]  Kate and Corey, why don't you start us off by telling us a little bit about the first learning objective? So I guess both what are some clinical competencies for counseling children and adolescents, but also why is it important for SLPs to be aware of and to develop these competencies? Cory Clark:  Yeah, so I'll start. Um, this really, for some context, this really started in the last five years where I, as a, um, counselor saw that counselors were being trained to treat adults from a more general model. And I found that working with, um, and teenagers was a very unique process. And I think that really started from working, uh, Kate and I met, uh, working at a preschool and, um, I had a, you know, background in working with kids in that way. And, and I saw that a lot of people were going into the field, just kind of treating kids like little adults, you know, and it was, there was an [00:08:00]  incongruency there. So I was really interested in what makes working with kids and teens unique because I knew there was. A uniqueness there, but I wasn't quite able to pinpoint it. And so, the last five years, I've really been focusing on interviewing experts in the field of, uh, child and adolescent mental health and identifying what makes working with kids and, and, and teens unique and what are the basic best practices and working with, with that population. And so, that is, is where I, um, published and, and, and focused a lot of my dissertation research. best practices for working with kids and teens. Um, and really what it comes down to is really the foundation around child centered therapy. And so what that means is child centered therapy is in its nature very non directive. Um, it is very much based on the Carl Rogers, uh, person centered counseling [00:09:00]  model, which is unconditional positive regard, having congruence and empathy for the, for the person. And And because of that, there's not really a lot of, like, specific behavioral goals in, in, um, child centered therapy, um, but a lot of research supports that a lot of behavioral change and, um, good, uh, coping skills and good development happens from that. Uh, play based child center therapies. So, um, that is sort of the foundation of, of a lot of the, the, um, best practices for working with kids and teens. And so, you know, looking at, uh, What kind of the model that I came out with initially, um, there's attitudes, actions, knowledge and skills. And I broke it down to those four kind of domains. Um, and so go ahead.  Kate Melillo:  Oh, so before we jump in, because are you about to jump into those domains before we jump into that. [00:10:00]   I just want to touch on why this matters for SLPs and why we see like a really big crossover with executive functioning skills. So, you know, I think like if you're listening to this, you're like, well, what does that have to do with what I do on a daily basis? Um, however, like at our practice where. Counseling and speech therapy all the time. I mean, and I think a lot of SLPs, especially when you're new, you go in and then you're like, Oh, I didn't like now a kid is crying in my office. And I didn't expect that. Right. Like, or they're dumping out like, Oh, well, my home, my mom told me this, like, they're just telling you everything. And actually, it's funny. I remember in grad school, I had this one professor who's like, you're going to be so surprised. They're going to come in and tell you everything. Cause you're like the sort of, you know, side person in their life. A lot of times, like you're like this extra [00:11:00]  support person. Who's not the parent. And there's no other, like, side person. Like, you don't have this other, um, stake in the game at, like, you know what I mean? Like, they are kind of coming to you, like, friendly, right? Like, I think, like, the SLP role tends to be really, um, warm, empathetic. The things that Corey just described, but like Kate said, like, we don't get a lot of this training. Um, even though we're doing this relationship based therapy. All the time. Um, and so in terms of where we see it a lot is this like crossover with executive functioning and that's a lot of times because, um, executive functioning at its core is really regulation, right? It's, it's how our brain can regulate itself so that it then can like plan tasks, organize tasks, um, Execute tasks, right? Like impulse control, working memory. Um, [00:12:00]  and a lot of that comes down to emotional regulation. Like I always say, like I describe to my clients, like when you're in mental health. is not in a good space, like your executive functioning skills become scrambled eggs. And so it's really hard for, for students to be regulated, right? Like cope and release emotions and then be like, okay, let's, let's work on pronouns. Like it, it, it just doesn't work like that. The human brain doesn't work like that. And I think a lot of times we go into sessions and we have an agenda where like, these are the goals. That's what you learn in grad school. You're like, these have to be like good functional goals. They must achieve them. The insurance company must approve them and you must do them like, you know, and then we skip over this other stuff. Meanwhile, like, you know. Little Johnny comes into your office and he's like, Oh, my [00:13:00]  grandma died this weekend. Like, you know, I mean, and you're like, but he's the, like, you're the person he trusts. And so he's told you this information. And then you can't be like, well, let's do some grammar, you know, like it, it, it doesn't jive.  Cory Clark:  Yeah, and I, I often say that, um, I am a, I'm the person for a lot of kids, right? And teens. And what that means, what I mean by that is, is a lot of times a kid will have a person that they deem supportive and safe to say those things to. And it might be a counselor, but it might not. It might be a speech therapist and, um, or another professional. And when you're the person, right? Or one of a few persons, um, it's a. Really big responsibility and as far as how you handle those moments where they say, my grandpa died or this and that happened, or I'm feeling X, Y, Z. And so it's important to capitalize on, on creating that space, um, for, for young people. [00:14:00]  And, you know, so, so that's where I'm, I'm going with a lot of this is these best practices, um, are not just. Really just counseling. It's cross discipline in that way, so that you can hold that space. wherever it comes as a professional.  Kate Grandbois:  I also want, I want to piggyback on some of what you've mentioned. It's making me think of a lot of the content that we've produced recently, particularly as it relates to self acceptance. Uh, for example, this has come up a lot in our conversations related to stuttering therapy, uh, or self advocacy. Um, and, You can't really work on self advocacy and self acceptance without counseling and this is what we are now considering to be best practice based on evidence in the field of speech pathology and you cannot uncouple those things. I think there's a specific. Uh, flavor to working as a speech language [00:15:00]  pathologist because you are working closely with someone who is, their existence is living with a communication disorder. That is a communication disability of some sort. That is, that's why we're in their lives. So I don't, I, I wholeheartedly, I'm thrilled to hear some of this, you know, some of these threads being woven together because it is so ingrained in the fabric of what we do. Did you like that little, that little similarity there, the threads in the fabric? I just came up with that on my own. Yeah. Yeah.  Cory Clark:  So going into kind of my, um, more into the background around attitudes, actions, skills, and actions. Um, I think. I looked through the best practices that I've been working on over the years, and there's a few that I want to highlight today that are really relevant, Kate and I feel, to the speech therapy world. Um, and so, Starting with attitude, um, [00:16:00]  specifically, there's three that I want to highlight and, and they are the, the first one is something that a lot of experts mentioned, uh, when asked about, you know, what's important when working with, with children. And that is to meet children where they are. And I heard that over and over again over the years. And I was like, what does that mean? And essentially what they're saying is. You can't go into a session, a speech session, therapy session, um, with a item by item, minute by minute, breakdown of here's what we have to do, here's what we're going to do that entire time. Because kids will come in and throw a curveball or a wrench in that plan real quick. And it's important to be able to be flexible, um, to what, flexible for what, The child or teenager needs to work on or needs to address right like Kate just said if they come in and mention something about their, you know, family member passing away. You can't just be like, well, we got to work on preposition. So we're going to move past that. Right. [00:17:00]  Um, you have to, you know, And, you know, like I say to a lot of my kids, like, think like a palm tree and say, all right, I'm going to bend to this and go, okay, uh, let's pivot. Let's hold some space. Let's reflect and, and, and be supportive and empathetic. Um, so it doesn't mean throw all plans out the window, but it means. meeting children where they are and what they're giving you that on any given day. Um, that attitude is, is very important. And secondly, um, all behavior is communication.  Kate Melillo:  Wait, I want to go back just for a second. So I wanted to say about that mean children where they are, the, you know, we said a couple of negative, really negative examples, but actually The positive example can also help propel your goals forward. So for example, if a kid comes in and they're like, Oh, I'm actually going. You know, like miss Kate, I'm going camping this weekend. Well, I, you know, [00:18:00]  we'll take that and make my examples and therapy about the campaign, right? Like it becomes more relevant. Um, and so it, it doesn't have to be like a big, catastrophic, traumatic event that you're kind of being empathetic to. You're really just like tying into the kid's life and like, great. That's a vocabulary builder. I can talk about planning, right? Like there's executive function. We're going to do working memory. Like there's so many things that can be based off those examples. And I think that, you know, interestingly, I've, I've had the experience where I explained this kind of model to like a newer clinician. And, you know, like I've had job interviews and stuff, like interviewing people to come and work at our, our practice. And they're like, I don't think I can do that. Like, I don't think yet I can, I can, like, that seems like an advanced skill. Um, now granted, I like what Corey and I are saying is, is a clinical, [00:19:00]  is your clinical judgment, like your clinical sense. And that does come with time. So I don't want to make it mean like, this is so easy on the fly. Think of 10 examples that you can use when the kid says one sentence like that. I get that that is like a really hard skill to do. Cool. But I think as SLPs, we can kind of hold this in our mind. Um, and we'll talk about at the end, some examples of how I incorporate, like how I get this going. All of my students know, um, what I'm going to ask at the beginning of every session before they come in. So they're ready and I'm ready. Right. So I've primed it so that like the structure of my sessions is ready for that acceptance, right? It's, it's, ready for whatever's snowballs come my way. Um, and we can talk about that a little later on, but I just wanted to say, I just wanted to note that I get that this is like, uh, takes a little bit of practice, especially if you're used to going in and being like, you know, this is what we're doing today. Um, it's [00:20:00]  definitely a change in that. And you're in your own attitude, which is also what Corey's found in the counseling world as well.  Cory Clark:  Yeah, I think, yeah, I think everyone has their own, uh, uh, preference in terms of how they want to go into a session. And also it's based on what your, um, specialties are and how you run your, your practice. Um, for me, being flexible is just, that's what I prefer, you know, and I, I don't have a lot of agenda in, in, um. A lot of my sessions don't  Kate Melillo:  like to plan anything.  Cory Clark:  I don't. I'm just like, I just want to walk in and say, how's it going? Yeah, I love it. But there's plenty of professionals that I work with that are like, no, I need I need an agenda. I need this. It's very structured. Um, so, you know, for some, it'll be natural. Some not as much. Um, but. The, the second thing I, I want to highlight is all behavior is communication and um, that sort of attitude and understanding is important with kids and teens because there's a, there's a saying in the, in the child [00:21:00]  counseling world, um, so it's important to listen with your eyes because when you're working with young people, they're going to be giving you a lot of information content wise, particularly when how they talk, what they're saying, um, what it's about, you know, what you're working on, but also, um, Non verbally, what are they giving you? What are they saying? Um, what is their body doing? And both of those things have to happen at the same time, listening with your ears and with your eyes. Uh, because kids communicate so much, in particular, and teenagers for sure, um, with how they're, how they're sitting. Are they fidgeting? Are they, You know, do they need to move? Um, do they need a break? Are they listening? Are they focused? Um, what is their affect? All of these things are happening in real time. And it's important to be attuned to that because otherwise you're going to miss really important cues as far as how they're able to be present with you and how they are in that moment. And if you can reflect some of [00:22:00]  that, That's really, really valuable learning for them and awareness. What does  Kate Melillo:  reflect some of that mean?  Cory Clark:  Um, I noticed that, you know, you're, when I ask you to do this, you start to fizz it around in your chair. It seems to me like you may be a little nervous. You're not sure what to do, right? That's a reflection of like, Maybe they know they're doing that, maybe they have no idea. But, and sometimes it's, you know, not accurate. Maybe it's a reflection that they'll correct me on. It's also a good opportunity for them to advocate and say, No, it's this or that. Um, but regardless, you know, listening with your eyes involves that real time kind of, interaction where you're listening to what they're telling you without words. Kate Melillo:  I also think it's ironic because it is what like we teach when we're teaching perspective taking skills, right? And social skills were like, look at the other person. What are they telling you? You know, like look at their body language. Like what did that, what did it mean when they started to walk away when you were in the middle of your sentence, right? Like it's so I think too, like [00:23:00]  we're sometimes go into the sessions, like not doing the things that we're trying to teach. And I, I, I like that, you know, in the counseling world, there is this piece of reflection because it, it, it brings everybody together, right? Like you as the clinician and the student, right? So you've got both parties being like, Oh, I recognize there's a behavior here. And I I'm, what am I trying to say or communicate to this other person?  Cory Clark:  Yeah, and the third aspect of sort of attitudes and understandings that I want to highlight is that all children must be and teenagers must be viewed holistically. And what I mean by that is sometimes it's easy to fall into kind of a The trap where you are looking at one particular aspect of development, whether it be, you know, from the counseling world, like a emotional development or something with relationships, um, [00:24:00]  but you have to think about young people in terms of all aspects of their development and, you know, in particular, I often kind of. Disregard or discredit certain things, not intentionally, but be like, oh, that, you know, looking at how they're doing emotionally at school is very much tied to their social life and their social development and also what's going on at home, right? And also physically, um, their physical development, how is that impacting their social life, especially with like tweens and teens and all of that, right? So you have to consider all these, you know, domains when you're working with, with young people.  Kate Melillo:  I think we hear this all the time. If you have a middle school student with articulation errors, you are not just like, Hey, let's fix those errors. It is impacting them socially, right? Like those friendships are coming into play. Um, and I, so I think this like core best practice of the [00:25:00]  holistic child is so important because, and I think, I do think like Some of these things are becoming more mainstream in SLP, where we are starting to look at, hey, how does this affect you in these ways? And maybe you're making, you're working on some like, um, social, like, strategies to, you know, help, not just with the articulation disorder part of it, right? So like, you're, you're, you're using multiple domains there, um, to help that kid. But I think that, It's different than what we thought of as like the traditional Western medicine model where we're like, let's just treat these one this one symptom and make it better. Like we really actually need to be looking at everything because that's going to round out a kid's mental health, and the way they interact with the world. Cory Clark:  And I, so the next. area, the domain that I want to talk about are knowledge bases [00:26:00]  and understandings, um, of counseling with children and teenagers. Um, and the first one I, I really want to focus on is, is the most common, um, issue I hear. And when people come to see me in counseling, they will say that, um, they've tried counseling before or they've tried some sort of, um, therapy service before. And the parents or guardians or caregivers were left feeling like I had no idea what was going on. Uh, they never told me, they just kind of went back into the session and I didn't know what was happening. And then they were left frustrated, like, I don't know what the goals are, what's going on, right? Or they didn't understand them. And so they come to me, like, will you let me know, like, what's going on, like, you know? And, um, I always tell them that although I'm, you know, I'm not going to say exactly what the content is of the session, like there's privacy there. You will always know what my treatment plan is and what my background [00:27:00]  is and what my training is and how I intend to use that to support your child or teenager. Um, so the, the first really knowledge base that I wanted to focus on is, um, how to involve family or caregivers or guardians in therapy services. Um, it's so important to involve. Other stakeholders in a sense, but family members in, uh, as appropriate, because kids and teens operate in a system, uh, they're part of a system, and you have to be able to translate what you're doing to, um, how it can be reinforced at home and other settings, um, so that involves communicating a lot of those goals and a lot of those things to parents and to, to, um, family members. And that can be tricky, um, depending on what the situation is in, in your service, um, but you have to be able to, to translate that, um, or else you risk losing the [00:28:00]  connection you have, um, with, with the family, um, and they'll pull, you know, maybe prematurely pull them from services or feel like it's ineffective. Or, in a lot of cases, think that you're not doing effective work because they don't really understand what, what the goals are.  Kate Melillo:  Well, and I was also going to add, because a separate, a separate best practice is also the developmental models and how to apply them, and I want to just integrate this into the sharing with the family, because the other thing we hear quite a bit is, you know, families will come and say, Like, I didn't know what was going on and not really for, for speech. I actually have a lot of parents in my sessions. I, I, I just prefer that. Sometimes if it doesn't work with the kid, I'm like, okay, you got to get out because you're, you're entering this session parent. Um, but I like the parents to hear because a lot of times I'm giving homework to the family and which is more counseling ask, right? Like, I'm like, this is how we're going to integrate this because we do hear a lot. Oh, I've tried that before, and it doesn't work. [00:29:00]  Um, Cory hears that in counseling all the time. Yeah. And the, uh, the developmental piece that I wanted to point out is, you know, we are in this field, we're experts at these developmental theories. Like, we know all of this, like, background information that a layperson parent doesn't know. So a lot of times parents will come and say, like, you know, Oh, my kid is like now climbing the bed with me. It, they don't sleep anymore, blah, blah, blah. And maybe that in that kid's life, you know, they're going through a developmental transition, which we know about. And we have other parents come and tell us like their eight year old did the same thing. And we're like, okay, now we can show that that's fairly common, but not every. You know, person is going to know, like Erickson, Piaget, Bandura, like they're not going to know that. And a lot of times SLPs, uh, we get like a little bit of that. And I feel like it also depends on your grad school program, right? Like where the focus was on those things. And they're so varied that maybe you [00:30:00]  don't know as much about that. Which is why it's like, we're talking about this because that's something to share with parents. Um, hey, let me find out more information about that for you. That's helpful. Or make a referral, which we'll talk about at the at the end here, but I I'm pointing that out because I think that there's times when families feel like they're just. navigating this alone. They're the only person that it's happened to. Um, and that it's just, that's just usually not true, actually. Like usually it's happening to a lot of people, but nobody's telling them that. And so when they come in your office, they're like, hello, professional person, do you have the answers for me? Um, you know, and so it's a good, it's a, it's always a good idea to involve the family as much as you can.  Cory Clark:  Yeah, and the next, uh, understanding that I want to highlight, I just want to have a caveat about, um, and that is, it's important to understand the basic foundations of play therapy, and the caveat there that I want to [00:31:00]  distinguish, I do not expect this. I did not expect every therapist to be a registered play therapist. I did not expect speech therapists and other professionals to be play therapists, um, that has a separate and distinct, uh, licensure and, and process and credential. But, the foundations of play are important to consider in working with kids and into teenage years, um, because they allow, um, Young people to express themselves in their natural, in the natural form, which is play. And, um, and so a couple of important points about play therapy, um, they, it's important to accept children exactly as they are and allow themselves to express themselves freely, um, and have a sense of permissiveness to do that. So, you know, thinking about where your, your practice is, whether it's telehealth or, um, an outpatient setting or a clinic somewhere. You have to think about what is that setting doing for them to be able to express themselves, [00:32:00]  um, and you have to ask yourself, like, what, what does that look like for you and your practice? Um, it's important that they have that space. They feel free to express and be themselves with whatever they're, you know, intending to do. Um, and as a therapist, you reflect what they're doing, like listening with your eyes, and um, allow them to gain insight into their own behavior. So that looks like, it can feel very, um, odd at times, because, you know, you're almost like narrating their life, like, like a, you know, bird's eye view, if you will. You know, someone's like playing and they're like, they hand you something rather than just, you know, like they're handing you a figure, you know, and they start, they want you to play with them. My instinct as like a father is to take my son's, you know, figure that he gives me and then I'm going to create like a game with it or a story or whatever. Let's play therapy a lot of times in most modalities. You're not going to do that. You're not going [00:33:00]  to direct them and, you know, say, Oh, now I'm going to create a story. You're going to say, Oh, you want me to play with you. You're really excited for me to play. No, you're giving me that. Okay. And then you sit down and you let them dictate what the play is. Because they're communicating that way. Right. And so in, in a, in a speech sense and that speech therapy, in a sense, it's being able to reflect what, um, your client, what your, your person is, is giving you in a way that allows them to gain insight into their own behavior and their own affect and feelings. Um, and that's really, really healthy and important for their development.  Kate Melillo:  Well, and I think speech therapists, speech therapists are doing this, right? Like if you think about like. the fundamentals of like early intervention really, you know, here's, you're at a kid's house and you're like, here's the farm that you have. I'll just use the good old farm example, where, you know, you're like, Here's the cow. What does the cow say? Right. So you've got a lot of opportunities there for [00:34:00]  like vocabulary building and all of that other like syntax stuff that you want to target. Um, and I, I, I wanted to point out that so play therapy gets the rap of being for little kids. Um, but court. So we haven't mentioned this yet. We didn't say this because this isn't really that relevant yet, but so we're also both trained improvisers. And so we do a lot of improv with our clients, especially tweens and teens. Because I think that the other thing about play therapy is that it's about that acceptance. And those improv games, that is what they are, right? Like if you've ever heard the concept of yes and it's, I accept the idea that you've just given me and I'm going to build on it. And that is what, that's actually what you're doing when you're in your little farm scene. That's what you're doing, right? It would be weird if the kid was like, here's my cow and the cow wants to drink. And you were like, [00:35:00]  ah, that cow's actually on a rocket ship going to the moon like that. Right. And that doesn't make any sense. That is one of the fundamentals of improv comedy. And so we use that a lot. And I think, um, it's confusing to parents, parents will, how many times have you heard, Oh, all they do, they go to that therapy and all they do is play. Um,  Cory Clark:  It's like saying, oh, I went to therapy and all I did was talk. And it's like, that's, that's right. You know, playing is communication. But, but that's not a common, I don't think, understanding that like, You know, and play therapy is very evidence based, and it's very, um, it's very clear how to do it once you learn it, um, but it's very misunderstood because we use the word play all the time, like, let my kid play, and my kid's playing in the other room, um, but, you know, I use so much improv with, with kids and teens where, you know, I'll have a figure and it looks like a superhero to me, like, But they'll hand it to me and say dad or whatever. I'm like, okay, this is [00:36:00]  dad, right? Like you accept what they're giving you and in that way They're telling you their story and you get to hear it from their lens not you know What your instinct is tell you like no, this is a figure of Batman, you know, whatever, right? So you have to be able to roll with that again be flexible and meet them where they are and reflect And I think that's essential  Kate Grandbois:  I, the only thing I have to add to that is some of my own experience. I've been trained. I had to go through this very specific training in child led play and it was hard. It was so much harder than I expected it to be because of exactly what you said. I'm like, Oh, playing. I can get on the floor. I can do some Legos. I can get out the cow and the chickens and you know, make some animal noises and make it fun. I can play. I know how to play. I'm a pediatric therapist, but really taking the child's lead and filtering your own responses and not coming up with [00:37:00]  directives and not asking a ton of questions and really letting them direct where the play goes is a Harder than you think. So if anyone is listening, and I just, I think it's a, it's a great exercise. What you're, what you're proposing is a really great exercise to really think about what play means from a therapeutic evidence based lens, because it might not be That colloquial casual. Oh, we're just playing. We're just on the floor. It's very different and it's gonna feel hard It can feel challenging. That was my experience  Cory Clark:  It's and it's so hard that I mean it's important to note There are some modalities that are more directive play therapy but You know, without getting into the nuance of that, um, there's a misunderstanding that like, oh, if I play UNO with a child, that's play therapy and that's, that's free play. That's, that's playing a back and forth game that has set designed rules. Um, so that's not play therapy. That's playing a game, right? So there's all these. You know, misunderstandings [00:38:00]  based on the language really. Um, and play therapy is, is a distinct process. Um, and I always say the most exhausted I am after a session is a non directed play therapy session because, uh, 45 to 55 minute session is, It goes by, you know, it's, it's exhausting. Kate Melillo:  Well, and I would say too, like, I don't know if you guys, have you read the Declarative Language Handbook by Linda K. Murphy? I love that book. It's a really good resource. It's not a play therapy book, but I use it a lot. And Cory mentioned terms that were declarative language. Like, I see you're doing this. What happens next, you know, um, Tara Sumter, too. She has her reflexive questioning guide. Like, those are also those reflexive questions. And it is, Kate, like, to your point, so hard to, like, bite your tongue and be like, But didn't you mean this? You know, and, or, like, weren't you going to do this with this? Or, like, you're trying to guess the kid's plan. And that's actually not teaching [00:39:00]  them the skill for that, like, future thinking, right? Those executive functioning actions of, like, Oh. You wanted to see what I was going to do. And then when they make a choice that's like, I don't, I don't know if that was what we were going for here. Then you're, you have the opportunity to discuss it and see how you could have done it differently. Whereas if you had done the directive play, you would not have gotten to that point. Um, it's also why we love those improv games because they're They're totally impulsive. Like you don't actually know what the kid's thinking. We can't know what anyone is thinking, you know, um, which is a big, that's a big like nugget there between the counseling and SLP world because we, since we do tend to go in with like, here's our strict, you know, plan that we've got, here's our goals and counseling. It's a, it's really a free for all. You're there to share what, It's going on with you. Um, and as [00:40:00]  SLPs, I think we, we tend to, I don't want to say like disregard it, but we're just not as, you know, it's not our area. We're not as skilled at looking for those clues. But when we do something like a child centered play therapy session. We open up the door, right? If we, if we allow kids to kind of lead, um, and also not tell them what they're supposed to do,  Cory Clark:  what we thought they were  Kate Melillo:  going to do,  Cory Clark:  right. And if, and if you're listening like, well, I'm not a play therapist, how would I know how to do that? And I do not expect even every therapist, every counselor to be a play therapist again. It's about. Um, understanding the foundations of what, what play can mean in counseling or can mean in therapy, um, and what it looks like and how you can reflect in a way that allows for that development, right? That's, that's incorporating play in, in therapy. That's, that's what this is about. Um, and the last kind of thing I want to mention about understandings and, um, knowledge bases [00:41:00]  is atypical versus typical child development. We all learn development of models in school and we learn, you know, the basics, but it's easy to forget some of the more kind of subtle pieces of development. For example, you know, someone will come in. And I'll hear, um, you know, uh, concerns from a parent or guardian around how their child is just so rigid about, you know, a sense of justice, like, it's not fair that my sibling gets this, or why does this peer or classmate get to do this and I don't, and it causes problems, and I'll have to kind of remember, oh, there's a very specific point in child development where that is just front and center in their development, like, I, this, deserve this, and this, and like, and there's very black and white thinking that is common, uh, as part of development. So, sometimes, you know, the therapy session involves me kind of walking through [00:42:00]  typical kind of phases that, that kids are going through that is commonly seen in certain ages. Um, and so it's important to kind of think about, okay, Is this behavior or is this issue, um, part of like common social development or is this something that's like, ooh, that they're 14 and still kind of chronologically still kind of struggling with this thing that is usually seen chronologically at age 8. And, um, we're doing that a lot as professionals in speech, I'm sure, but it's easy to kind of get lost in the nuance of that. Mm  Kate Melillo:  hmm.  Cory Clark:  All right. So, um, moving into. best practices and skills from a counseling sense. Um, I've mentioned a lot of these before, but the first one, you know, basic counseling micro skills is what, what I'll say. Um, what are micro skills? These are the little, not little, but subtle behaviors that a counselor or a [00:43:00]  therapist does in sessions to allow someone to feel heard, to feel supported, to feel that they're not judged. And so, you know, the main things I want to highlight are It's important to reflect, like I've mentioned before, um, what you're, what you're getting and, um, encourage rather than praise, uh, so, you know, I always have to stop myself from saying like, oh, that's  Kate Melillo:  good job,  Cory Clark:  good job with that drawing you made, right? And that's, that's praise. Um, encouragement is your work. You worked really hard on that. You were so focused when you were doing that, right? That is encouraging them and their behavior in the process rather than the end product. Um, so, uh, another important piece is being creative, um, and in sessions. Um, so. You know, being able to tailor what you're working on, um, as far as your goals and sessions to be, you know, being creative around how that looks. Um, we get, we settle into our, our favorites kind of [00:44:00]  activities or interventions. And sometimes we can get frustrated when we're like, oh, that didn't, it's not working. Right. And it's important to be creative, um, as far as how you. adapt to, you know, what a, a young person is giving you in sessions. Um, and, you know, staying up to date on, on the, um, at most evidence based practices in your field, I think is another piece that you have to always incorporate, um, like doing this, like staying up to date with, with your, what you listen to and, and trainings and, you know, specialties. Um,  Kate Melillo:  I would say like, so this like resonates with me for my just SLP practice where. I get in like ruts of I use the same material or there's a trend I'm seeing with a lot of kids at the same time. And so I'm like saying the same thing over and over or something like that, right? Like you're just like, you get in these like cycles of like, oh, I'm really hot on this game right now or [00:45:00]  whatever. Um, I don't know if that resonates with everybody. Maybe people are just like way more creative than me, but I don't think that it's, it's not just about like, there's some really creative, like type B SLPs. You know, like if you like a teacher's pay teachers who make like amazing materials and I'm like, wow, that's incredible. But beyond that, I think it's about creativity in the way you think like using. practices that you wouldn't normally do or even like leaving the room that you're in. Like, you know what I mean? Like just thinking outside the box a little bit, um, which again, I know is a stretch because sometimes they're so limited and what the timing that we have for a session, like the space that we're in for a session, those are all realities. So I'm not trying to like, give you a blue sky pipe dream here, but I think that it's, That's where it really resonates with me because I feel like I, I personally, I feel like I do a good job keeping up with evidence based practice. And then I'm like, how can I even implement this? Like, this is going to be hard for [00:46:00]  me to do, even though I know it's the right thing. Um, yeah. Yeah.  Cory Clark:  And that sort of leads into my, my last kind of domain around. Clinical skills, and that is, you know, actions in and out of sessions. And the first one is about, you know, again, making sure you're have the right supervisor, the right CEUs, the right education over time to match what your people are giving you, right? What they're presenting to you. Um, and then making referrals appropriately as, as you need to. Um, we see it a lot with our practice with it being a speech and counseling practice. Um, know, What an appropriate referral to counseling looks like, or to OT, or to physical therapy, or to feeding therapy, or, no, makes sense, speech therapists, but, um, other professionals. Because, you know, for example, a common kind of stuck point is, if a young person's anxiety has gotten to the [00:47:00]  point where it's so severe across settings, they can't really learn very effectively at school, or in a speech therapy session, because they're so Uh, and a heightened state of tension and anxiety. Uh, they need more support and getting to a place where they can, you know, be regulated to learn. Um, and so knowing how to, to refer, knowing where to refer, getting to know your area, I think is really important. Um, so, you know, researching that and, and kind of making a few calls if you need to, to see what's open in your area, what's appropriate referrals is important. Um, and then I've mentioned this before, but the last one is, you know, empowering others to have a larger role in their child or teenager's life. So again, that's involving family as needed, um, as appropriate. To, you know, allow them to reinforce the things you're working on, um, is, is really important in working with young people. [00:48:00]   Kate Melillo:  Um, okay. So I wanted to talk about like, we just, Corey just told us like so many things and there's actually like a billion other best practices that he researched. And those are like just the highlights. So I realized if you're like falling asleep now, you're like, okay, thank you. That's enough. Um, yeah, yeah. Sorry. You're boring. Nobody's falling asleep.  Kate Grandbois:  We're on the edge of our seats over here. We're listening  Kate Melillo:  with our eyes. Yeah, there you go. There you go. There you go. Um, but I think so taking all that I've mentioned it before. Um, I, I read this, I think it was, I'm in Tara center's community for executive functioning and I, somebody posted like something. It was like, um, once you see executive functioning, you can't unsee it. I don't know who said it. So I'm trying to give credit to the person who said it, but that, that is like, My whole life because a lot of times really every session kids are coming in and I'm like, oh gosh, like there's so many, it's not just those like surface [00:49:00]  goals, those symptom things that I need to address. It's really how the entire brain is functioning as a whole. And that's why I mentioned at the beginning that like, when your mental health is, is not in a good. space, your, your executive functioning becomes scrambled eggs, then you can't do a lot of other things. Right. So there's sort of this like hierarchy, um, where you, you're needing, like Corey just mentioned, making those referrals appropriately so that you get services in an order that makes sense to you. Like there's a lot of times where I get parents coming in and saying, Oh, I want executive functioning therapy for my kid. But then I learn like, The parents are going through a recent divorce and, you know, the kid lost a bunch of friends because he had to move due to that, right? Like, so there I'm like, Oh, let's pause this for a minute. Like, I get that. Maybe he's not firing on all cylinders, but there's other reasons for that. And so we see this crossover with counseling and executive functioning all the time. [00:50:00]  Um, You know that exact. Oh, I haven't even mentioned the word anxiety yet. I don't know. Have you, have you guys see this? I see, I, I work with a lot of teenagers and like tweens and the level of anxiety that I see on a daily basis is, is really striking. I mean, and there is also new literature about this, right? Like we know that the mental health stigma. Um, state of tweens and adolescents in the past five to 10 years has significantly, anxiety has significantly increased. So it's, it doesn't surprise me anymore, but it's almost like I immediately have to take that consideration into my treatment plan. Um, because honestly, sometimes I have to parse apart with parents, like, Ooh, this trouble with executive functioning is actually anxiety, right? And, and they go, so they're so closely related that what the behavior looks like, right, [00:51:00]  that what the kid is doing, um, that the parents like, well, What do you mean? Like if he, okay, prime example, my kid doesn't want to go to school in the morning. And I'm like, yep. Okay. So what, why is that? And they're like, well, they, because they're ADHD. And so they don't like, they can't get their backpack together. They can't do this. They can't do that. Well, few sessions in, then I'm finding out like their first period is math. They don't want to go be going to math class. They are procrastinating for that and that is actually a symptom of anxiety. And so I'm having to like really juggle like this. We have to address that anxiety piece because yes, they probably do need help getting that backpack organized. Let's be honest. Like a middle school boy backpack. I don't know if you guys have seen them, but they're a nightmare. Um, there's a lot of crumbs, unexplained crumbs and crumpled papers. As a parent  Kate Grandbois:  of two tweens, I can confirm the crumbs.  Kate Melillo:   [00:52:00]  It's a real  Kate Grandbois:  problem. It  Kate Melillo:  is a huge problem. It's not always like the kid has, you know, this like severe executive functioning disorder. Sometimes they do. Um, and every middle schooler could use executive functioning help. Let's be honest. But the, the brain regions between, um, That prefrontal cortex and limbic system, like they're going, you know, I don't know if anyone wanted a brain review today, but executive functions live in that prefrontal cortex and those emotion responses that emotional regulation lives in the limbic system and they interplay, right? And so if the kid is having a ton of anxiety, uh, or. Depression, a lot of fear, a lot of times, a lot of fear in the tween space, right? Because it's a new, you've got hormones, you've got new friends, you've got transition to middle school, like there's so many factors at play. Um, so to bridge this kind of gap, we try [00:53:00]  really hard in our practice to like, build on these relationships, which goes, this is where those best practices that Corey talked about come in. Those are all relationship building practices that I think we need to do a little bit better job of incorporating into our speech sessions so that we can parse apart. Is this anxiety? Is this actually executive functioning? Is this, you know, a pragmatic language disorder? Right? Those, those kids with, um, ASD, ADHD, you know, disruptive behaviors a lot of times, like if you have kids on a BIP, or you know, does everyone know what a behavior intervention plan? You don't know sometimes, like, what's the origin? of this, right? A lot of times, um, on my case, so to get kids who are just like simply misunderstood, uh, and some of their behaviors are, they are from ADHD, but they have never been addressed with actual executive [00:54:00]  functioning strategies. They are often just like, go in this other room, be pulled out to this other class that will help you. And then they throw a chair in that other class. And they're like, why didn't this help? You know, like, Ooh, well, what, probably if you, you can't unsee the executive functioning. So part of the relationship building is also getting that team. Corey and I just talked about this with the family. The other thing we didn't mention is like related caregivers. You know, um, we, at our practice, we have it so that like, if. A lot of times, Corey and I will see the same client for different things. And so, like, we're talking to each other with permission, right? Like, getting those, um, other providers on the phone sometimes can be really helpful. Because I've also found that when I have a kid come to me for executive functioning therapy, but they're also receiving counseling somewhere, they, a lot of times, tell me things that they don't tell the counselor. And I'm like, You know, and [00:55:00]  it goes back to what I said at the beginning, where like, the counselor seems more threatening, maybe, right, like, I'm supposed to go there and tell them all these deep, dark secrets, but if I go to Miss Kate, I'm just like, well, you know, like, I stole a candy bar, you know, like whatever it is, like, I don't know. I live in like 1955. So like, I'm like, go to the corner store. Yeah. And I love that milkshake. I don't know. Um, but we're trying to like get the everybody on the same page. Um, So when we're trying to bridge these gap in sessions, this is what one of the things that I do at the beginning of every session. I, and some people I've heard a couple of people mentioned this, like in my SLP circles, I do a high low and a Buffalo at the beginning of every single session. Um, so. My kids know that I'm going to ask this. I actually love it. It's great working memory. It's like excellent working memory. That's right off the [00:56:00]  bat, like executive functioning, and they don't even know I'm targeting it. And I'm like, what's your high, low Buffalo? So high, something good that happened to you. A low, something not good that happened. And a Buffalo's weird, funny, silly, interesting, kind of out of the ordinary. And I, you know, every single tween or teen will be like, I don't know. Whereas I've seen this kid for a year and they know exactly what I'm going to ask at the beginning of the session, I'm like, nope, we've, we've got a good thing going here. You're going to tell me all about your life. Um, you know, I've heard like there's some, there's like a rose and a thorn is another one that people use. So that's like a good thing and a not good thing. I, I tend to like the buffalo just because it makes a little more fun. Um, I like the buffalo. I've never heard the buffalo before and I like that a lot. But I set the precedent that the session is going to be about the kid, right? So like, those kids know that they're one going to be asked that question. And two, that I kind of expect them to to share [00:57:00]  something meaningful because like I said earlier, I will take that information to inform how I target those goals that day. And I, again, realize that that's, this is a little bit of an advanced skill. You do have to have like kind of a lot of things in your toolkit in order to be able to do that. But once you get good at it and make that the expectation, it becomes easier, right? You've got. This opens the door for like all of that play stuff. Like our first example of a strategy is small world play. I don't know if you guys call it small, small world is kind of like the dollhouse or the farm or in there. I've never heard it called small world play, but I like that. I used to work at, Corey and I, another fun fact, I used to live and teach abroad, and I worked at the British School of Beijing for a couple years, and in the UK curriculum, that's what they call it, is Small World's Play. So you're a little. I love it. I know, it's such a good little name for that.  Cory Clark:  Right.  Kate Melillo:  Um, that, and, and Corey too, we [00:58:00]  haven't talked about SANTRE, which is a whole other certification for, for counseling. But SANTRE is basically miniatures.  Cory Clark:  Yeah, a lot of minifigs.  Kate Melillo:  Yeah, like minifigs in the, in a SANTRE. And that is like a, cause, The reason they do that is it's a blank slate  Kate Grandbois:  like  Kate Melillo:  we were talking about earlier with play therapy. It's like a totally there's no predetermined thing. It's just whatever you're creating that sand tray. So when you're one, I start the session with this high low Buffalo. And then if we're using this example of small world play. I, this leans into heavily what we were saying earlier, you've got a lot of improvisational problem solving and perspective taking. I tend to, um, I, I really love the phrase reading the room. I use it a lot. Like, I try to give my, and we'll talk about this with social dilemmas too, but I try to make sure that like, Even if my kids like my students on my caseload don't have like [00:59:00]  glaring pragmatic issues. I'm still incorporating this in a small world scenes because they're just there. There's that is like the integration of life, right? Like that is taking the communication skills that you've been practicing and and throwing them into some sort of like realistic scenario. Um, so I love small world play for, for those social nuances and targeting some of that. And then you get that extra piece of counseling where you can reflect and empathize, right? All the skills that we just talked about before.  Cory Clark:  Yeah, and I want to talk about one exercise I love to do that's, it's more of an art therapy blend, but it's an excellent crossover between mental health and executive functioning kind of therapies. So what I do is, I saw it from an exercise for particularly with those with ADHD, but it can work well with any, any young person. Um, [01:00:00]  So I, I get a video from YouTube, just find something, a short, maybe five minute ish, uh, video of how to draw a basic. thing, right? Like how to draw a dog, how to draw an elephant, or a house, whatever. And I will put it on with the instruction, uh, that me, myself, and the, um, child or teenager are going to draw it together. Um, we each have our own paper. We're going to draw this house or this elephant together. And that's it. I'm not going to stop the video. We're just going to draw. And I, at that point, I've done it, uh, a bunch of times, right? I do it over time. And so I, can just do it, or it's, it's, I'm not great, it's not perfect, but it's, I can do it. Um, but it's their first time ever seeing this video. And so, we just draw it, without stopping, and then when it's over, it's done, right? It's simple, right? Like, we're just drawing an elephant, for example. But what we do is, in processing it, it's important to then say, Okay, a lot of [01:01:00]  kids, for example, will get frustrated because it's too fast. And so what do they do? They either quit, or they start purposely messing up, or they put an X through it, or they're scramble the crumple the paper, right? Um, or maybe they do it, but they're working through a lot of, um, frustration tolerance or a lot of negative thoughts during, right? And that mimics a lot of school, a lot of school behaviors where if they get lost in math or lost in something, um, it mimics that process. And so it allows me to work in real time to process. Okay. What was going on in your head when you started to, you know, get, get behind and drawing that elephant or, um, what do you think I was thinking while I was doing that, right? Perspective taking. Um, what kind of allowed you to keep drawing even though it was getting harder and harder to keep up, right? Um, I noticed you put the pen down and quit after about three minutes. What was going on? What happened, right? Um, it allows you to [01:02:00]  process with them. Kind of what barriers they had, um, you know, what kind of thinking traps they had or distortions, um, and kind of really make a plan for, okay, next time, what can we do that where you can work through that? And then we'll do it again, right? Um, either next session or whatever, um, to, to work on that process so they can translate that across settings.  Kate Melillo:  Well, and that's executive functioning one on one, right? That second piece of like here, next time we're going to make a plan for how to do this and we're going to apply these steps So that you can be successful because then, you know, maybe the kid has an issue with initiation, right? Like you're making a plan to get over that hump. Maybe it was the emotional regulation or making a plan to get over that hump. Those are all those executive functioning skills that a lot of times we see behaviors for, and they're misconstrued or misdiagnosed as possible language disorder. Or Pragmatic disorder when in fact, like they're really lying executive functioning. [01:03:00]  Um,  Cory Clark:  although one time I did that and uh, This is teenager. No, they drew the most amazing elephant i've ever seen in the entire world And I was just like, uh, let's process it. That was just amazing. Good job I didn't know what to I don't know how to like do my process after that. They just  Kate Melillo:  Great artists. Yeah.  Cory Clark:  Yeah  Kate Melillo:  So the last, the last kind of example here, which I think a lot of SLPs use, and there's, there are a lot of resources for this, are social dilemmas. You know, any of these like social cards, we also have, um, like some of the teen talk cards. We really liked those at our practice too, which are a little bit more open ended than the dilemma itself. Um, and I'm sure every SLP has seen these vignettes of a social dilemma. Like, what would you do? The. The thing that I think makes it a little bit lean into the mental health piece more is if you can start incorporating more of the emotional language that goes along with these, [01:04:00]  because sometimes we're focused on the problem solving outcome. And so we want the kid to quote unquote do the right thing. Um, and I know in like the neurodiversity world we're, we're, Leaning away from that and saying, like, well, what is your perspective on the situation? What was the other person's perspective on the situation? As opposed to this is the right way to do it. This is the wrong way to do it. Um, but I think that one of the important things is pointing out those emotions that come with what happens with the social dilemma, right? Like, um, There's that the concept of those like upstairs downstairs thoughts, which I think is Dan Siegel. I want to say it's Dan Siegel who it could be. I would have to check that. But I think that's because that's on the what's that workbook? Yeah,  Cory Clark:  it's upstairs and downstairs brain.  Kate Melillo:  Yeah, yeah. Um, so if you're not familiar with his work, that's a he's a really good resource. He's got like workbooks that go along with those. [01:05:00]  Like emotional thought processes, and in the SLP world, we're, we do tend to look at that perspective taking piece, um, but there's more involved in it than that, right? Like, why did that person, like, why did that person do that action? Well, they were feeling XYZ, right? And so I think that there's a really big crossover opportunity there. Um, and also we have not talked about this, which is self monitoring. And self advocacy. So self monitoring is like, well, what I would do in this situation is this. Um, and then I'm like, how do we feel about that choice? Right? Like providing that, or we can give social dilemmas, have them play them out, role play, and then self monitor. Those responses. Um, I use a scale of negative two to positive two. In my practice, I do not like a scale of one to 10 when I'm self monitoring, um, because [01:06:00]  the one to 10 I feel like what's the difference between like six and seven. Right? Like to me, there's like not really a difference. Like, how well did I do on this scale? Six or seven is kind of the same thing. Whereas in the scale of negative two to positive two, a zero is actually meeting the expectations. A one is doing better than that. A two is doing like amazing. Negative one is like, I did not meet the expectations and a negative two is like, I totally blew it. And so that scale allows a lot of my students a little bit more. One, wiggle room, right? Because they're not like judging between a six and a seven. But two, they're like, well, now I know I didn't actually do the thing I was supposed to do, right? Like, or what I did was unexpected. Um, other people might think that the, their perspective is that was a little strange and maybe that's okay for them. Like that, that's, maybe that's fine for them, but it, it is a, an actual skill to be able to go back [01:07:00]  and self reflect and then use the self advocacy to say like, Hey, next time I needed X, Y, Z, right? Or I would prefer if you said something like this to me, whatever it is, I'm in this social dilemma. So the last part is when to refer. Cory Clark:  Well, we've covered a lot of this. I don't want to kind of go too far into it that we've already done, but it's just really important to know your area. Like I said before, to know how to know where to refer. Um, for things like when the anxiety is getting too heavy to really, you know, carry out sessions. Um, when trauma has been noted that you didn't know before, you know, early on. A lot of times you don't know, um, when you start services with someone and then it comes up, you know, throughout. Um, or if, you know, someone's behavior is, you know, Getting to the point where they're so aggressive or disruptive at school or at home to where it becomes unsafe to, you know, to, um, [01:08:00]  do therapy services or, um, you know, just hearing about unsafe things at home. Um, it's important to refer. So, you know, connecting with local counselors in your area is important. Um, creating relationships, creating a referral list if your practice doesn't already have one. Um, of where, you know, you can refer to where they won't be turned away, right? And it's really hard, um, nowadays to, to. To find places that are accepting, uh, new, new clients, uh, that see kids, aren't  Kate Melillo:  full.  Cory Clark:  Yeah, they accept the insurances they need, you know, so it's important to know what's available, what's possible in your area.  Kate Grandbois:  You've shared so much with us. I could talk to you for a whole other hour. I already, I'm already thinking of all of these additional questions about how to approach this in a school environment, about, but we don't have time to go to any of these, these Avenues that my brain maybe that's my executive functioning really failing me here wanting to go off on all these tangents You've just shared so much helpful [01:09:00]  information And reaffirmed so much of of my own personal perspectives of how important counseling is So much of what we've said on this show in the past in our last few minutes Do you for? For the SLP or the special educator who's listening who might be somewhat familiar or somewhat new to this general area, do you have any, you know, final thoughts or words of, of, um, words of wisdom and, and suggestions for next steps?  Kate Melillo:  I, so I think the biggest takeaway here is to, for SLPs to like, I challenge you kind of to go into your next session and change the way you think about how you deliver the session, right? Like, change your mindset around like how you're going to approach those goals today and make it more about the relationship with that student and not about the goals. Um, because that that's really like the crux of what we're saying [01:10:00]  here, because I think you'll see things like the executive functioning stuff like bubble up, like, you'll see things like the other goals, um, come into, you know, in front of your face. If you just made it about the kid and the relationship that you have with them, which I think is definitely. A mindset shift. Um, it's not the way that everybody approaches their session. And yes, it could be your, you know, maybe it's preference, but the evidence actually does lean this way. Um, and a lot of new research and social skills and social emotional learning. So that would be my challenge to everybody after today.  Kate Grandbois:  Thank you so much for being here. We really appreciate all of your time. I have learned so much. Um, I'm sure our listeners have too. Everything that you've mentioned today will be in the show notes. So anybody who's listening while they're driving, walking, whatever, what have you, um, all of those links will be there. Thank you again so much for your time. This was really awesome. Thanks for having us. Thank you. [01:11:00]   Amy Wonkka:  Thank you.  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. .

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 EpisodeSponsor 1 Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are here today with a guest who is going to discuss congenital heart disease, which is something that we've never really talked about on this podcast before. So we're very excited to welcome [00:02:00]  Nashifa Hudamomen. Welcome, Nashifa. Hi, guys. Nashifa Hooda Momin:  It's a pleasure to be on with you guys. Yeah, we're excited for this conversation. And Nashifa, you're here to discuss feeding. infants with congenital heart disease. But before we get started, can you please tell us a little bit about yourself for our guests who might not know you? Yeah, absolutely. Um, so my name is Nushita. As you guys mentioned, I've been a practicing speech language pathologist for about 11 years. I currently work in an acute inpatient, um, children's hospital and work primarily with pediatric feeding and swallowing and pediatric dysphagia. And my passion is working with infants with congenital heart disease, um, specifically infants with single ventricle physiology. Um, and I am wrapping up my doctorate this month. Um, we'll be actually graduating this upcoming August and, uh, speech language pathology from MGH Institute of Health Professions and outside of the speech bubble, I like to read. Listen to podcast, um, a [00:03:00]  run, uh, and really just hang out with my kiddo. Um, she's five. So it's a lot of fun times right now with her. That is so exciting. Congratulations in advance. So we're recording this episode in the summer of 2024. And by the time our listeners are listening to this, it may be some, maybe winter out. We're not sure. But, that's really exciting about the doctorate, so congratulations. Kate Grandbois:  Or we talk about all of the good stuff. I'm going to go ahead and read our learning objectives and disclosures, and then we will learn everything about a topic that I genuinely don't know anything about, which is always the most fun. All right, here we go. Learning objective number one, identify three common feeding problems observed in infants with congenital heart disease. Learning objective number two, describe at least three medical considerations that directly impact feeding in infants with congenital heart disease. And learning objective number three, describe at least two feeding strategies utilized in therapy to enhance oral feeding skills , for [00:04:00]  infants with congenital heart disease. Disclosures, Neshifa's financial disclosures, Neshifa is an employee of Children's Healthcare of Atlanta. Neshifa received an honorarium for participating in this course. Neshifa's non financial disclosures, Neshifa 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 SIG12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children.  Amy Wonkka:  Amy's financial disclosures, that's me. Uh, I'm an employee of a public school system and co founder of SLP Nerdcast. And my non financial disclosures are that I am a member of ASHA, I'm in Special Interest Group 12, and I also participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, Ms. Shiva, maybe before we even get into the first learning objective, could you just give us a little bit of background on typical heart function? Nashifa Hooda Momin:  Yeah, absolutely. I think that's a great place to start [00:05:00]  off. Um, so let's talk about what the components of a heart. The heart is composed of four chambers. We have the left atrium, the right atrium, the left ventricle, and the right ventricle. And then there are also four valves, which are the aortic valve, the mitral valve, the pulmonary valve, and the tricuspid valve. So overall, what's happening is that the right side receives deoxygenated blood from our superior inferior vena cava. And that pumps it to from the right side of the heart to the lungs to then get oxygenated. And then that brings it back to the left side of the heart. And then that goes up to our aorta to then be pumped out to the rest of the body. That's in the most simplistic terms of what is happening to our blood. Um, and then But I do think if we want to talk about more specifics, I like to like walk through like what the blood if I was a drop of blood, where would I go? It's something that I always talk about. So if you had blood that was entering the body, um, and you need it to get oxygenated, the blood is going to go towards the heart from, like I mentioned, the superior [00:06:00]  inferior vena cava. and it enters into the right atrium. And from there, it's deoxygenated blood. It then goes through the tricuspid valve to the right ventricle, and then from the right ventricle, it goes into the pulmonary valve into the lungs. And like I mentioned, that's where the blood then gets oxygenated. So then the blood then returns from the, to the left side of the heart through the pulmonary veins and goes to the left atrium through the mitral valve to the left ventricle. And then from the left ventricle, it goes through the aortic valve to the aorta and then it's pumped out to the body and that's oxygenated blood going to the rest of the body. So that's normal heart physiology. And then I feel like it's also important to talk about fetal circulation because that's different. Um, and the reason that's different is the oxygenated blood that the fetus is getting in the mom is all oxygenated. There is no process of Deoxygenated to oxygenated. It's oxygenated blood is coming from the mom and it's going to the fetus. And that [00:07:00]  happens through the process of three fetal shunts. Um, and so during fetal circulation, all the oxygen, the nutrients from the mother's blood are transferred across the placenta to the fetus. Also, I think it's important to note that when a baby is in utero, the baby's lungs are mostly fluid filled, so the blood is not going to want to go in the direction of the lungs, especially when it's when they're in utero, because there's a lot of pressure and a lot of times you'll hear this referred to as pulmonary vascular resistance. So the three fetal shunts. The fetus that the fetus relies on in utero are the ductus venosus, the foramen ovale, and the ductus arteriosus. So now let's talk about blood flow in utero, right? So you have the ductus venosus and what happens is that that branches off near the liver and goes straight to the inferior vena cava and then sends that oxygenated blood, remember it's going to be oxygenated, to the right atrium. So from there it's a little different because the blood can in two ways, right? So [00:08:00]  Like I mentioned with normal cardiac physiology, we're kind of going from the right side, going to the lungs, and then coming to the left side, and then being pumped out. But here, what it can do is it can cross from the right atrium straight to the left atrium through, um, the second fetal shunt, which is called the foramen ovale. And remember, it's oxygenated. Our goal is really just to get that oxygenated blood everywhere in, in, um, the fetus, right? So that's the second fetal shunt. The second way is kind of the typical way we were talking about, which is going from the right side to the right atrium, down to the right ventricle, and then up through the pulmonary artery. And there's another fetal shunt. called the ductus arteriosus. And remember how I mentioned that the lungs are very fluid filled, right? So if I was a drop of blood, I don't want to go in that direction. I'm going to do anything I can to find a different route. And so a lot of times what happens is from the pulmonary artery, it'll go up through the ductus arteriosus straight to the aorta and then be pumped out to the rest of the body. So that's kind of how fetal [00:09:00]  circulation works. And the reason I think it's important to talk about this is because when we talk about congenital heart disease, These fetal shunts are so important for a fetus, um, because once the baby's umbilical cord gets clamped, the baby is no longer getting that oxygenation and nutrients from the mother, and that's when things start to change, right? So that's when our lungs expand, um, the alveoli in our lungs are clear to fluid, there's an increase in the baby's blood pressure, and there's a significant decrease in those pulmonary pressures, which then causes, um, um, which then usually results in the closure of the foramen ovale as well as the ductus arteriosus. Again, like the ductus arteriosus can take a bit to close, but all of that changes in pressure, changes in pressure will usually cause these to close. And then if you have an infant with congenital heart disease, that's when it really starts to put pressure on to how are we going to manage that. Pulmonary and systemic flow for these patients, especially are critical congenital heart disease. So that's just a [00:10:00]  brief introduction. I always like to start with blood flow because I think physiology is extremely important. And if you can understand general physiology, it helps us better understand, um, what's going on and why clinically they present the way that they do and how we as providers can provide strategies to support them. Kate Grandbois:  So yeah, I love that you said that that was a brief review. I, every time I talk to you, I am so astounded by how much, you know, I'm also astounded by the fact that we have the same degree that you're a speech pathologist, because this is very complex. I mean, I think as a field, maybe we get a little bit of this background knowledge in graduate school. I really appreciated that refresher of I haven't used the word, you know, I haven't looked at the chambers of the heart in I don't even know how many years so that was really, really helpful. I have a question, just because I want to make sure everybody has a solid understanding of what the anatomy and physiology is here. When you say a shunt, [00:11:00]  can you describe what that is?  Nashifa Hooda Momin:  Yeah, so it's essentially like the almost like with the direction of flow, um, I think that's the best way to explain it. So, shunts can be two things. So shunts can be like the direction the blood is being shunted from the right to the left side. The blood is shunted to from the left to the right, right side, but they can also be a shunt that you're actually placing to help make the blood go in a specific direction. Kate Grandbois:  Okay, that was that that was that definitely answers my question. So thank you. And then I also want to, you know, say this back to you to make sure I've understood some of the basic fundamentals here. So we have, um, Uh, typical anatomy and physiology of blood flow or of the heart and blood flow in adulthood. And then we have this in utero experience that is significantly different from post clamping of the umbilical cord. And that's kind of the big, that's where the show begins. I assume for these, for these little babies. Okay. Now that we've, now that I have my bearings and I apologize to anyone in the audience who already, who already knows all of these things,  Nashifa Hooda Momin:  I [00:12:00]  do not. I think it's great. That's kind of what makes our field so fun, right? That we can all do so many different things with our degree.  Kate Grandbois:  Very true. Okay. So now that we have a solid understanding of the basic anatomy and physiology here, what is the, once that, once the baby's, uh, once the umbilical cord is clamped and things start to change, what happens next when something is not going well? Nashifa Hooda Momin:  Right. So, um, that, that's a great question. So depending on the type of diagnosis, like you will, that's going to depend on the intervention. So if you have a patient, like I mentioned, that has critical congenital heart disease at our institution, we are not a birthing hospital, but the patient, That's being delivered at an outside hospital will then be immediately transferred over to our facility and then there's going to be usually just generally there's going to be an echo where the patient's likely going to be in prostaglandins. So [00:13:00]  prostaglandins are a way to keep the ductus arteriosus open to then help that balance of that pulmonary and systolic. Um, so there's going to be a lot of interventions that will happen, especially if you're an infant with critical congenital heart disease. Now, if you're an infant with, um, and we'll talk a little bit about this. I'll kind of define what congenital heart disease is. But, um, when you say you have a patient that has like an a cyanotic defect, they're generally doing okay. That patient may be okay to go home and be followed closely with the cardiologist until they're ready for their intervention if they need a surgical intervention. So we can go, um, okay. In different ways, depending on the critical severity of the congenital heart defect.  Kate Grandbois:  Okay, and so this brings me to my next question, which is, what is congenital heart disease? You already mentioned we were going to talk about that. And on top of that, when that, you know, do we know ahead of time in uniro, that a baby has congenital heart disease? Like, what is the, what's the [00:14:00]  sequence there, and what is it? That's  Nashifa Hooda Momin:  it. Love it. Okay. So congenital heart disease is any type of structural abnormality in the heart that's present at birth. And these defects can widely vary in their severity and their impact on heart function. So remember we talked about the four chambers and the four valves. If anything is underdeveloped or if there is potentially like we will like to refer to it as like a hole between the two atriums or between the two ventricles, it's going to impact the way the blood is going to flow. And that's going to, that's going to be your defect, right? So that is a general explanation of what congenital heart disease is. And um, yeah. Interestingly, it's one of the most prevalent, um, type of anomaly that we see in, in, in, in terms of congenital malformations, which is super interesting. And then it impacts one in 120 babies born in the United States. So it's pretty common. Um, but in terms of your question of like, what is what happens, right? So you get the, how do you get this diagnosis? When do you get this diagnosis? So yeah, usually around 20 weeks when you go for [00:15:00]  your 20 week ultrasound. Um, it could be diagnosed at that time, at which point they may notice that there is something, um, different, uh, in terms of normal physiology for the heart and they'll refer out to get more testing done. So you can get a prenatal diagnosis of congenital heart disease. There are times that. it can get missed completely and that can be, um, something that can happen because of potentially it, it got missed because it was a fluke, but it could also be because there wasn't great prenatal care, um, for the mother. So it is something that you can catch postnatally. A lot of times you'll clinically see this in the child, if it's especially a postnatal diagnosis, um, where we don't know, of course, prenatally and the patient is born clinically. There are going to be signs that the patient is in distress and they'll really quickly figure out that it is congenital heart disease. Um, but yeah, so it can be prenatal, postnatal, really both ways. [00:16:00]  And what causes it? So in the majority of the cases, there's no known cause. There are certain things that have been shown to increase the chances of having congenital heart disease, like a family history of congenital heart disease, genetics, environmental factors, or a combination of all. And, um, it, when we talk about congenital heart disease, it can really be broken into two different categories. It's the easy, I think it's the easiest way to really understand that you have a cyanotic defects and cyanotic defects. And I've kind of talked a little bit about that, but an a cyanotic defect is when you have too much blood going to the lungs. Meaning that you have a so remember, let's talk through that physiology like we talked about. So you have the blood that goes from the right side of the heart and makes it to the left side of the heart. Um, and say that there's a hole between the two atriums, um, or between the two ventricles, the blood that's oxygenated then goes back to the right side of the heart to then get re oxygenated. So what we like to call it, that is left ventricle. to [00:17:00]  right shunting, right? So that blood that was already oxygenated has gone back to the right side to then go back through the system again. So clinically, this patient is going to have a lot of endurance issues. They're going to show clinically, they're going to show work of breathing there. And clinically, as a speech language pathologist, our interventions are going to be based around that. So that's an a cyanotic defect. And cyanotic defect. Um, there's also so cyanotic defect. There's also there's decreased blood to the lungs. And the reason is because what's happening is that the blood is going from the right to the left side, meaning that it's not all getting oxygenated. And these are the babies when we look at their oxygen saturations. Prior to any interventions, they're not going to be at 100%, right? They're going to be at 75 or 80, 85, somewhere around there. Again, this is going to depend on the type of cyanotic lesion that they have. Um, and we like to refer to this as right to left shunting and some examples. Um, you'll see this a lot, um, In the [00:18:00]  literature, and just in when you're talking about congenital heart disease, we talk about the five T's, and there's more than the five T's of cyanotic lesions, but um, there's truncus arteriosus, there's transposition of the great arteries, there's um, tricuspid valve abnormalities, tetralogy of fallot, and then TAPBR, total anomalous pulmonary venous return. But that is kind of the two different types of congenital heart disease.  Amy Wonkka:  And you mentioned that if you have one of these cyanotic injuries, you may see oxygen levels like in the seventies. Can you remind us what is normal? What should we be seeing? If we're seeing something  Nashifa Hooda Momin:  in the seventies, we should be at a hundred. So imagine when we go to our doctor's office, you know, when they put the, um, the little. on and then they look at the rhythm. So that's supposed to be at a hundred percent or they'll put the little sticker on around your finger to check, but it should be at a hundred percent. So that's a real big difference. Yeah. And so remember when we were talking about the fetal [00:19:00]  circulation, so during, um, uterine utero, what's happening is that foramen O'Valley and that ductus arteriosus are bypassing the bypassing those pathways. But once they close after birth, that's when these complications start to really pop up for critical infant with critical congenital heart disease. Um, so at that, that's why, that's why we have to try to optimize keeping that ductus arteriosus open so that we can balance that circulation. We're getting, we're getting blood to our lungs, but we're also getting blood systemically, um, until the patient has their type of intervention.  Amy Wonkka:  So this is something that's affecting the whole baby, you know, I mean, the oxygen level across their entire body, their entire system, what are important things for us to be thinking about if you're working in an environment like that? What are things that you need to be thinking about if you have a patient like this  Nashifa Hooda Momin:  going on? Absolutely. So when we're thinking about working with this population as a speech language pathologist, I think it's important for us to think outside of the box. I think that, you know, we can sit there [00:20:00]  and treat the symptoms as it goes. But like I mentioned, I really think it comes down to physiology and really understanding what's going on to the patient. fully to then be able to provide the specific interventions that they need. So again, I am giving a very inpatient acute lens because that's where I work. We'll talk a little bit about outpatient as well. Um, but in my head and I, I like to break it down into four categories. I like to think about post surgical complications, airway considerations, GI considerations, and comorbidities. And those are all medical things, but they really truly impact oral feeding success. So when we talk about post surgical considerations, many of these infants, um, after they have any type of intervention, they're going to be on sedation and pain medications. And this can cause nausea, constipation, drowsiness, and that can impact oral feeding. So a great example is think back to when you had a procedure or any, or know somebody that had a procedure or surgery, think about how. they felt or [00:21:00]  you felt weaning off medication and it can make you feel really out of it and nauseous and I obviously can't say we're 100 percent that's exactly how a baby feels but it's a consideration you don't feel great right um and and then when you have a speech language pathologist that comes Right right after they have surgery and they're nauseous. We have to make sure that we're not just like giving them a recommendation and that is the single recommendation. We have to remember that it's that this their journey is going to be very variable. It's going to change. They're going to feel better soon and then we need to be very adaptable and our assessments need to be ongoing because oral feeding is going to be changing very rapidly or especially post operatively. And then we also may see withdrawal symptoms, um, this can be in response to the medications that they have. Some infants are more sensitive to this if they've had in utero drug exposure. Clinically, these patients may, we may see tachycardia, tachypnea, hypertension, irritability, tremors, decreased alertness, and all of that is going to play a role on our clinical assessment for feeding, right? So [00:22:00]  making sure that we're adaptable and knowing that our plans are going to be consistently changing. Um, chylosuffusion is another post op consideration or chylothorax. Um, and what that is, it's a buildup of fluid in the space around the lungs, um, in the chest cavity. And this happens because of injury with. To the thoracic duct, um, and this results in the buildup of Kyle in the plural space. And this is a Kyle is a fluid that's made by your intestines when you eat that. Um, so the reason why am I even talking about this? It's because if a patient has a, um, a Kyla suffusion or Kylo thorax, they're going to be recommended to be put on a low fat or nonfat diet. So imagine a patient maybe who'd been orally feeding with breast milk or formula who then now has this complication. They have to be on this low fat, non fat diet. So that could be the introduction of formulas like Toler X or Infopor, which are okay, but for a patient that's been having yummy, delicious formula or breast milk, and then you're [00:23:00]  introducing this new formula, it's not as palatable, and that has definitely impacted oral feeding success. On the other hand, I have seen patients completely chug a full bottle of Toler X, but it is just another consideration that we have to be thinking about. Um, And then there's also a high risk of stroke, hypoxic brain injury, cardiac arrest, secondary to any type of medical intervention. We know that when we're thinking about, um, the physiology, there are a lot of neurological complications we see after cardiac surgery or after cardiopulmonary bypass. So that's the first category.  Kate Grandbois:  Um, yeah, I know you have other categories that you want to walk through, but I just have a quick sidebar question. I'm thinking about my experience feeding my own children, what I know about infant development and how important fat is. And how important from a nutritional standpoint, so I know we are not nutritionists, but in this moment, when you have a baby who is now having a, you know, a nonfat diet recommendation or other feeding specifications that [00:24:00]  could impact their nutrition, how much of that is a balance and how closely are you working with nutritionists and pediatricians to make sure that they're getting the nutrients that they need for development? Nashifa Hooda Momin:  Absolutely. So I will say that the diet is temporary. It's not, um, something they'll be stuck on for a whole year and nutritionists, um, are so critical. So just to kind of give you a little layout of how our teams are set up, especially in the ICU setting, we have the physician, we have a nurse practitioner, you have maybe an advanced practice, um, advanced practice practitioner. I think that's APP. Um, and then a nutritionist there, a pharmacist there that are, you know, All rounding on every single patient every single day, and that similar model is also there in our step down unit. Um, and so I, like, it is a huge consideration because we are watching their weight game very, very closely. I will say that it's usually temporary and, um, You know, pediatricians or cardiologists that they get discharged to are also kind of keeping an eye on it. I [00:25:00]  think the big thing is making sure that that Kyle stops building up. And once we, that resolves, then you can kind of resume back to your normal diet. Yeah, that's helpful. Um, so the second category that I wanted to talk about is airway and respiratory considerations. Some of our kids will require prolonged intubation. Um, and that can place a lot of strain on the vocal folds. We may see this after extubation. So usually I'll be able to assess this with vocal quality. Um, if especially If I've seen the patient preoperatively and done feeding with them preoperatively and I see them postoperatively, operatively, and I can usually be like, wow, their voice doesn't sound like their baseline. A lot of times their caregivers are great about saying, no, they're definitely not as loud as they used to be, um, you know, picking up on if they have, obviously, if they're crying and they're not vocalizing, then we know there's some aphonia. Um, dysphonia and hoarseness, really assessing that, so that can be a consideration. Another thing is that infants that are super [00:26:00]  critical may end up, um, in a situation where they may require ECMO, which is extracorporeal, extracorporeal membrane oxygenation. And for our cardiac patients, we usually use VA ECMO, um, but it's a temporary solution to offload the heart and the lungs. Um, but we have also seen that ECMO can, we've seen right sided vocal fold paralysis, and I think that has to do with the placement of the catheters for ECMO, so that's another consideration we have to be thinking about, especially when we're doing our clinical assessments and working with oral feeding. And speaking about vocal paralysis, a lot of our infants with congenital heart disease will, especially the ones that have surgeries near their aorta, like a PDA, um, and Norwood and aortic arch surgeries, they all have a really high risk of recurrent laryngeal nerve damage, um, and that is going to impact vocal paralysis. Vocal fold, you know, closure and can cause vocal fold paresis or paralysis. Um, so that's another consideration. And just to kind of review the recurrent laryngeal nerve, um, it [00:27:00]  supplies most of the intrinsic muscles of the larynx. It functions for speaking, breathing, and the opening of the vocal fold. So if an injured, we're going to see that vocal fold paresis and paralysis. And again, clinically, what I'm going to be looking at is this patient is, has dysphonia or aphonia. They may have some stridor. Um, or and then that's going to put them all at an increased risk for aspiration. So definitely a lot of airway considerations. There's a few more. Um, so phrenic nerve damage is another thing that can happen. Uh, the phrenic nerve originates around cervical vertebrae four, um, and it goes over the heart. And if there's any type of damage post operatively, sometimes we'll see these kids where their respiratory rates are really high. So say, You already have an infant that, um, preoperatively, their respiratory rate was in the 70s, which is high. Um, and then postoperatively, their respiratory rate's in the hun in the hundreds. And just to kind of put that into perspective, that's like per minute. So imagine, like, 70 breaths per minute, now bumped up to 100. And you're asking them [00:28:00]  to take an oral, like, orally feed. Like, take a bottle. It's a lot. to do right in terms of coordination. It's really hard to coordinate your sex while breathe coordination when you're breathing that fast. And so in that particular population, these kids may require a diaphragm implication, which is another type of intervention that they'll have to do to help kind of help with that phrenic nerve damage that could have happened with surgery. Um, other considerations are subglottic stenosis. This was something that I, um, came across recently, maybe It's not as common, but it's something that popped up for one of our cardiac patients, and it's interesting because this is something that, you know, you may not even be thinking about, but it's a patient that like, for example, they get extubated, and they're actually doing well, going along in their post op course, and then they start to get worse with their feeding. They have Schrader, you're noticing that, Um, they're more noisy. They're having more signs of aspiration, almost where you would have seen more improvement. Um, and so this happened with one of the patients that I was working with and we [00:29:00]  ended up doing a fees on the patient and noticing that there was subclotic stenosis. And so then they had to go to the OR for a dilation. But again, it's something that you would, it's in our head that like after surgery, we're only going in the pathway of improvement, but as speech language pathologists, especially in this type of setting, You just kind of have to be on your feet and being able to read and advocate for your patients and knowing that, hey, this is, this doesn't sound right, um, because you get so close to your patients. And then finally thinking about respiratory support. So that is something that a lot of our patients are going to need. And so think about an infant who is on five or six liters of high flow. Um, and then you're again, like the same concept, you're requiring, you're asking him to take a bottle of water. when they're already have this baseline work of breathing and then they have all this extra flow that there's no research to say like, hey, you can't feed babies on five liters or less or five liters or more, six liters or more. But like, you have to look at the infant as a whole, right? If they are. are really to Kipnick [00:30:00]  and you're asking him to take a bottle without strategies or, or with strategies, like the plan is going to be very dynamic in the sense for that baby. So those are some airway considerations.  Kate Grandbois:  There are so many considerations. There are so many considerations and the whole time you're talking, I'm thinking this is a tiny little person. Yeah, I know.  Amy Wonkka:  Well, and it's, it sounds like it's, it's just, it's a lot, it's a lot of problem solving in a very fluid, in what can be a very fluid environment, right? So you're thinking about so many different variables. I know you had mentioned gastrointestinal considerations. That's like a system, a system we haven't gotten to yet. What are some of the gastrointestinal considerations?  Nashifa Hooda Momin:  Absolutely. So there's, um, there's a, you have to think about reflux. Um, obviously a lot of our babies have reflux. Some are symptomatic, some are not. There has been some literature to show that infants with CHD do have a higher percentage of having reflux. Um, another consideration is necrotizing intercolitis. Um, so necrotizing intercolitis has been a little bit more prevalent in infants with congenital heart [00:31:00]  disease. More specifically, um, Our single ventricle population. Um, so again, just in the reason we talk about these things, why is this important? Why does it relate to oral feeding? If you are having issues GI wise, it's going to be hard to push through oral feeding. And if you're not addressing these issues, you're kind of going to be dealing with another slew of issues, like. oral aversion in the long run, right? So like being able to clinically look at your patient and see that they're having signs of reflux is something that you need to be pick, you pick up on and tell the team so then we can adjust medications or adjust strategies, whatever needs to happen, right? But if you power through with oral feeding, then the patient's eventually going to clinically not be interested to eat. And then you're going to have another issue. Um, and then finally comorbidities. So how do existing comorbidities impact the patients? Um, we know that there are underlying genetic syndromes like Trisomy 21, Kabuki, Turner's, DeGeorge, that are often seen with CHD, and we also know [00:32:00]  that they Um, and so, um, you know, with baby can impact feeding. We see, like, poor muscle tone with them. Oral motor dysfunction, structural abnormalities. And so with an infant with CHD, it just adds, like, another layer of complexity to oral feeding. Um, some other comorbidities are cleft palate, trach and bent, tracheal malaysia, laryngomalasia, vascular rings, vocal fold paralysis, um, and again, there can even be congenital subglottic stenosis. So it's, it's something that, you know, We have to also be putting into the picture. I almost like to think about it as a formula. It's not a formula, but like there's a lot of things you have to think about to make a feeding plan for a particular patient.  Kate Grandbois:  I have another question and I know you have some, you're giving us so much. important information. I am, I'm, I'm just, again, I, every time I talk to you, I'm kind of floored by how fluently all of this comes out of your mouth because it's so much information and it's so helpful. And I have a question that is a little bit of a sidestep and maybe we'll get to this in more detail and you can, you can push it off, but. [00:33:00]  Yeah. As you're talking about comorbidities, I'm thinking about the parents. I'm thinking about, you know, they've, they've just had a baby. Maybe they knew ahead of time that there were going to be some genetic issues. Maybe they didn't. Maybe they knew they were going to, there was going to be a congenital heart disease. issue. Maybe they didn't, but there's so many professionals involved. There's so much triaging. There's so much coordination. It sounds like you're, you know, just constantly trying to put out fires is, is, is what, depending on, on what's going on with the kiddo. And at what point do you have a conversation with the family and really put your counseling hat on to feel, see how they feel about what to do? component of this is more or less urgent or, you know, long term implications for some of these things. This just feels like a very complex issue where counseling would really have to be at the forefront of all this. Is that a, is that a reasonable assessment? [00:34:00]   Nashifa Hooda Momin:  Huge. Yeah, absolutely. So a lot of things I think in this, in this career or in this, um, job that I've been in, I guess for a while now, one, the importance of learning how to effectively communicate with the team and that multi, we talked about multidisciplinary, interdisciplinary, Transciplinary like buzzwords all the time, but truly how important it is to have this conversations with the team to come up with a plan that's very patient centered, but in terms of counseling with caregivers, it is at the forefront. So when we're meeting caregivers, sometimes. Um, if it's a baby, like I mentioned with critical congenital heart disease, they may be transferred over to our hospital and there may or may not be a caregiver on the first assessment because a lot of times we are consulted immediately when they're admitted for babies under three months. But as the minute we meet the caregivers, it is, hey, we are speech language pathology. Most of the time they're like, well, my baby's not ready to speak right now. Um, and then, you know, kind of explaining what the role is that we're [00:35:00]  here to really work on feeding and swallowing and What we're anticipating. What are common complications? How are they feeling? What have they done? How is a lot of it? It's also even like, Hey, how mom are you pumping? Is that how's that going? And what can we get for you and, and advocating for them as well as like a unit, um, and then providing that education. And the great thing is because we are consulted preoperatively, we've established those relationships. very, very early on and then follow them through the surgery and then follow them through step down. Um, and then make sure that we plug them in right into outpatient. We have a rehab, um, outpatient case manager who helps them, plugs, plugs our cardiac patients right into outpatient therapy. So there is a lot of, um, Treating the patient and assessing the patient. But it's like, like you said, you have to have your counseling head on at all times when you're interacting with caregivers. Um, and I will say, thinking kind of about long term implications. I think that I will say that [00:36:00]  I've. I've learned that you never know, and I'm kind of on that boat of, hey, by the time they get to step down, I'll have a general idea of kind of what the next steps are going to outpatient, but it's hard for me to meet a baby on day one and know what's going to happen, so I'm usually very transparent on, hey, like, Let's take this one step at a time. These are kind of my goals for, for your baby. Um, and, but I also want to hear what you're thinking and, you know, what, what your goals are, um, for feeding, because I think that's important to understand, especially when we're thinking about breastfeeding and, and how that can be sometimes challenging for an infant with multiple lines and, um, you know, just the complexity of where they are, but listening to that. So then you can advocate again to the team that this is kind of what the caregiver is thinking. I hope that answered that question.  Kate Grandbois:  It did. And I appreciate you. I appreciate you taking a second to hold space for that only because it just, again, it just feels like such a complex work environment, a complex baby, a complex patient, you know, [00:37:00]  family dynamics. So I, I appreciate you answering that question. All right. Let's talk about the feeding part. Yeah. What? Okay. So why? Why? How is feeding related to all of this? I don't know. It seems like a dumb question. There's so much going on.  Nashifa Hooda Momin:  There's so much going on. Um, so outside of all these considerations, now you have all of this to think about. These infants are going to have an increased cardiopulmonary load, which is going to result in decreased endurance. So they're going to be very easily fatigued. So that cardiac output that they have is insufficient to meet the metabolic and energy demands of the body, especially. Especially when it is related to oral feeding. So oftentimes, what we see as their clinical presentation, we'll see, um, I mean, depending on the age of the infant, we may see poor state control. And the reason I'm even mentioning that is, remember that they're already, they already are very easily fatigued. And then imagine how that impacts their state control, especially as a newborn infant. Um, they are going to have baseline tachypnea with reduced baseline saturations, [00:38:00]  especially if you're a cyanotic. Maybe you're going to see that poor coordination of oral feeds again because of that underlying tachypnea, underlying fatigue issues. You may see oral aversion. That oral aversion can happen for various reasons. It could be the fact that this patient was intubated for two, three weeks, we have to be thinking about, like, how long they had that endotracheal tube between their vocal folds. And then, and then now, we're gonna come on and try to be like, hey, let's take a pacifier, hey, let's take a bottle. And it's a lot of negative excitement. and we're trying to like add the oral feeding component. It could also be, oral aversion can be because the patient has a, is a single ventricle baby and they have poor blood flow to their gut and that's gonna result in feeding intolerance. So every time they eat, they may throw up, because we're trying to figure out that nice balance of what they can tolerate. And so then now they've associated every time that I get food in my belly I throw up and I don't want to eat so That can be a reason for oral aversion. They may have decreased hunger cues because they're on continuous feeds because of that poor feeding intolerance. We just [00:39:00]  talked about, um, also dysphagia. Dysphagia is extremely, extremely prevalent with this population. Um, to kind of take it back to literature, there was a study done in 2022 by Nirwana et al, um, and they looked at 374 patients retrospectively. Um, and I encourage you guys to read it. It's a great paper, but really they found that 70 60 percent of these patients had oral dysphagia and 64 percent had pharyngeal dysphagia. And there are specifics in terms of like aspiration and silent aspiration and vocal fold involvement. And so like, it's a dysphagia is extremely prevalent with this population, which obviously explains why speech was so involved. Um, but, What are we thinking about as speech language pathologists with these diagnoses? We have to be thinking about the patient clinically. So again, we come to bedside, and if they have increased work of breathing, then we're working with our skills to give them the strategies to help kind of work around that work of breathing while also orally feeding. Um, but say if they're a cyanotic baby, they may still have that work of breathing, but in our heads, we also have to be [00:40:00]  thinking about, okay, so they're cyanotic, How is the blood flow going to their gut? Do I need to be kind of thinking about that, depending on their physiology? Okay, what about their brain? Are they getting great blood flow to their brain? These are the things that I like, like to be thinking about, even though they may not be at the forefront of our treatment, um, because long term we're going to be thinking about this, right? So like, again, like advocating for, educating our caregivers, but advocating for the patient and then also thinking about next steps, right? Um, And like to kind of think about that blood flow that that might be blood flow to the brain thinking about neurodevelopmental delays down the line.  So as SLPs, other things, other common strategies that we think with this population is what position are we going to use to feed them, right? Cause these are, most of the time I'm working with infants, um, nipple selection and then the use of pacing, right? So babies under three months, I think my go to is elevated sideline. My preemie flow nipple, like a Dr. Brown preemie nipple or, um, an extra [00:41:00]  slow flow nipple and then offering pacing, meaning. Offering a breath between, because remember, these are babies that are going to be potentially feeding for the first time, especially if it's a newborn, and they may not have that successful abrief coordination, and then you're kind of supporting there, but also that underlying CHD where they already have endurance issues and fatigue issues, so offering pacing for that. And then a huge, huge part of, uh, speech language pathology with feeding is making sure that the bait feeding is very cue based, meaning I, I feel like sometimes, um, it feels. You know, when a baby can't speak, right? But the way that they communicate is through cues, right? And I think there's so much you can get from, um, feeding a baby with their cues, with the way they move their hands, with the way they move their, um, with the way they make grimace and like, you know, Have gaze aversion or have stopped feeding and changes in vitals. I think there's so much going on in a feeding that is not with words, but you can pick up on. And as a speech language pathologist, it's a dialogue, right? So as a feeder, I'm watching those cues, and I'm [00:42:00]  adjusting my strategies to make sure that I'm supporting the feed. And then really empowering our caregivers to do the same. So yeah, that's a little bit about like, what yeah. What is feeding with this particular population and what a speech therapist may do with this particular population? Um, yeah.  Amy Wonkka:  What if PO feeding is not appropriate at that time? Like, how, how are you making those determinations? How, how are you working with the team to help identify some indicators that might be telling you, Hey, Not quite ready for this just  Nashifa Hooda Momin:  yet. That's a great question. Um, and so as our role, it's, um, important for us to look at those cues that we talked about and then seeing, Hey, can I offer strategy? And if that strategy doesn't work, then really knowing when to stop. And then, like you said, advocating for them to say, Hey, like that, we may not be ready because of X, Y, Z. And oftentimes what all often see is like breathing difficulties, meaning that. Maybe, um, their respiratory rate is in the [00:43:00]  90s or 100s, and they're really not even with strategies and everything that I'm trying. It's just not going well, and I'm seeing a lot of stress signs. They may have decreased alertness where they're not even participating. They may be medically unstable. For example, that could be, um, Changes in color. I might see like a desaturation event while I'm PO feeding or signs like I'm like I feed them and they're gagging and hiccuping and turning away and pulling back and shutting down gaze aversion like I mentioned, or they're extremely disorganized despite all the strategies. Another one that I have seen is like fingers playing where they're going to try to stop and put the stop sign up. Um, so what is again? What does all that mean? We have to stop. We have to support Um, and advocate for their needs promoting safe feeding so we can prevent long term issues down the line long term issues like over time. Um, so, yeah, those are some of the strategies.  Kate Grandbois:  And how does that conversation go with the family, especially for maybe moms who really want to [00:44:00]  have that skin to skin breastfeeding time? You know, there are so many emotional components to feeding your child. I have to imagine that if you are seeing signs of distress or any signs that PO is not an option at the moment, that could be a really difficult conversation to have. Nashifa Hooda Momin:  Yeah, absolutely. And I think that that does come up quite a bit. Um, and I, one thing that we promote a lot of is non nutritive breastfeeding, as long as the infant is stable and not showing signs of stress with that. And what I mean by non nutritive breastfeeding is if the mom is interested, um, Having her pump prior, putting the patient to skin to skin and then eventually to breast to really just work on those oral skills, um, and have that bonding time with mom and the infant. And again, it really just depends on the infant. So if the infant is showing signs of stress, if the infant is showing medical instability, I think like, hey, like, what if we just do skin to skin, right? We don't even have to do non nutritive breastfeeding. Let's do skin to skin. Um, and it is, it is a little bit of a culture change too, [00:45:00]  right? Because I feel like. A lot of times our focus can be very hyper focused on the medical things and so kind of taking that step back like you mentioned and really seeing where we are, what we can do what we can control and a lot of times when we can't control, we can still promote that bonding experience and and do the skin to skin and. Give room for that. So yeah, it's again a very much like you've mentioned It's very counseling very reading the room reading the situation and promoting and advocating for your patient And it's interesting because I do feel like that's one perk of being a rehab therapist PTOT or speech is that you really get to know these families, um in a different level and understand kind of what the dynamics are of that family and Provide that insight to the medical team and, and our medical teams are fantastic and have been so supportive and, um, are 100 percent like on board to support, like make sure that care is very patient centered  Kate Grandbois:   [00:46:00]  now. So what happens next for these families?  Nashifa Hooda Momin:  Oh, outpatient, right? So let's so there I know I'm more inpatient, but I do, you know, interact with a lot of our outpatient providers and, um, and it's an important factor and these patients come back and we're always in constant communication, like I've talked about, but when these patients get discharged, we have to think about where that patient is at that current time. Okay, so, okay. One thing is, like, I always come kind of back to, like, where, where is the patient? Are they repaired or are they unrepaired, right? So you may have a patient that is Let's just say it had a prenatal diagnosis. They come to the hospital. Let's say it's a cyanotic defect, like Tetralogy of Flow. Clinically, they're doing well. The medical team decides, hey, you know, the patient is stable and we can send the patient home. And then we'll, that patient will follow up with cardiologists. And then when they're will kind of determine their plan for surgical intervention when they're a little bit older, because [00:47:00]  again, sometimes we know that literature has showed that a baby when they're bigger and healthier, um, and have kind of some more meat on them, they're going to do well, right? With surgery. So sometimes that's the option, right? So these patients may go to outpatient therapy and clinically, these patients are going to be unrepaired. So they might have that baseline worker, breathing, working really hard. And in fact, that might actually get them Get worse as they get ready, getting ready to need the surgery. And so as a speech therapist, it's going to be more like, Hey, I need to provide strategy. So the patient may come in and say they're using a level one nipple, and they're feeding in sideline. They're not really using pacing. It takes them 20 minutes to feed. They're doing fantastic. Okay, well, week three, they come in and you notice that the patient's actually really struggling. They're pulling, they're tugging. Okay. Okay, let's kind of go down to a newborn nipple or a preemie nipple and offer some strategies, maybe a 10 minute rest, like a break at 10 minutes, give him a rest break and then start over again, maybe adapting the plan. And it can even be that the, and this has happened in the past where [00:48:00]  the outpatient speech therapist is the one that reaches out to the cardiologist. And it's like, hey, this patient is not finishing their feeds. They're really tugging. They're really not doing well. And then they get followed up. And usually right around that time is when they need that surgical intervention. So it really is a lot of communication and being in that setting, knowing that, hey, this patient is struggling and we need to advocate and do something about it. On the other side, you may have a patient who's repaired, right? So the patient comes in, say this is a, um, a, a cyanotic defect. We were talking about a cyanotic defect before, but, um, they come in, say they're a. BSD. Um, and they have their, initially they had endurance issues. They worked in the inpatient, had some strategies. They get to outpatient. And this is the kid that might actually do great. And this is the patient when you might be like moving up along the totem pole, right? You might be making their, maybe their nipple was at preemie. You're going to go to a level one. Maybe they'll go from elevated sideline to cradled upright. And we're kind of moving them along the process of like, Hey, like. Let's get [00:49:00]  them fully orally feeding if they aren't already and supporting the caregivers as they need them. So those are kind of the two things that I feel like generally we're thinking about as they get to outpatient. Um, but one of the major challenges that I hear, um, is the, How, navigating recommendations from various providers, so, you know, say the patient, an inpatient had, um, we found that the patient had vocal fold paralysis, so ENT was following them, and say they were discharged with an, with an NG tube, so you have GI following them, um, and then you have cardiologists, then you have the pediatrician, and then you have the speech language pathologist, right, or, or OT, PT, whoever is involved. Say the patient comes to, so, therapy, and as a speech language pathologist, I feel like I'm ready to push them, but I'm not sure, and I can't really get in touch with everyone because I'm in my outpatient bubble, and it's hard to get, walk over, and just ask someone a question. So I feel like that's a really big challenge, is to kind of navigate these, Recommendations from the so many, many [00:50:00]  providers and then trying to see documentation and then making a plan and feeling confident about, Hey, can I make this plan on this particular patient? Because it seems a little complex. So I feel like that's a big challenge that I hear a lot, um, from a lot of our outpatient colleagues. Um, and I, I'm hoping that there's a better way at some point that we can, we can support these families. And instead of this, I feel like working in a little bit of a silo, even though we are multidisciplinary, but we are in our individual islands when we get to outpatient. Um, but yeah, but I feel like that's a big challenge. And then lastly, um, I kind of do think that, um, one of the big things that I, I, I want to kind of highlight is that even when we talk about repaired and unrepaired, we really have to be thinking longterm, right? So remember, we were talking about, you know, Cyanotic and like thinking about, um, blood flow, right? So how is the blood going to their gut? How is their blood going to their brain? And thinking about, like, long [00:51:00]  term implications. So even if you have a baby that's doing well, PO feeding, um, and say they have a cyanotic lesion, again, like, how are we making sure that they're plugged in to getting assessments and thinking about neurodevelopment and thinking about the long, um, term implications of that? So I think that's another outpatient thing that we, I mean, I think it's an inpatient and outpatient consideration, but it's something that we all need to be thinking about. So I feel like those are some things that come up when I think about outpatient.  Amy Wonkka:  Yeah, just monitoring for those referrals to early intervention when they need to be made. I wonder if you can bring us back just thinking about the infants and the families who you're working with. Um, what are some of the, some of the helpful things that you have learned in your time in this position?  Nashifa Hooda Momin:  Yeah, so I will have to say that, um, My lens changed quite a bit when I became a mom myself, and I think realizing how it's much more [00:52:00]  than just a b c d. These are the things that we're going to do. This is how, um, feeding works in this inpatient setting all the way to outpatient. It's really, um, as kind of Kate mentioned, thinking about the family and putting them in the center of the care, right? So, um, one of the things that I feel like that I have learned is Being being more mindful about the recommendations I'm making. So, for example, making sure that the plans are feasible for our families, um, thinking about what are their social determinants of health, thinking about health equity, thinking about what are the logistics of going home, like, um, one thing that came up was a we had a family recently that had nine Children, and we were recommending, um, thickening for this particular population. The mom was not at bedside. So yes, the patient needs thickening. But how do how do I make sure that this is going to be a feasible plan? Right? Will they have the resources? So really, getting that time to talk with mom and seeing like, [00:53:00]  Hey, what can I do to make this work? And will this work? Because what's the point of making a recommendation if we're just if it's not going to work? So I think that's been one of the biggest things that's changed is to think about feasibility. Um, yeah. And really take a minute to understand what the caregiver's goals are themselves. Um, so that's been a huge, I feel like, change. For me, um, that I am, and I think I still have a lot to learn and a lot to grow on, but that's been something that I've been really trying to focus on more recently. Kate Grandbois:  I also have to assume that cultural competency comes into a play quite often as well in terms of cultural expectations for a, you know, for the postpartum period for the mother. I mean, there's just, there are so many layers to this population that I can't imagine Cultural competency not also being a consistent consideration as you're making recommendations, engaging in [00:54:00]  counseling, all of those kinds of things. Nashifa Hooda Momin:  Absolutely. I think that, um, and that's, that's another, uh, big factor is this was like years ago where we had a family wanting to really focus on breastfeeding, um, and, um, Making sure that the plan was around that because culturally that was what was going to work and it wasn't even it was culturable. It also came down to resources and kind of their where they were and how the feasibility how they could do things in their current setting. So I think realizing that, hey, I can't keep recommending a bottle to you if that's just not going to work. And that's not culturally what you've done where you've come from, right? So I think taking that into consideration is huge. Um, so yeah, I, again, like very learning one of the biggest things that I've learned. Um, and that's been more at the center of my attention, I think, has been thinking about putting the patient at the center and making sure that plans are feasible, making sure we have caregiver buy in. And we talk so much about this when [00:55:00]  we talk about adults, right? Like we're like, Carryover. Like, how are we going to make sure the adults have carryover? But for our kids, it's the parents, right? Like, it's, how are we going to make sure carryover happens? It's getting that buy in from the caregiver. Um, and so I think that's, that's been huge. Amy Wonkka:  This is sort of a tangential question, not super related, but I was just curious, how often, I know you mentioned in the case of the, of the patient who you've had, who had the subglottic stenosis, that you did a fees. Um, how often are you using imaging? To help aid in your choices that you're making as far as like, maybe whether a baby is going to be PO or not, or, you know, what, what  Nashifa Hooda Momin:  some of your strategies might be. Yeah. That's a great question. So the two types of instrumentals that we can do are, um, fiber, uh, sorry, fiber optic endoscopic evaluation of swallowing, which is a fees. And we can also do swallow studies, um, video fluoroscopic swallow studies, um, and both of those, I feel like it's interesting. I like to, I will do a swallow [00:56:00]  study when I. need to get more information. So clinic, so the thing is when you have a patient that's post op in my head also, I feel like they're recovering, right? They're recovering. They were intubated. Um, and so if I can clinically assess and I see clinical signs of aspiration, I don't know for me, if I would jump to a swallow study right away, but if I'm answering a question, so for example, The patient is fully PO feeding post operatively, no clinical signs of aspiration, but they're there every time they eat, they're having changes in their vitals to me. I'd be like, okay, hey, let's get down to fluoro and find out, am I missing something? Or is this something related to their physiology? What's going on? Let's, let's get more information. So I feel like that's kind of when I would want to do a swastika again, it's variable and I think it's patient specific, but that's a good example. Um, A fees is also extremely helpful because, um, so for that patient that we talked about with the subglottic stenosis, we did do a swallow study. And the swallow study, what, there was no penetration, no aspiration. And it was so [00:57:00]  alarming to myself and other, um, colleagues because clinically we were hearing Strider and clinically we saw signs of aspiration. So we were all floored. Um, and then when we ended up doing the fees. To get that different view, it was, like, we didn't even get to the fees because the minute that the ENT passed the scope, we immediately saw the subglottic stenosis and immediately they were like, this patient's going to need to go to the OR and, you know, um, next steps from there. But I think that I like to, I think it's like, where, how will these tools help guide my plan? Right? So I don't want to, and that's another big consideration is like, when we think about Swallow Studies, it is thinking about radiation. So like, if I'm just doing a Swallow Study just to check a box, that's not, that's not the best for the patient. So where can I add this in to clinical care that's going to help me change my clinical plan? Um, That's kind of how I feel like our institution does it for both of those [00:58:00]  assessments.  Kate Grandbois:  And I think that, I mean, that sounds very much in line with our evidence based process for a lot of other things in the field. That was really helpful to hear. I wonder in our last few minutes, if you have any advice for our audience members listening who are maybe working in a hospital, working as a med SLP, working in feeding and swallowing, but not necessarily with infants or in NICU or with congenital heart disease. What advice do you have for those individuals who might be interested in getting into this field? Nashifa Hooda Momin:  I think that I would, I think when I first started, and one of the greatest things was just being able to learn and shadow, um, from all the SLPs that were in my area. So I think starting there, and if you don't have like an ICU or, um, an ICU setting, um, then I would try to see if you could potentially, one of the things that I've had other colleagues do is PRN, and if you're, if you're interested, just to kind of get your feet wet and [00:59:00]  learn what, um, Kind of an inpatient setting is and then, and really just gaining experiences and seeing and testing it yourself. I feel like a lot of times you just have to put yourself in that situation to see, hey, like, this is something that I thrive in. For me, it's a lot, and you probably can tell from our conversation today, I'm big on problem solving. Um, I, I like to look at all the pieces of the puzzle and come up with something. Um, and that to this kind of environment, I feel like is a great Good fit for me. And that's not to say that, you know, the same personality wouldn't be somewhere else. But when I, when I'm in the ICU setting with high stress, lots of moving parts, it works great for me. So I think that shadowing and putting yourself out there is one recommendation. And I think learning, I think like just constant learning is an, um, Putting educating yourself on different areas and topics like for me, I feel like when I first came into the field as a speech language pathologist, I didn't want to do peds. I was very actually pro adult neuro. That's where I started. And that's where I thought I would end. [01:00:00]  And I took my position here. And Again, cardiac was not even in my radar, and I trained in the pediatric setting, and I found myself kind of like inching towards cardiac over time, but I think that it's just that learning and exposure of different areas and different topics and different people and their expertise and kind of be a sponge and soak it all in, um, and I, I think that would be my advice is just keep yourself learning, um, and, and I'll say 11 years in, I'm still I like love to just, um, in the mornings when chart reviewing with colleagues, just to say like, Hey, like, what does this mean? Or what do you think this is? Or, um, and I, I just like, love to learn. I love to like, learn new things, which I feel like is, um, yeah, I think it's a great thing to do and a great. Right for SLP intercast.  Kate Grandbois:  Thank you so much for being here. This was just a true wealth of information. I know I've said it twice, but again, I'm just [01:01:00]  astounded with how really this information flows out of your brain. You're clearly an expert in this content area and we're so grateful for all the time you've spent with us. Um, we will put all of the references that you've given in the show notes for anyone who is listening while they are driving. folding laundry, what have you. Thank you again so much for being here Neshifa. Really, really wonderful.  Amy Wonkka:  Yeah, it was awesome. Thank you.  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 [01:02:00]  email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

[00:00:00]   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 EpisodeSponsor 1 Kate Grandbois:  Hello and welcome to SLP Nerdcast. We are here today with a totally brand new, different kind of episode. For those of you who have been following along with us for a while, about six months ago, we announced the launch of [00:02:00]  something that we call SLPD On Demand, which is an opportunity for our members to write in. with their clinical questions and our resident doctor of speech language pathology, Dr. Annapala Moomy, is going to walk us through the case study. She's done a little bit of research to, um, basically answer your clinical questions. So welcome, Annapala. Why don't you start by telling our audience a little bit about yourself?  Ana Paula Mumy:  Follow me and a program director and associate professor at a small private university in East Texas. And I've also been in SLP for nearly 25 years. It seems crazy to say that, um, and I just love clinical work.  Kate Grandbois:  Well, we can tell because you always, I mean, I'm just looking at all of the research that you've done for this clinical problem. Uh, I'm really excited to get into it. Today's question comes to us from [00:03:00]  one of our members. Lauren P. Um, and B, the question in and of itself was related to childhood apraxia of speech and how that intersects with eligibility criteria in the schools. Um, so we're going to read the question, unpack everything, but before we get into that, I am going to read our learning objectives and disclosures. I will try and get through that quickly so we can launch right into the good stuff. Learning objective number one, list at least two potential adverse impacts on educational performance for children with apraxia of speech. And learning objective number two, Describe the role of specially designed instruction on dismissal criteria. Financial disclosures. Kate, that's me. My financial disclosures. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures. I am a member of ASHA SIG 12 and I serve on the AAC advisory [00:04:00]  group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Thank you. Ana Paula, how about your disclosures?  Ana Paula Mumy:  Yes, I received compensation from SLP Nerdcast for my work as ASHA CE Administrator and as the SLPD on demand. I'm also employed at East Texas Baptist University. In my non financial disclosures, I'm the co founder and president of Sparrow Stuttering. I'm a member of ASHA and TISHA, and I serve on TISHA's University Issues Committee. And I'm also a member of several special interest groups. with ASHA fluency and fluency disorders, issues in higher education, administration and supervision, and cultural and linguistic diversity.  Kate Grandbois:  Excellent. All right, well, why don't we start by Reading this clinical problem. So what did Lauren P have to say about one of her students and how can we help her?    [00:05:00]  Yes, so I'll first share the a little bit of information about the student She has a first grade student in an elementary setting who was diagnosed with Childhood apraxia of speech, and she does really well with, um, their target lists in blocked and distributed practice, and is demonstrating carryover of those words into conversation. Ana Paula Mumy:  And Lauren also says that Um, let's see, their difficulty is that they'll randomly come across curricular or random words that she'd like to be able to say, so they go back to working on sequencing them. Is there a better way to approach this, and how do I know when we're ready for discharge? Um, she's obviously always going to have apraxia, so at what point do we know that we can exit from therapy? And so here's her, um, more formal question that came from this little blurb here. Just when do I [00:06:00]  end treatment for students with childhood apraxia of speech that are intelligible but still have occasional difficulty with novel multi syllabic words? If they respond well to traditional CAS interventions and quickly are able to sequence the novel words with carryover, when do we say that our skills services are no longer needed? Kate Grandbois:  That's a great question, and I wouldn't even know where to begin finding that answer. So I know that you went to the literature to kind of figure out what the research says about that. Maybe we should start unpacking this clinical problem by leveling the playing field a little bit and talking about like what characteristics of childhood apraxia of speech are present that we then kind of need to work with. Go for it.  Ana Paula Mumy:  Sure. So I'm just going to start with a working definition of CAS, uh, which is essentially a motor speech disorder where children have difficulty learning and [00:07:00]  carrying out the complex sequenced movements that are necessary for intelligible speech. And when we think about speech, I was actually just, fun fact, I was looking at just some of the, um, information about speech movements, and I'm also teaching phonetics, and so this is really interesting to me, um, that speech movements meet some of the most exacting coordination demands of any human muscular system. So I think we know that intuitively, but just, you know, Good reminder, right? There's just a ton of coordination that's happening, not just the placement, right? But just that, um, coordination of movement. And so, that's really where children with apraxia of speech, um, break down, is being able to sequence those complex, uh, movements. And we'll see things like, um, inconsistent errors, so not saying words the same way every time. Uh, we may hear issues with stress on wrong syllables or words. Um, You might hear distortions of sounds. [00:08:00]  A lot of times vowels are impacted, which is different or, um, unusual in the sense when compared to phonological disorders. They also tend to struggle with longer words. So that fits Lauren's case where the multisyllabic words are a problem for this child. Um, and then it also may co occur with other language issues, reading issues, and so on. But. There is a really good, um, leader article that talks about, um, discriminative characteristics. So I'm just going to do a quick overview here. Um, this article talks about the often present, but not necessarily discriminatory characteristics of childhood apraxia of speech. So those would be things like, A limited consonant and vowel repertoire, which you could also see, of course, with phonological disorders. Um, the use of simple, uh, syllable shapes and frequent omission of sounds. So again, it [00:09:00]  could also mimic phonological disorders. Uh, numerous errors, um, so they'll score poorly on articulation tests and then poor intelligibility. So those are kind of the Um, you know, maybe more umbrella or kind of like the overarching things that you would hear, but then if you really want to discriminate, um, between childhood apraxia of speech and a phonological disorder, you would be looking for things like, um, difficulty moving from one articulatory configuration to another. So. maybe they're, you know, clumsy in how they articulate things. And that's why you hear some of that variability in how they might say something one time versus another time, right? Um, you might also see, uh, groping, um, or trial and error type of behavior where they're almost like searching for the position for that sound or, or how to, um, you know, place their tongue or whatever it may be. So you see some maybe facial, um, Uh, groping behaviors. [00:10:00]  Um, I mentioned the vowel distortions. So these are not necessarily substitution errors, but just distortions of the vowel sounds. Um, because maybe. how they're shaping their tongue or their mouth, um, you know, is just different. And so you're, you're hearing those differences in their vowels. And then the prosodic errors, hearing either, um, lexical stress differences, um, maybe even phrasal stress. So you hear some like intonation patterns that maybe sound different. And then the, um, last one is inconsistent voicing errors. So the child might use, um, Corrective voicing inconsistently, and that's one I think characteristic with CAS is that inconsistency that you, you know, because with, phonological disorders, you know, there's a very distinct pattern of error. And you can pretty much count on like, okay, they're going to be, you know, fronting their K's and G's, or they're going to be [00:11:00]  omitting final consonants, you know, and it's a pretty consistent pattern of error. Whereas with CAS, there's just a lot more variability and inconsistency, which makes it difficult. Kate Grandbois:  Okay. So all of this, all of this kind of tracks with, you know, what I think most of our audience is speech language pathologists who. You know, remember this at the bare minimum from graduate school. I think what's really interesting about this clinical question is the intersection of eligibility criteria, because in a lot of districts, at least in my experience, you know, I have heard the argument, well, speech sound disorders don't prevent access to the curriculum, right? They might not impact reading or writing, um, which we know doesn't feel good, but I'm curious to learn what The actual literature says about CAS and how that intersects with like IDEA and, and our general requirements for eligibility in the schools. What did you learn when you went [00:12:00]  a digging in the literature? Ana Paula Mumy:  So because eligibility for this particular child was already determined, what I'm going to zone in on really is the question at hand, which is essentially, is there continued adverse impact, right? Which is. The other thing that we looked at because, well, let me back up. So, of course, when we're thinking about eligibility, thinking about, you know, does the child have a disability, right? Is there something, um, that is impaired? And then is there impact? So does disability adverse, adversely affect, um, the child's educational performance? And then we have also, um, instruction where we look at the, does that student require specially designed instruction in order to access the curriculum and, um, thrive educationally? So, so for this child, we know She's eligible. She's been receiving therapy. So now we want to know, is there a [00:13:00]  continued impact? And then is there a continued need for specially designed instruction? So when we think about impact, we have to look at, is there a relationship between the child's speech difficulties and their academic achievement when it comes to, of course, reading, writing. We could also think about Phonological awareness is that speech difficulty translating into difficulty with phonological awareness, um, or even spelling difficulties. So those were, would be questions to potentially ask it or things to look into, um, through, You know, teacher interview through, um, looking at maybe samples of the child's work and those kinds of things and really just asking the right kinds of questions to determine, um, is there something happening, you know, beyond, um, just the intelligibility piece, which we know based on Lauren's little blurb that she's [00:14:00]  saying she is intelligible, but there's still times when communication is breaking down, right? So, the, the second question might be, you know, are there persistent errors, or if there are persistent errors, are these errors limiting that child's participation in the classroom? So, for this child, if she is largely intelligible. Maybe it's not impacting her or limiting her participation, but maybe, um, there is still significant awareness of those challenges, or maybe the child's afraid to speak up, right? She's afraid to maybe, um, contribute to a classroom discussion, or read out loud, or maybe Or those like  Kate Grandbois:  awful oral presentations that they made us give, or like the terrible book reports that they made us do in the front of the classroom.  Ana Paula Mumy:  Right. And of course, for this child, she's a first grader, so I'm not, uh, she's probably not doing any kind of like formal presentations, [00:15:00]  but they're still having to maybe, um, I think even love situations like if they do, you know, show and tell, or maybe it's a more social like, uh, type of participation in class where they're just talking through things and, and, or showing something and, and having to, um, explain or describe or, you know, whatever the case may be, but is. Is the child or the continued difficulty that she's having with particular words, is that impacting her to, in a sense that she's becoming withdrawn or maybe not, uh, willingly participating. So that would be something to look into. And then is this, um, or is the difficulty still noticeable across settings? So, um, and if it is, is it drawing undue attention to that child? So thinking about, you know, maybe she's. relatively comfortable in the classroom with her classroom teacher, but in other, [00:16:00]  uh, types of class room settings, like maybe art or P. E. or, you know, there's maybe other areas where the student is Um, participating throughout the day where there are more significant communication breakdowns potentially, right? So just looking further beyond just that regular classroom. And then, um, is the student consistently intelligible to all the adults, significant adults in their lives, right? So parents, teachers, other professionals, um, and peers, of course, right? Um, without knowing. All the detail about this child, she's reporting intelligibility, um, and just difficulty with more complex utterances or in multisyllabic words, um, but if the child is still feeling an impact from that, it could potentially justify additional [00:17:00]  work, right? So I wouldn't just say, well, just because there is intelligibility, most of the time that it would just completely erase. any potential impact that could be present. So we would just have to dig further. And again, I would just talk to the teachers and talk to the parents and talk to the child and just try to gauge, um, how is she feeling? Is she, you know, talking openly and not feeling, you know, some kind of, um, barriers there?  Kate Grandbois:  Would you also maybe think that in that instance, it could be, um, Good practice to check in with the school counselor or, you know, if you don't have a lot of counseling skills to maybe have a conversation with them about questions you could ask to kind of, you know, I'm just thinking of a small child, if they're having a negative social impact or not speaking up in the classroom or feeling, you know, that they're hiding their communication in any way, that might be a really difficult thing for a small child to handle. communicate about maybe they might not [00:18:00]  even be aware of it. Just, just given the nature of their age. So I would also imagine that there has to be some counseling that's happening and not all of us have had counseling training. So I'm, I'm wondering if like, you know, there's a room, there's room here to kind of have a conversation with the school counselor and get some tips. Like what are some things, what are some strategies to kind of best measure and best gauge this level of social, emotional impact?  Ana Paula Mumy:  Sure. I think absolutely. If you. feel less ready to do that or to have those kinds of conversations. I think the counselor definitely could, um, help you figure out how to elicit more from the child. Um, I would say because of my background with working with stuttering and having those vulnerable conversations sometimes with children or teens, um, I, I feel fairly comfortable whether it be through Um, maybe utilizing a storybook that would kind of open up the opportunity to talk about it, right, or maybe it's through [00:19:00]  drawing or, um, you know, just whatever the case might be, but, but definitely I think if you feel less capable to approach that, um, I think the counselor could be a great, um, source of help, so for sure. So moving into specially designed instruction, I would say. The two questions that came to mind were, does the student know what to do most of the time? So do they know how or what strategies are needed in that moment? Or can they? relatively independently, um, figure it out, right? So like if I'm struggling through a word, um, do I know what to do with my tongue? Do I know what movement or do I know if I slow down enough or if I articulate with more precision or what does that look like, right? So if the child is able to cue themselves relatively, um, Like, or was just minimal, [00:20:00]  uh, excuse me, minimal support, um, then I think maybe that specially designed instruction is no longer necessary because they're showing that they're capable, right, of doing it on their own and maybe just need some periodic reminders, right? Um, Um, then if that, those periodic reminders are needed, if they need maybe some cues or modeling or explanations or whatever it might be, could it be provided by the teacher or a paraprofessional or somebody else, rather than it still needing to come, you know, from me as the SLP. So if you feel like the child. knows what to do and has the skills that are there and just needs maybe an extra boost here and there, then maybe there could be someone else, you know, that is providing that reminder or providing some kind of minimal instruction. But if they're still needing, I would say, you know, moderate to significant [00:21:00]  levels of prompting or instruction, then that's going to be more our role and reserved for our Specialized instruction that we can provide, you know, for that child, and it's also making  Kate Grandbois:  me think of, um, service delivery, because, you know, if you're thinking about possibly transitioning out of direct service and making sure that other communication partners are trained, maybe shifting to that 3 1 model where you three sessions of direct instruction and one session of consultation to kind of talk to the classroom teacher, make sure they know what prompts to give or what the history is there. Just kind of like leveraging some of that indirect service that we don't tend to see very often in our field, but we know from lots of different research studies across the entire span of our field is very, very important and effective.  Ana Paula Mumy:  Right. In thinking about, for example, if you use any kind of tactile cuing or, or even if it's just [00:22:00]  verbal cues, does the teacher know what those are, right? So the video can be that continuity across what you're doing with what they're doing. And of course, if you're doing it from the get go, the teacher is going to feel very comfortable being able to provide those occasionally if they're needed, right? Whether it's a tactile cue or verbal cue, um, or, or a sign, or whatever it is, right? And so I think, um, definitely if we're doing, I would say if we're doing our job well in terms of collaboration with teachers and really preparing them to essentially support what we're doing. outside of the classroom, then when it is time to move maybe towards more of a consultation model and them maybe, um, helping you along to maintain that carryover, then I think they'll be, you know, ready and there won't be a huge need for a lot more. So it's almost like they're already doing it anyway, right? They're just [00:23:00]  continuing essentially what they've been that we've already been doing in a sense.  Kate Grandbois:  Mm hmm. So I know this, you know, concept of service delivery and indirect service provision is also making me think about our service delivery. And I know you found a really interesting research article on dosage. And I'm really excited for you to share that because I'm very curious.  Ana Paula Mumy:  Yes. Um, I think we've always known, uh, well, I shouldn't say we've always known, but I think it's relatively known at this point that we need high frequency. Um, of repetitions to affect change, right? When there's any kind of motor, speech motor concern, um, whether it's phonological or CAS, I, I think the, the research shows intensity being really important, um, and high number per session, um, and ways to, uh, so that. you're essentially doing a lot of drill play or [00:24:00]  drill type of activities to get as many repetitions as you can. So I think that's a relatively known concept, right? I don't think we struggle with that. And I think too, we've seen more research pointing toward, um, having maybe shorter, um, more frequent sessions, right? So I can get a hundred repetitions in 15 minutes. That would be much more useful to do over two to three days than just trying to do one session that's 30 minutes long. Are you really accomplishing more by doing that, right? Not really, because I can get 200 reps pretty quickly and have a relatively productive spin that way. Um, so what, what I found when I was looking is that for the, um, phonologically, uh, disordered. Child or the child with a philological disorder that the, the research is pointing to an average of 29 individual treatment sessions for at least parents to come, uh, [00:25:00]  begin to rate a change where they're perceiving a difference. Okay.  Kate Grandbois:  29.  Ana Paula Mumy:  29.  Kate Grandbois:  That's a very specific number.  Ana Paula Mumy:  It ranged from 21 to 42.  Kate Grandbois:  Oh, okay. Average. Yep. I can do math. Some. Yeah.  Ana Paula Mumy:  So average 30 ish. Right. Interesting. This was, and this was 45 minute sessions. And again, I don't tend to function that way. I tend to say I would much rather work with that child twice in the week for 20 minutes and get 40 minutes that way versus one long session because I can achieve a high number of trials fairly quickly. So that's my own personal. Uh, bias or, or preference, and I think that the research does support it, but when it came to the, um, the children with childhood apraxia of speech, it actually required a hundred and fifty sessions, an, an average. So it ranged from 144 to [00:26:00]  168 for there to be a noticeable change. Um, in intelligibility. And again, this is based on parental, 150, 150 sessions. I  Kate Grandbois:  just grabbed my calculator. I'm doing 150 divided by 20. That's five times as many sessions.  Ana Paula Mumy:  So 81 percent more individual treatment sessions are needed. Um, for childhood apraxia of speech than for a child with a severe phonological disorder. So and we're just talking about, you know, achieving games across, um, and again, this is based on, you know, parental perception of speech change and intelligibility.  Kate Grandbois:  But that's functional change in their, in their everyday environment. That's very important. It's an accurate measurement.  Ana Paula Mumy:  Yes, so I, I was like, wow, this is really impressive, um, or, or just really impactful information because I think if you think [00:27:00]  back, so I'm looking at Lauren's question again, right? And she says, she's been working with this child for what, a year or so, um, she's in first grade. Have they achieved what they want? a significant number of sessions for there to truly be this change that's going to last over time, right? And of course, we're seeing that she's responding well. Um, she reports she's responding well to CAS interventions. She's quickly able to, um, sequence, novel words with carryover and so on. So this child, of course, is responding to treatment, right? And there's been marked improvement based on what we know. Um, but at the same time, we also know that kids with childhood apraxia or speech are going to need a way more, um, contact, right, with us, um, than a child that just has a severe phonological delay. So I just think that's really important to consider when we're thinking about dismissal, that we don't [00:28:00]  do it too early, um, and that, that child really has achieved some solid gains and has a clear, um, Understanding of what are the strategies that they're utilizing to be able to be more intelligible, to achieve the consistency, right, to, um, work through those prosody, um, differences, you know, so I think it's just really important to, um, not to quickly arrive at, oh, they're good, right? Kate Grandbois:  Right. Right. I mean, that's a tremendously high number of sessions.  Ana Paula Mumy:  It is.  Kate Grandbois:  I mean, in comparison, that's, I mean, it doesn't, I guess, doesn't surprise me. We know that I was always told that, you know, the number of trials that you need for motor speech is way higher than what you would need for, or for apraxia specifically is way higher than what you would need for, let's say articulation. Um, so it doesn't surprise me, but I think I'm, I'm still taken aback by how that. [00:29:00]  Level of intensity would fit into a school model and would intersect with all of these other variables as well,  Ana Paula Mumy:  right? And so if you think about it, you know, I did the math too and thinking about 36 weeks of school right in one academic year Um, if sessions are occurring twice weekly, we would say we need about 75 weeks, which would be at least two academic years, right, for that child to really, um, for you to see those measurable gains. Um, if sessions were occurring three times weekly, we would still need about 50, you know, so it is still a big chunk, right, of time where we are very intentionally working with this child. And, um, of course, um, Aiming for a lot of repetitions, and so just a high number of trials, you know, per session.  Kate Grandbois:  And that doesn't even touch all of those other social emotional components that you mentioned earlier. I mean, that's another, that's another big factor.  Ana Paula Mumy:  Yeah. [00:30:00]  One thing that was interesting too, there was another study that showed that the continuation of novel word challenges is to be expected. So that does. seem to align with what Lauren is seeing, right? So that difficulty with those multisyllabic words, it could persist over time. So this one particular study, uh, Lewis et al in 2023 showed that it may persist into adulthood, um, for individuals with CAS. So that is not, um, Maybe a shocking thing that she is still struggling with those. Um, so just something to consider there. The only other thing I would add is then looking at, you know, is there any potential impact on literacy? Right. There is some research that shows that. Sometimes kids with CAS are at risk of being placed back on an IEP by fourth or fifth grade because of learning issues or because of some literacy related, um, [00:31:00]  aspects, you know, uh, whether it be because of phonological processing or language or reading difficulties. So just something to be, again, just aware of, um, in considering that an impact on literacy and not being too quick to dismiss without looking into those components.  Kate Grandbois:  That's so interesting. This was so, so helpful. I didn't know I could learn so much in such a short period of time. What I love so much about unpacking Clinical problems like this and case studies is looking at the intersection. So this is not just necessarily about childhood apraxia of speech, right? But we've talked about everything from eligibility criteria to literacy to communication partner training. Uh, social emotional impact, um, and I think when you are in, you know, Lauren's position of trying to decide whether or not to discharge, I think it's so, it's so important to kind of take a step back for a minute and really think about how the dominoes fall or think about [00:32:00]  the, the incidental impact of, of some of, you know, these lived experiences across these different domains. So thank you so much for, Doing all of this digging for us. This was really really interesting  Well anyone who is listening who would like to write in with their clinical questions There is a link in your SLP nerdcast dashboard for members to write in clinical questions for our SLPD On Demand, our resident doctor of speech language pathology, Ana Paula, to dive into the literature, and we will unpack it on the show. So we hope to hear from more of you moving forward. You can look forward to more of these SLPD On Demand clinical cases to be published in the future. Ana Paula, thank you so much for your brilliance and expertise, and we will be back again soon.  Ana Paula Mumy:  Thank you.  Kate Grandbois:  Thank you so much for joining us [00:33:00]  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. .