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 EpisodeSponsor 1 Kate Grandbois:  Welcome everyone to SLP nerdcast we are here today with a whole panel of people to talk about a very timely topic, advocacy and change in our field. The title of this course, advocacy and you be the change. [00:02:00]  We are really excited to have this discussion. I am not going to bother introducing everyone because I will do a terrible job. There are so many people here. So everyone on our panel, why don't we start this conversation by having everyone introduce themselves. Thanks so much for having us. So I am Jessica Linden Holt. I have been a speech language pathologist for 17 ish years and served in a number of settings with both pediatric and adult clients. Jessica Lenden-Holt:  I am currently the chief clinical officer for Sidekick Therapy Partners, which is a private pediatric practice serving school and outpatient clients in Tennessee and in North Carolina. I also serve as the vice president of legislative affairs. For the Tennessee Association of Audiologists and Speech Language Pathologists, also known as TASLP. Shequria Williams:  Hello, my name is Shakiria. I am a school based SLP and I've been in practice for 14 years. I am currently [00:03:00]  serving as the SEER representative for the state of Tennessee and the SEER champion for the southern region of the United States, in addition to my role as Senior Director of Clinical Services at Psychic Therapy Partners. And I'm super excited to be a part of this presentation today. Hi, I'm Casey Hammonds. I have been a school based SLP for seven years and I'm currently serving as the State Advocate for Reimbursement or STAR for Tennessee. I am also a clinical lead for Sidekick Therapy Partners and I am so looking forward to participating in this podcast today. Kacey Hammonds:  Thank you all. Hello, I'm Jennifer Henderson. Thank you for having us today. I have been an SLP for about 15 years working with both pediatric and adults. I am currently a clinical lead at psychic therapy partners as well as I lead our quality assurance team here and I currently serve as the state advocate for [00:04:00]  Medicare policy for the state of Tennessee. Kate Grandbois:  I think that's everyone. It's so fun to have such a great group of people here. Before we jump into this presentation, we do need to go through our learning objectives and our financial and non financial disclosures. I am going to read through them as quickly as possible, and I appreciate everyone bearing with us. Learning objective number one, define advocacy and the importance of state level and national level efforts on the field. Learning objective number two, identify four advocacy roles that exist at a state level for speech language pathologists. And learning objective number three, outline five ways SLPs can get involved with advocacy at a state and national level. Disclosures, Jessica's disclosures, Jessica received an honorarium for participating in this course. Jessica's non financial disclosures, Jessica currently holds an advocacy leadership role at the state level.  Shakira's financial disclosures, Shakira [00:05:00]  received an honorarium for participating in this course. Shakira is nonfinancial disclosures. She currently holds an advocacy leadership role at the state level. Jennifer's financial disclosures. Jennifer received an honorarium for participating in this course, Jennifer's nonfinancial disclosures. Jennifer currently holds an advocacy leadership role at the state level. Casey's financial disclosures. Casey received an honorarium for participating in this course. Casey's non financial disclosures. Casey currently holds an advocacy leadership role at the state level. Kate, that's me. Uh, my financial disclosures. I am the owner and founder of Grand Blot Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures. I am 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 the. Amy Wonkka:  Amy's financial disclosures. That's me. Um, I'm an employee of a public school system and co founder of SLP Nerdcast. And my non financial [00:06:00]  disclosures are that I am a member of ASHA, I'm in Special Interest Group 12, and I also participate in the AEC Advisory Group for Massachusetts Advocates for Children. Alright, we have shared our objectives and all of our disclosures. Um, I'm excited to hear. Kind of what brought all of you into your current roles in advocacy, but before we talk about that, what is advocacy? Can you guys define for our listeners just what that means in the scope of speech language pathology? Jessica Lenden-Holt:  Absolutely. Uh, I can give you the Oxford Dictionary definition as well, which is just Public support for or recommendation of a particular cause or policy, and advocacy can look like so many different things. I think most of the time people think of advocacy and they think of the day on the hill events and going to the Capitol and talking to legislators, but it can be so much more than that. It can be. As simple as having a conversation, uh, with a colleague, with a principal, with an administrator, or with a legislator. It can be writing a [00:07:00]  letter, sending an email, presenting information on policies, um, or procedures to others. It can be meeting with state legislators. It can even be helping draft policies and bills. Serving on committees and so, so much more. And so throughout our career as speech language pathologists, we're going to need to advocate for ourselves, our profession, our clients, our patients, our students, and, and our families. So it's just super important that we embrace our roles as advocates and a speech language pathologist.  so How comfortable do you feel to advocate on behalf of yourself, your clients, and your profession? Uh, in a survey of 194 school based SLPs, researchers found that only 15 percent of respondents had received training in advocacy, and only 14 percent had participated in an advocacy event, and 45 percent reported feeling ill equipped to advocate, but viewed advocacy roles as important. So 45 [00:08:00]  percent of SLPs saying that they feel ill equipped, I mean, that's almost half. That's, that's a lot. So a few questions we would like you to ask yourself right now. Have you ever received any formal advocacy training? Do you have resources, or mentors, or even know where to access information if you would like to learn more? Do you consider yourself to be an effective advocate? Hopefully you leave today feeling more equipped, as the goal of our presentation is to share information related to local, state, and national advocacy roles. Opportunities and ways to engage in advocacy at a state, local and national level and share advocacy resources in order to educate you as an SLP on advocacy and hopefully improve your perception on being an effective advocate. And often we stop ourselves from getting involved with advocacy due to feelings of inadequacy or the imposter syndrome. I'll definitely share a personal experience of [00:09:00]  mine. Um, We just kind of start to think I can't do that. Or there are people out there doing it better. They don't need me. So we would like to really encourage you all to change that thinking. I think each of us on this call felt this imposter syndrome when we first stepped into our roles. And so we really want to encourage you to think instead of why me, Ask yourself, why not me? If not you, then who? Um, I know that when I was originally asked to consider the VP of Legislative Affairs role, I did not have any formal advocacy training. I had not attended a Day on the Hill event. Or let a letter writing campaign before there was so much that was that was new and honestly incredibly intimidating, but I was willing to learn. And so that is what I did. I met with other advocates I networked I researched I asked a lot of questions. And I was passionate about helping our profession and our clients. And that's all you really need to get started. [00:10:00]  So your goal is not to be the person that knows everything about everything. That's impossible, right? Uh, you can't be the person who is best at everything in the room, but your goal can be to be the best learner in the room. So we really want to encourage you to be the change that you want to see in the world. So if you're listening to this podcast today, then you are already taking the first steps in being the best learner in the room. And we want to share specific ways you can plug into advocacy. So let's get started as Shakira shares more about state associations and advocacy.  Kate Grandbois:  I have a question first. Am I allowed to ask a question? I'm, I'm wondering, about the feelings that come along with advocacy and some of that imposter syndrome. And maybe while we'll talk about this a little bit later, and I'm jumping the gun, I'm just wondering in your experience, if this requires a tremendous amount of. Vulnerability. I mean, in terms of fear related to [00:11:00]  rocking the boat or getting critical feedback or quote unquote stepping out of your lane, right? We are, you know, stay in your lane kind of feeling. Is that something that you've encountered as, as something that you've had to overcome?  Jennifer Henderson:  I'm, I'm going to say for me personally, that's exactly what I thought, like those questions that Jessica asked at the beginning, my answer was no to all of them before I like got into advocacy, but then, like, I had all this fear and anxiety when right before day on the hill. And what you find is when you go out there and you start talking with other, like, SLPs and audiologists, like everyone is learning together and they share some of the same experiences and goals and ideas that you have. And I'm telling you, for me, like, just having that experience that day on the on the hill really kind of changed a lot for me because I'm like, oh, we, we all kind of share it. Some of the same similar goals. And so [00:12:00]  stepping out there really is kind of what helped me like get over my fear because you have all these ideas. Like I can't do this. Like, where am I supposed to start? And it really can be just as simple as like sharing your own stories with someone else. Whether it's like, I thought legislators were going to be like big and scary. They're not, they're like people just like us. And it was so easy to talk to a lot of them, actually.  Shequria Williams:  And I completely agree with everything that, um, Jennifer has said as well. Um, imposter syndrome definitely is, is real. There is definitely fear. Um, anytime you step into something that is new and into something that is different. But in addition to all the things that Jennifer has explained that actually helps with those things, I think it's also important for you to surround yourself with the right people. Those people that are going to. Going to be encouraging. It's going to be uplifting. Those people that understand the feelings that you're feeling, because they have also felt that way, because those are the [00:13:00]  people that you want to surround yourself with, connect with, because they're going to be the people that are going to actually help you to also ease some of that fear that you're experiencing. Jessica Lenden-Holt:  Creating that network. Like I sort of said early on was so key for me. So all of these incredible women, uh, female leaders and advocates on this call, We help each other, right? So there is a level of vulnerability. There is a great learning curve sometimes. And yeah, sometimes you're getting feedback that, that kind of doesn't feel the greatest or maybe, um, you know, you feel like you're just not doing your best. And so I think surrounding yourself with others, learning from others is really key, uh, in embracing an advocacy role and getting started. And also just like they've said, just jump in and do it and try it. And you'll kind of be surprised with what you can accomplish. Kate Grandbois:  Thank you for answering my question. You're welcome. And so now I am going to share with you the importance of state associations. Um, so let's talk a little bit about why they're important. [00:14:00]  So our state associations are important for the advancements of the fields of speech language pathology and audiology. Shequria Williams:  Our advocates are on the ground working to improve matters in the areas of public policy, popular opinion and political action. at a state or local level. Oftentimes, a lot of the changes that we see, observe, and experience as SLPs, um, in our day to day work are the products of advocacy efforts at the state level. And so some keys to successful advocacy include membership and active participation, which is a topic that we will discuss in detail a bit later. Collaboration, because you will oftentimes have to brainstorm and consult with a variety of individuals that work alongside you within your state organization and other SLPs and audiologists throughout the state. It requires a lot of patience. Because we, as we've all heard throughout some time about in our lives, slow and [00:15:00]  steady wins the race. And then it also requires persistence. There will be times that you will be on the ground advocating for this, you know, something. And it just seems like such a difficult task. But no matter how difficult the task, May seem, you know, I want to encourage you all to keep trying. Use ASHA as a resource to learn about what it means to be an advocate for the professions of speech language pathology and audiology, in addition to learning about advocacy efforts at a national and state level. ASHA has many great resources to keep you informed about how you can get started in your advocacy efforts. And you can find information and websites related to your state association. All you have to do is visit ASHA. org. You can scroll to the bottom of the page and click Become a Volunteer. Under State Association, Volunteer Opportunities, click State Association Member Benefits. This is a website that contains information related to benefits of [00:16:00]  advocacy at the state level. It also contains clickable links under the heading join that allows you to access the websites for each state association. If you wish to become a volunteer or if you're interested in knowing What openings your state organizations are looking to fill, you can do so by clicking open volunteer opportunities with state associations located on the volunteer under the volunteer heading on the same webpage. Feel free to utilize websites or reach out to your members of the state organization for which you wish to participate in for more information. So I have provided some images of what the website that you will access for each state associations webpage looks like. Again, it is the State Association Memberships Benefits page that you can find on ASHA. org. So you can use this site to learn about how to become a member of your state organization or to simply see what [00:17:00]  advocacy efforts have been put forth to advocate for SLPs in your state. Each state association has a name or an acronym that they identify with. So for example, in Tennessee, our state organization is known as TASLA. which stands for the Tennessee Association of Audiologists and Speech Language Pathologists. In Illinois, the state association is known as ISHA, which stands for Illinois Speech Language Hearing Association. And in addition to visiting the state association sites, I want to also encourage you all to also follow your state associations on their social media platforms. We're familiar with Facebook and Instagram, so definitely check them out there because you can find lots of great information there, too. So, you may be wondering, does it cost me anything to join my state association? The simple answer there is yes. Each state organization has a fee associated with becoming a member. Your annual dues for membership to your state organization support [00:18:00]  payment to lobbyists, and lobbyists are extremely necessary as they keep the organizations up to date with happenings on the Hill in addition to presenting bills created by state organizations to legislators. Thank you. Your fees are also used to support hosting of the annual virtual or in person conventions where you get the opportunity to network SLPs across the state. In addition to networking opportunities, your fees also give you access to many other perks including discounts on convention attendance, CEU opportunities, updates on legislation and advocacy efforts via the e news and other sources, and so many other wonderful things. Membership fees and types can vary from state to state. So for example, annual fees for full membership for these states are as follows. In Alabama, the annual membership is 55. But over in California, they're 180. Down in Florida, they're 125. And here in Tennessee, they're 85. [00:19:00]  New York actually has a couple of different options. So for a one year membership, it's 100, but you can buy two for 180. So that's kind of a discounted rate there if you go ahead and purchase the two year membership. In Texas, active membership is 130, but in the state of Washington, they're 70. Many states also offer a variety of membership opportunities, including student memberships, associate memberships, Affiliate memberships. and lifetime memberships. Information regarding membership fees can be found by viewing state association member benefits on ASHA's website asha. org and you can click the state you wish to view the information for and then you can click membership or join now on your state organization's web page to kind of learn more about those fees. Now Jessica will start us off with telling you about what advocacy roles exist in each state association. Jessica Lenden-Holt:  So, um, I mentioned earlier, I'm the Vice President of Legislative Affairs. Most states have a VP of Legislative Affairs or a VP of [00:20:00]  Advocacy or a similar title, um, so we're sharing some general information about the state of Tennessee's VP of Legislative Affairs role, but please reach out to your state association to ask how this role might be different, um, or similar for your state. So the VP of Legislative Affairs is a state association. board member role. It is a two year term. Um, you attend monthly meetings and provide updates to the board on any advocacy efforts. You stay up to date with legislation and advocacy, usually using ashes website. Some of the network, um, networking opportunities I've mentioned. We have, um, state level meetings and national meetings as well. We set strategic plans with the State Association Board, the Advocacy Committee and with our state lobbyists. We organize and attend the State Association Day on the Hill. Ours is typically in February or March. We organize letter writing campaigns for the State Association members and non members, and that is sort of an ongoing effort [00:21:00]  throughout the year. We work on newsletter and social media write ups related to state or national advocacy and connect with ASHA leaders. The Department of Education, the Department of Health, and other organizations as it relates to advocacy. And we connect very often with the state SEAL, STAMP, and STAR representatives. And Jennifer's going to share a little bit more about the STAMP role. Yes, so the STAMP is the acronym for State Advocates for Medicare Policies. And state, um, stamps basically help provide leadership, guidance, and support on matters that affect coverage reimbursement and the delivery of services under Medicare funding. Jennifer Henderson:  So each month, I basically attend meetings with stamps across the country to learn. More about Medicare related issues that affect the service delivery of speech pathologists and audiologists. Um, we basically discuss the topics that are related to caregiver training codes, value based care and other [00:22:00]  Medicare reimbursement related topics. So now I'm going to throw it right back over to Shakiri to talk to us about the SEALs. Shequria Williams:  Okay, so SEAL is the acronym for State Education Advocacy Leaders. by providing leadership guidance and support on matters that affect funding and delivery of services of SLPs and audiologists in the academic setting. In our state, I am the SEALS representative. I am also the SEALS champion for the southern region of the U. S. I have had the pleasure of connecting with the SEAL representative across, uh, with SEAL representatives across the country to learn of policies that are currently affecting our professions in addition to learning about all of the actions that the representatives in each state are taking to try to overcome some of those issues affecting our professions in the academic setting. So each month I attend meetings to connect with others and talk about ways to make, uh, service delivery in the academic setting better. Some topics that we discuss include caseload and workload [00:23:00]  caps, which is a big topic of conversation right now. Um, because so many SLPs are experiencing shortages in the schools, that is another topic that we discuss. We also talk about salary supplements, um, state tests and licensure, um, that, uh, SLPs also require to work in the academic setting. And we even brainstorm ways to increase membership in each of our state organizations. I've had the pleasure of connecting with therapists within our state that seek support and information necessary to learn how to advocate for themselves on matters that affect their ability to provide or supply faith to their students, which is free and appropriate, um, education. And now Kasey will share with you information about the STAR role. So STAR is the acronym for State Advocates for Reimbursement. STARS aid by providing leadership, guidance, and support on matters affecting coverage reimbursement and the delivery of services [00:24:00]  under both Medicaid funding and private commercial pay. Kacey Hammonds:  In Tennessee, I am the STAR representative. So each month I attend meetings with STARS from across the country to learn about Medicaid and private pay related issues as well that are affecting the service delivery of speech pathology. pathologist and audiologist. I have had the pleasure of discussing topics related to developmental coverage, F code issues, habilitation exclusions, and telehealth coverage fee reducing in some states, as well as network adequacy among a bunch of different things. We touch on a lot in our meetings, they're very informative. And so in this slide, If you're looking on YouTube, we've included a link from ASHA that takes you to the state based advocacy network page. This is a really handy page on ASHA's website because it contains your contact information [00:25:00]  for the various state based advocacy representatives, as well as the ASHA liaisons for those advocacy networks. Kate Grandbois:  And for anyone who is listening, all of these links will be in the show notes as well. So most state associations have advocacy committees. These committees are comprised of practicing SLPs and audiologists from various settings. Like in the STARS network, I personally am school based through a contract agency, but we have a lot of private practice owners, some SLPs and audiologists that are medically based, a few other school based SLPs. Kacey Hammonds:  It really varies widely in that network, which is great. The requirements for becoming a state association advocacy member are pretty simple. One is being a member of your state association. So, for instance, in Tennessee, I am a member of the Tennessee Association [00:26:00]  of Audiologists and Speech Language Pathologists. Um, So if you're interested in participating more in your state's advocacy committee, your first step would just be checking on that ASHA link that we shared, like you said it was going to be in the show notes, um, to get in touch with your state's advocacy committee and just emailing them, calling, seeing what positions might be open or maybe what positions need a little bit more help. So in summary, what does a state advocacy member do? They help with a number of different things, like Jessica and Shakira and Jennifer have already mentioned. Maybe we're doing a letter writing campaign. We're organizing surveys. That's something I'm currently working on now as the star representative for Tennessee. Maybe we're doing day on the hill preparations, getting ready for your state convention, etc. There are a number of different opportunities based on your availability. your interests, and what motivates you. [00:27:00]  If being a state advocate is not something that interests you, just being a member of your state association might be a good alternative. Active membership in your state association could look like attending your annual conference, which in Tennessee, I really can't recommend enough. If we have any other Tennessee audiologists or speech pathologists listening, the TASLIP convention is wonderful. I loved it last year. Um, it could also look like meeting your legislators on day on the hill or just sharing an advocacy post that means a lot to you on social media, your membership dues primarily go to advocacy efforts and to pay your state lobbyists so that they can advocate for you. Jessica will now, now share some ways to get involved at the national level. And I just want to say before we move on to advocacy at a national level. I know we hate paying dues. I know we hate paying extra. I feel like we're always paying something. I totally get it and understand it. I will just say that lobbyists are not cheap. Jessica Lenden-Holt:  And a [00:28:00]  lot of times we hear all these changes we need to make, all these things we need to do, and it is very hard to do those things without support. a lobbyist. So I promise that your dues go to great things at the state association level. Um, almost all of our dues go straight into paying for our lobbyist. So just wanted to put that little plug out there. I know we hate paying for dues. It is truly how we get things done. And we're able to take all of the things that you all bring to us at a state level and work, work to get those needs met. So just wanted to put that plug out there. I know none of us want to pay more. Um, but now onto advocacy at a national level. So ASHA has the public policy agenda that is available to everyone. You, it identifies the public policy issues that are of particular importance to the profession and they send out a survey to members to complete so that you can weigh in on issues that are important to you. So make sure that you are [00:29:00]  responding to those surveys and let your voice be heard. You can view ASHA's public policy agenda on their website. site at ASHA. org backslash advocacy. You can also follow them, um, ASHA advocacy on Facebook. So at ASHA advocacy, you can sign up for ASHA headlines to receive your 60 second advocacy update and learn more about letter writing campaigns that they have going on again at that ASHA backsplash backslash advocacy. It will get you there. You can learn about ASHA pack. Which is the political action committee for ASHA. And if you are listening right now, we would love for you to take a brief pause in this podcast And go ahead and do an action item so you can already say that you are on your way to participating in advocacy I love this quickly or if you really can't maybe you're driving. I don't know take a note for later But sign up for the advocacy alerts It takes just a minute and you will stay up to date on advocacy issues. [00:30:00]  So again, if you visit asha. org backslash advocacy, it will take you to all of these great links. Um, so take a moment, sign up for those so that you can know what's going on at a national level. Uh, and Jennifer's now going to share some specific additional action steps that you can take to get started on your advocacy journey. Yes. So we're going to talk about 12 actions that you can take to get involved in advocacy. You're probably thinking, what can you do? Okay, what can you do? The first thing you can do is staying informed about current legislative issues and debates that impact our field. Jennifer Henderson:  You can achieve this by regularly reading news and research articles. Keeping up with the latest studies and reports can provide valuable insights into Everything that's going on, anything that's developing. Casey mentioned earlier, like attending conferences and workshops, that is also highly beneficial because [00:31:00]  it does allow you to learn about the latest trends. And also it just allows you to network with other professionals in our field. So. Who doesn't want to do that? Um, another effective way is just to stay informed by becoming a member of both your state and national organizations and by participating in advocacy committees. These organizations, they do often offer resources and updates on all the important issues that are going on. So staying updated on state and national level issues is very, very important. Um, you can accomplish these things by just subscribing to your state association's email listserv or the ASHA Advocacy Update newsletter. All right, what else can you do? Well, very important to help others understand the importance of speech language pathologists. Um, when we share with our friends, family, and our community about what we do and how we are impacting the lives of [00:32:00]  others, We can get more support for making important changes. Sometimes people don't really realize just how important our roles are, but when they do, they're more likely to stand with us in our advocacy efforts. It's also great to just reach out to your legislators. Um, we can share our concerns and show our support for needed changes by writing those letters, making calls, or even taking the time to schedule meetings with some of them. Um, when we talk to legislators. Sharing personal stories when discussing issues and trying to think about potential solutions can really make a difference when we're talking to them. Very, very easy to find out who your legislators are and keep up with relevant bills. Basically, all you have to do is visit your state government's website to get more information. Now, on our next slide, if you're watching this on YouTube, I am going to give you an example of how, um, to search for that on our state [00:33:00]  organization's website. So, I've gone to tn. gov here. I'm going to go to government, and then I can go down to legislative bill search. That is going to take me to the bill search page. On our government page, you can type in either the keywords. Or if you know the bill that you're searching for, you can type in the bill number, HB just stands for House Bill. So the bill I'm pulling up here is in regards to extending the interstate compact for the state of Tennessee. Um, on this page, you can see all the actions that were taken for this bill. You can see when the governor signed. You can see when it went into effect. If I want to find out who my legislators are, I just go up to find my legislator, and it brings up the map, the state of Tennessee map, and then I just put in my address there. And when I put in my address, it will bring up my legislators for my district. And when you go to search for your legislator on our intent in the [00:34:00]  state of Tennessee, you can click on the their name, and it will open up a separate page that will give you more information. Um, information about that specific legislator and most, uh, state government websites are similar. So you just, again, just have to visit your government state website page. All right. So, so far we've talked about staying in the loop, joining advocacy committees, spreading knowledge, and getting in touch with lawmakers. So, what else can you do? Well, one more powerful move is teaming up with other professionals, um, by uniting with OTs. PTs, other educators, other, like I stated before, just others who share in some of our same goals, we really can make our efforts even stronger. So just remember that working together often has a bigger impact and it does boost our chances for success. So when we team up guys, like [00:35:00]  our collective voice is so, so much louder. Get involved in grassroots campaigns. Also very important. These efforts are a great way to just raise awareness and advocate for the change that we are seeking. It can be just as simple as sharing our needs with our state advocacy leaders. Filling out those surveys that we talked about earlier or taking part in any rallies that might be going on in your area. Um, also arranging local events or getting involved in advocacy campaigns that are led by your professional state organizations or advocacy groups are awesome ways to get in on the action. All right. Still chatting about a bunch of ways to advocate. There is still so much more that we can do. We talked earlier about social media. Social media is a huge help. Especially in this day and time. Alright, everybody's online, everybody's on social media. Um, basically it's a great way to help spread info, sharing resources, and getting support for making [00:36:00]  laws. We can join online groups. Plan digital campaigns and use those hashtags to get our messages out there. Don't forget guys, go to your state organizations, um, Instagram, Facebook, whatever, social media, go ahead, like comment, share those advocacy posts from groups like Asha and your state associations, because every, every interaction really does help spread the word. Another important way to get involved is just doing research and using evidence based practices by doing research or using evidence based practices. It really does help back up our push for the laws that we're wanting to change, right? So, when we show, like, what we find and what we've done, we are able to raise awareness and influence policy decisions with solid evidence. So, research and evidence can make a strong case for why certain changes are needed. It makes our, just our advocacy efforts. It just makes it more believable when they can see [00:37:00]  like what we're doing is working. All right. I know we're still talking about like advocacy actions, right? So I don't know what number we're on. We're on number nine. Okay. So let's talk about two more important ways to get involved. Um, again, like just sharing personal stories can be super powerful. When we gather and share stories of children and families who have benefited from our services, it really does bring our work to life. These stories can raise awareness, and they also just inspire support for legislative change. People are really Often moved by like just real life examples. Like, I mean, a legislator that I spoke with during our day on the hill, just talked about the services that he was receiving after, um, having had a stroke. So just like being a part of it and understanding what we do really helped him understand [00:38:00]  and really helped him want to advocate for. advocate for some of the things that we were wanting to advocate for. So that goes down to just building those relationships with policymakers, legislators, and their staff. All of that is very important. If you ever have a chance to just attend a town hall meeting or any committee hearings, um, or other public events, I strongly encourage you to do so because this gives you a chance to meet and engage with your elected officials. Building those relationships really can help you become a trusted resource and advocate for legislative change when legislators. Like know you and they understand your passion. They're more likely to listen to you and. support your cause. All right, we've already covered a lot of fantastic ways to get involved in advocacy. Let's just go ahead and wrap all of these up with two final action items. [00:39:00]  Join your state and national day on the hill events. These events are awesome opportunities to meet with your legislators and talk about important issues just face to face. It's a chance to make your voices heard directly. Where decisions are made, but being there in person also shows our commitment and helps us build strong relationships with the policymakers. And again, like this was like a game changer for me, honestly, just attending our own state day on the hill. It was, it was so fun. It was very important, informative, but it also made the legislators to me, like more human, like I was stating before, like, because to me, for me personally, it was like, Scary people in this, you know, on the hill, right? Like making decisions about things that they really don't understand. But that's why it's important for us to educate them. And it turns out like, at least the ones that I talked to just, they were so nice and really wanted to listen. So I definitely encourage you to [00:40:00]  attend your day on the hill events. Um, and then the last thing, another powerful advocacy tool and participating in state and national level is just participating in state and national letter writing campaigns. Um, letter writing campaigns are a great way to share our concerns and express support for legislative change. Listen, these letters are impactful, especially when so many people are sending those letters into your legislators. So, By joining your Day on the Hill events and participating in these letter writing campaigns, we really can make significant impact on the legislative process. And Jessica is going to talk more about what Day on the Hill looks like, but she's also going to talk to you about how you can do those letter writing campaigns. Like I said, I'd never been to a day on the hill. I'd never participated or led. I guess I'd never led a letter writing campaign at this point. Jessica Lenden-Holt:  So there was a lot of mystery behind [00:41:00]  it. And mysteries can sometimes be scary and intimidating, and we can come up with all these reasons why we shouldn't do it. So we want to kind of like, Take the veil away and kind of show you a little bit about what it looks like. And this is an example from Tennessee. Of course, your day on the hill might look a little bit different. Um, but really it's a, just an interactive event. So you heard a little bit about Jennifer and her experience. Um, they're really true. It's just a fun, interactive event where you have a lot of different professionals or graduate students coming together during the legislative session. To advocate or to share stories. And so again, ours is typically held in February or March. We have professionals and students that, um, that come and we first educate them on what are the current legislative affairs that may potentially affect our profession and our clients. Like what is the background on some of these bills? What are the things that are on the table that we need to discuss? And we provide members with a one pager that they give legislators. That contain all the talking points regarding [00:42:00]  our advocacy agenda and professionals meet with Tennessee legislators, their state legislators to advocate on behalf of our profession and clients. And these are scheduled appointments that we schedule ahead of time. And during those meetings, the participants will not only review the current issues with the legislator, but also just describe how it impacts our field, what we do, like Jennifer sort of mentioned, like some of them know what we do, some of them have no clue, right? So you're kind of sharing a little bit about. who we are. Um, and then we just advocate for our desired outcome. And a letter writing campaign typically occurs around the same time as Day on the Hill, but they can also take place throughout the year. Uh, we send ours out via email to all of our members, as well as post them on social media. Um, and when individuals are not in a meeting for Day on the Hill, we usually ask them to participate in some of our letter writing campaigns. So the day on the Hill concludes with a meeting between all of the participants where feedback from our meetings are discussed, and we just plan for actions moving forward. And [00:43:00]  again, this is, we typically are going around in small groups. There's usually a leader who knows a little bit more about what's going on, who's helping kind of guide the group through. Legislators are just always excited to meet their constituents and especially students. They love meeting students. Um, and they really just want to learn more about our field. They often share personal stories, like Jennifer mentioned, of how an audiologist or a speech language pathologist has impacted their life or the life of a family member or a friend, so it's truly just a great opportunity to connect with lawmakers and start building a relationship with them. I did, we've mentioned letter writing campaigns so much, but this is such an easy way to connect You know, in between Netflix shows or whatever you're doing, you can write this super quick letter and participate in advocacy. So we are going to show you just how simple it is. This is another one of those do it along with us. So if you need to click pause or jot this down as an action item to take letter later, you're going to go to asha. org. [00:44:00]  Backslash advocacy. So state associations may send out their own letter writing campaigns and templates. We are going to show you a quick way walking through ASHA's website just because we can all advocate together with this one since we all come from different states, but we would love for you to pull this up and follow along with us. So when you get to the website, you'll see lots of great advocacy information and updates. If you look on the right hand side, you'll see a box that includes the public policy agenda and right below that there is a take action link. So if you click take action, you're going to be taken to the ASHA take action page where you can sign up for alerts. Find your legislator, read about all the bills going on. Uh, and if you look on the left hand side, that's where you're seeing all the different advocacy agenda items. Click one that you're interested in learning more about. And once you click on that topic of interest, that's where you're going to see additional information about the issue, any bill information. You can also download the full issue [00:45:00]  brief. And then on the right hand side, You'll see where you can enter your name and information to send a letter to your legislator explaining and supporting the bill. So if you're already signed in, ASHA will automatically include your legislator so you don't even have to look them up. Um, and they provide a template for you to use. You can choose to make edits or add in personal stories or notes or you can choose to send as is. And that's it. So it literally only takes a few clicks. a couple of minutes to participate in a letter writing advocacy campaign through ASHA. So I would really, really like to encourage you to pause this podcast, take notes, participate in at least one. Pause it, pause it, pause it. Yes. Pause and come back though. Um, so that you can participate in at least one letter writing campaign today. Um, cause it really is that easy and that simple. All right, Casey, over to you to share more about volunteer [00:46:00]  opportunities. All  Kacey Hammonds:  right. Thank you so much, Jessica. So, one of the most fun and rewarding ways to get involved with advocacy is to seek out volunteer opportunities. So, let's take a few minutes to explore what these opportunities could look like for you and how you can advocate for the prevention of speech language pathology or audiology through volunteering. You can find some of the most fun fun and engaging leadership and volunteer opportunities by, again, attending your state convention. I mentioned before, and I'll say it again, that I particularly, particularly enjoy the TASLIP convention that's held every September. State conventions in general are a wonderful source of education, connection, and networking. Conventions provide an opportunity to meet SLPs across your state, many of whom will have very [00:47:00]  similar advocacy concerns. For example, the private practice SLPs in your state might be worried about a new private payer in the state that's taking months to authorize treatment and then getting a lot of denials. Maybe your medical SLPs are worried about the new Medicaid or Medicare policies and your school paced SLPs. Desperately need a caseload cap, let's say, everyone has something to advocate for and your state conventions are a great way to get a feel for what our colleagues across the spectrum of speech language pathology are needing, are wanting. Serving on committees and being involved in your community are both essential for knowing the why behind your advocacy. I know personally for my advocacy as the state advocate for reimbursement, knowing the why and my recent efforts for trying to get us increased reimbursement for Medicaid in the state of [00:48:00]  Tennessee has really just lit a fire under me and trying our best to get those reimbursement rates. Elevated. I'm trying Tennessee. So again, attending the ASHA convention and your annual state conventions are great opportunities for diving into advocacy. The convention setting gives you that opportunity to meet with your national reps and your state advocacy reps. You can attend sessions related to advocacy, connect with your state association and ASHA leaders. present and view posters and sessions, volunteer on commit on convention committees and of course, earn CEUs. Just in general, the conventions are a great chance to network with and more importantly, learn from others in our field who might be practicing in different workplaces, settings, or even states. There is so much that we can learn from one another. And it's [00:49:00]  surprisingly easy to serve on committees at both the state and national level. Asha actually has approximately 45 committees, boards, and councils that provide numerous volunteer opportunities for members. The link in the slide that we're showing and that will also be included in the show notes, if you click on that link, it will take you to an Transcribed by https: otter. ai Extensive list of all the committees, boards and councils that ASHA provides. There are groups for a variety of issues in any in our field, anywhere from infant hearing to multicultural issues. The contact information from members on the committees. is available on the ASHA website. If you're interested in participating in ASHA advocacy, there is surely a committee for you. If you prefer to advocate for SLPs at the state level, you should contact your state association to learn more about committee opportunities. I'm [00:50:00]  sure that they would be happy to have new state association members ready to lend a hand and volunteer. We have discussed naTional and state committee participation, but volunteering directly in your community Is one of the best ways to advocate, advocate for the people who matter most, our clients that we're serving. Personally, one of the most rewarding ways for me to connect with our community and find out what our true advocacy needs are. Is my participation in the Adaptive Football Camp that we have each year in Elizabethton, Tennessee. I have had the opportunity to connect with our local zoo to provide a presentation about how best to accommodate autistic individuals and adults that come to day camps at the zoo. Jennifer helped me with that and we had a great time there. So these volunteer opportunities have allowed me to connect with the community and hear from the individuals directly impacted by the bills and laws that we are advocating for. [00:51:00]  Shakiria is going to take over now and we'll answer some important advocacy related questions. Shequria Williams:  All right, guys. So just in case you're wondering, does my voice really make a difference? Yes. Yes. Your voice absolutely does make a difference. And I am going to share with you all about how your voice makes a difference. So, of course, your voice matters. There's, of course, power in numbers, which is why we are encouraging you today. So if you feel it right now, just take another pause. And go ahead and join your state, uh, organization. Um, I will share with you a bit about what TaskLift has advocated for and some things we have accomplished due to our advocacy efforts. So let's dig a little deep in here guys. So in Tennessee, um, SLPs used to pay 400 annually for what we call a professional privilege tax to the state. I am [00:52:00]  pretty sure that every SLP in the state of Tennessee dreaded the month of June because that is when we had to pay this tax. And so our, you know, task force members and SLPs advocated to remove this and we made it happen guys. This passed in 2020 and we couldn't be more thrilled not to have to pay this annual tax every year. Telepractice approved for reimbursement past COVID emergency. This passed in 2021 and it became a permanent stay in 2022. Tennessee joined the interstate compact and that passed in 2022. SLP licensure timelines, uh, that bill passed to keep processing times at 60 days or less, and that passed in 2023. SLP workloads, we're still working on that, it's a work in progress, um, and guys we can't stress you enough, your membership dues into the state organizations are definitely used to support our lobbyists, and so we are still working on that in the state of Tennessee. Um, we've [00:53:00]  also had a Medicaid rate increase that, um, well, we've not had one, but that's a work in progress. Our STAR representative, who is so fabulous, Casey, she's definitely working on that guy. So again, be patient because she is working hard to advocate for those Medicaid rates.  Kacey Hammonds:  Check your emails, , we've got a survey coming that how the way that Tencare is set up, we, we need your help on it. Shequria Williams:  Yes, definitely. Definitely. So again, your voice matters. Let's hear from you as well. Um, so let's talk about what some other states are doing. So for example, in Kansas, they have actually accomplished a lot of major things as well. So in 2016, the bill for the language assessment program for death. and hard of hearing children was passed. In 2018, they passed the teletherapy bill. In 2021, um, they opposed cuts to Medicare reimbursement. And in 2021, they passed the air state compact. So lots of things, [00:54:00]  lots of amazing things are happening, um, in states across the U. S. Right, and you can learn more about advocacy efforts across the country, uh, simply by visiting ASHA's advocacy website to stay up to date with advocacy efforts impacting schools and healthcare. Um, you can also learn more about professional practice and workforce issues. patient, client, and student issues, and diversity, equity, and inclusion issues. You can find ASHA's public policy agenda that Jessica spoke about earlier by visiting the 2024 advocacy priorities for audiologists and speech language pathologists on ASHA. org. In the area of workforce priorities, ASHA is enhancing efforts to help address the shortage of practitioners that often contributes to high workloads, burnout, and dissatisfaction across the work setting. In the areas of payment and coverage priorities, ASHA's advocacy efforts address policies that limit client patient [00:55:00]  access to care due to unsustainably low Payment rates for services provided by audiologists and SLPs and inadequate coverage for their evaluation and treatment services. And in the areas of service delivery and access priorities, ASHA is working to address barriers that impede the ability of audiologists and SLPs to provide robust and inclusive access to care. So all of the actions that ASHA is taking to work towards meeting their 2024 goals are outlined on the website and instructions for how you can become involved are also located there as well. So now we're going to pass it on over to Jessica to share with you some of our resources.  Jessica Lenden-Holt:  I know we've shared so much with you today. It might seem a little bit daunting at first, but even if you just take a couple of those key action items, I promise you it does make a difference. Like Shakira mentioned, your voice matters. State associations can't do it alone. Your star rep, your stamp rep, your seal rep, we can't do [00:56:00]  it alone. Um, ASHA alone without you. Pushing and encouraging and answering those surveys. No one is doing this alone. It takes all of us, right? So, really want to encourage you all. Take the one thing that you think you can do, and do it today. Take that first step. I promise it gets so much easier. Um, and once you write that first letter, for example, it doesn't take but a few more minutes to go over and write. That second, third, fourth, fifth letter, right, Jennifer? I think Jennifer was like, Oh, this is all you have to do. And then she wrote like five. So, I mean,  Jennifer Henderson:  it took me five minutes, maybe to write five. I mean, not even five minutes, you know.  Jessica Lenden-Holt:  It seems so daunting at first and then you get there and you don't you're like, Oh, this is all this is I can do this or a survey, like Casey mentions, we send out surveys all the time and, you know, sometimes it's a little disappointing that we don't get a lot of responses back. So we know people have concerns, they have issues that need to be addressed, but we need to hear your voice so we can't carry the torch alone, we [00:57:00]  need all of us. So just want to really encourage you to. Use some of these resources. We've added different citations and research links and articles as well as all of the great, um, resources we've mentioned today. You will all have access to these and we're also always available to help answer questions. So you're welcome to reach out to any of us at any time. My Personal email is jlh at mypsychictherapy. com. We've given you lots of resources and ways to reach out to your individual state representatives as well. Um, and your state seal star stamp, VP of legislative affairs. So we just hope that you take some key things away. That you get involved with advocacy today and that you feel more equipped and have some tools to advocate for our profession, yourself and your clients after today. Um, that's really just the goal of our presentation. So really hoping that you all take something from this and, and try it out.  Kate Grandbois:  Thank you [00:58:00]  so much for sharing all of this wonderful information. I think for me, one of the biggest takeaways from listening to you all speak is related to dues being applied to something that is action oriented. Um, I know there has been a lot of conversation, particularly online and in social media about. How many dues we have to pay, licensing fees, ASHA dues. And there's a lot of frustration around financial transparency or transparency with which, you know, what is our money actually doing? What are we getting out of it? And, um, I think on the tail of that, this, you know, there is a difference between what a state association is capable of doing and what, uh, what ASHA is capable of doing, right? So I, I really appreciate. Just highlighting the impact that dues at a state organization can have in terms of [00:59:00]  action oriented outcomes. I hope I, I hope that makes sense. And I hope you agree. And I didn't get something completely wrong.  Jessica Lenden-Holt:  We are all volunteers. Board members are not paid. They're not paid positions on our state board. Uh, we don't have, um, a big fancy building. We don't have, you know, we, we're really operating on a very, very tight budget here. And so the dues are so important because like I mentioned earlier, lobbyists are not cheap, thousands and thousands and thousands of dollars a month. And that adds up across the year. And so it is, um, it is really key to have a large membership. Tool in order to pay for a high quality lobbyist. So definitely need our lobbyists to continue to help us advocate throughout the year. And that is really the bulk of what our dues go to.  Jennifer Henderson:  Yeah, and I just really encourage you, if you want to know what your dues are going to, like, go to your state association websites, go to the ASHA Advocacy Action site, like, those sites will tell [01:00:00]  you exactly what, um, ASHA and your state, um, Organizations are working on. So I just encourage you again to just go to those websites to find out Amy Wonkka:  for all of you who have been involved in this level of advocacy for so long. What are some of the benefits that you've experienced through being part of this process that might be something that would help somebody who's sort of on the fence and a little bit intimidated. I  Jessica Lenden-Holt:  love I love that you said so long. So I would love to point out everyone on this call, we have been in our role three years or less. So we are all newbies, which is why we thought we were the perfect people to come out here and like, tell you, like, you don't have to know it all. Just give it a shot. Just try it. Connect with that. You sound like you know it all. You sound, you sound like you're lying.  Kate Grandbois:  I think you're all lying. I think you know everything. We most definitely  Jessica Lenden-Holt:  do not. Um, but we can [01:01:00]  network and we can ask questions and we can research. And so I think that's actually my biggest takeaway. Like you don't have to have been in the field 25 plus years. You don't have to have been involved in advocacy for five plus years. You don't even have to have been a member of your state association for 15 plus years. Like Where you're at today is  Announcer:  a great place to get started. I'm not going to  Jennifer Henderson:  jump in and agree with what Jessica said as well. Like, just don't be afraid to get involved in advocacy. We definitely don't know it all. Like I need all the people that I surround myself with to like, encourage me, or I needed them to encourage me and let me know that I can do this because I didn't realize how easy advocating really could be just like those simple, just answering those surveys, like Casey. Mentioned that come through the email or going to the, um, ASHA action site to writing those letter campaigns. And again, I, Shakira mentioned just surrounding yourself with people who have similar goals and sharing your [01:02:00]  stories and, um, just encouraging each other because we all need each other because again, we don't know everything. We, we ask all the questions so that we can learn together.  Shequria Williams:  And I'd also have to add in that. It's also very rewarding. Um, when you are working hard to advocate for this thing and you see it come into fruition, that's very rewarding. When you get an email from an SLP that wants to know more about how to advocate for themselves and their students, and you give them advice, and they actually take the advice and use it, and they email you to say, hey, this actually worked. I was able to advocate for myself because of all the tools that you gave me to feel confident enough to do so. It is extremely rewarding. Kate Grandbois:  You all have shared so much. I feel very inspired. I've been sitting here looking at the Massachusetts State Organization website on the side browser. Thinking about all of the ways I feel a little bit of shame that I'm sitting here hosting you all with Amy, and [01:03:00]  I'm not a member of my organization. Don't be ashamed. Sorry. Sorry, Masha. I'm getting on it. I swear. I swear. Don't be  Jennifer Henderson:  ashamed. Don't be ashamed. That's what we're here for. There's no shame and blame.  Kate Grandbois:  There's no shame and blame. Um, you've just shared so much, and I feel very inspired to at least, Join my state organization and contribute funds that are going to go to helping with workload and, you know, licensure and things that genuinely impact our jobs. I think that's very powerful. In our last few minutes, do you have any, any additional last words of advice for anyone listening? Announcer:  You can do it. We all believe  Jessica Lenden-Holt:  in you. You can do this. You've got this. Just go out and do that one thing. Just go out and do that one letter. Just go out and research, um, your state association website. Do that one thing.  Jennifer Henderson:  One thing. I'm just going to jump on what Jessica just said, just because I already kind of gave my little tip [01:04:00]  earlier, but that one thing, remember your voice really does matter. It does make a difference. We need everyone.  Shequria Williams:  I agree. Today is the day. Take action, guys. We're looking forward to seeing all of the wonderful things that you are going to do in your venture in advocacy.  Kacey Hammonds:  I'll jump into to say when you do take that one step and reach out, please don't be afraid. We like the advocates at the state level are just normal people. All the stars in the ashes stars meeting are just regular SLPs. Who knew when I first started in those, I was like, Oh, these must be, I don't know, experts in the field, which they all are, but they're great. They're so sweet. They're so nice. They've helped me so much. So take the first step and don't be afraid to reach out and ask any question that you need. Kate Grandbois:  I love this. Thank you all so much for being here. This was really wonderful. We so appreciate your time, your expertise, your enthusiasm. This was so great. Thank you again so [01:05:00]  much.  Jennifer Henderson:  Thanks so much for having us. Thank you so much. Thank you. Awesome.  Amy Wonkka:  Thank you so much. This was great. I'm going to go do the one thing. Jennifer Henderson:  Yay.  Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Kate Grandbois:  Welcome to SLP Nerdcast. We are here today with one of our favorite repeat nerds. We are here to talk about stuttering and the neurodiversity movement with one of our favorite guests, Nina Reeves. Welcome, Nina.  Nina Reeves:  Hi, [00:02:00]  I'm, I'm so glad to be back with y'all because we're spreading the nerd love.  Amy Wonkka:  I love it. I love it. It's so nice to have you in the nerd room once again. Um, and you are here to talk to us about neurodiversity and stuttering, but before we get started, can you please tell us a little bit about yourself?  Nina Reeves:  Oh, uh, sure. Um, for those of you that are unfamiliar with me, uh, I am a school based speech language pathologist for all of my career, uh, except for last year, which is kind of interesting. My whole identity shifted, but it's okay. Um, we grow, we change. And I am a stuttering specialist. I have been for, uh, since the initial cadre of stuttering specialists way back in the day. And I work with Scott Yarris as my co author to, uh, produce lots of information and resources for clinicians working with stuttering. Kids who stutter.  Kate Grandbois:  We've [00:03:00]  learned so much from you over the last few years. You've come, I think this is maybe your fourth or fifth episode with us and I have learned so much from you. Your perspectives on stuttering, you, you've taught me everything I know. Your perspectives on stuttering are refreshing and, um, so needed in our field and we're really excited to have you back to talk about all of these things.  Um, You mentioned Scott Yaris, you all co own stuttering therapy resources. So for any listeners out there who are not familiar with stuttering therapy resources, a tremendous wealth of information. And again, something that we've learned so much about stuttering from you all, so thank you again for being here. I do need to read our learning objectives and disclosures before we get started, so I'm going to go ahead and do that quickly. Learning objective number one, describe how the neurodiversity movement is impacting our work with people who stutter. Learning Objective Number Two lists two ways to create a paradigm shift that is meaningful for people who [00:04:00]  stutter. And Learning Objective Number Three lists two ways SLP roles have changed to meet the needs of students who stutter. Disclosures. Nina's financial disclosures. Nina is part owner of Stuttering Therapy Resources Incorporated with ownership, interest, royalties, and intellectual property. Nina's non financial disclosures. Nina has no non financial relationships to disclose. Kate, that's me. My financial disclosures, I'm the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and 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'm a member of ASHA, Special Interest Group 12, and I participate in the AEC Advisory Group for Massachusetts Advocates for Children. All [00:05:00]  right, all that stuff is done. On to the good stuff. Nina, why don't you start us off by just telling us a little bit about that first learning objective? So how Is the neurodiversity movement and how has the neurodiversity movement affected our work with people who stutter and maybe how has this changed over the past few years? Nina Reeves:  Oh, that's a, that's a wonderful question. And it's one that, um, those of us in the stuttering community have talked about, uh, ad nauseum for, for the past three or four years, especially it's kind of interesting. Um, it's changed a lot and it hasn't changed. A lot. So let me let me clarify that. Um, those of us who have been in this for decades. Think about the fact that we've been talking about neurodiversity. Um, concepts for a long time. It's okay to stutter was the is is and was the motto of the National Stuttering Association for decades. [00:06:00]  And what was happening is we were all talking about that. It's really okay to stutter. And I think the world was like, it's okay to stutter, you know, somewhat. There was kind of a limit on it in society. And we were like, no, it really is okay to stutter. So we were, you know, stutter affirming before stutter affirming was cool. However, now we have the language and we have the groundswell of understanding, um, came with the autistic population and the, the voices that came up and said, you know, we are who we are. This isn't, this isn't, you know, an articulation lisp. This is us. And who we are neuro wise and so trying to have people who stutter act like they're not people who stutter decreases their identity and doesn't allow them [00:07:00]  to show up authentically as who they are in society. or in any speaking situation. So the neurodiversity movement has really, you know, been that sort of open call that, uh, that now the profession is really, you know, moving into an understanding. And I think that that's an amazing part of the last three, four, five years is that understanding that trying to fix stuttering, which every clinician knew they weren't doing. Or couldn't do, but they went ahead and tried to do it because they thought that was expected of them, or that's how they were trained, or that's what the parents wanted. This is, that's what the kids wanted, right? They wanted us to make it go away. And instead of sort of sitting back and saying, wait a second, this is not really our [00:08:00]  role because scientifically we're not rewiring anyone's brain. And so let's try to help and align, let's align with the stuttering community, the voices that are saying, I'm, I'm me, uh, let me be in that way, but also support me in my journey, because this isn't something that everyone can just do on their own, is to learn how to navigate stuttering in a world that doesn't get it. Kate Grandbois:  I love that you use the word groundswell. Uh, I think it makes me think of, you know, this, this cresting wave, which implies this momentum, this forward momentum. Um, and I have to assume that with that momentum that was presumably started by the autistic community, there was this, there was [00:09:00]  this cresting wave of, of forward movement for the stuttering community as well. And I, I have to imagine in just thinking about. That groundswell, that forward thinking and all of the small changes that we've seen. So therapists now using words like neurodiversity, affirming therapy, neurodiversity, affirming goals, bringing in the voices of mark from marginalized groups, listening and centering those voices, which has always been a part of our EBP triangle. We've always have patient centered value, you know, patient perspectives and values as part of our EBP triangle. But. Really should making that shift to put that at the center of what we do. I have to assume that this is not just for preschoolers who have a diagnosis of autism. This is this is everywhere. So what are you seeing? How are you seeing this trickle into the detail of working with individuals who stutter?  Nina Reeves:  Great thought. It's I love [00:10:00]  the momentum that you mentioned. And the idea that this is helping to switch. All of those SLPs who never thought that they were supposed to be trying to fix kids who stutter, they're taking a big, deep sigh of relief. Okay. Like, wow, thank you for giving me permission to stop writing fluency goals when I never felt good about them anyway. Um, and to look at stuttering the way, uh, it, in my heart of hearts, I knew these kids did not need me to fix them. However, Now, if you're going to sort of empty that cup of, you know, let me work on tools, let me work on tools, this is what I do, then we have to be ready to fill up the cup with what am I doing instead. And there lies the [00:11:00]  shift that is still happening. It's, you know, and I'm sure I know, I feel that it's not happening fast enough, but what we have to realize is that this is like turning a, a, a cruise boat, like the culture surrounding not only the stuttering community, but also the profession of speech language pathology is the idea of. Slow, but sure, we've been trying to turn the cruise ship for a long time, but now we're having some momentum, but it's still not going to be overnight because we have a couple of generations of SLPs working in the field right now, who that's all they know is how to do tools and how to, and in fact, if we can get down to the nitty gritty, how to do fluency tools. People call their kids [00:12:00]  fluency kids. They call their therapy fluency therapy. We've been yelling about that for a long time. It's stuttering therapy. Call it what it is. And now people are getting it, even people in the upper echelons, say, of our profession, um, who are finally understanding that the fluency focus was always in the direction of Increasing negative impact for people who stutter. Um, instead of decreasing it, because we know from from literature now that those people who have the idea that they have to stop stuttering have more negative impact on their lives. And those who realize that coming to terms with stuttering. Even though that's not just, you know, easy coming to terms with stuttering and [00:13:00]  accepting that part of their identity have had a, an easier road of it. So it's important to realize that that's, that's the shift.  Amy Wonkka:  Right. And from a, from a clinical skills standpoint, there must also be, I know we've had you on before and we've talked to you a lot about counseling and how important counseling is. Um, and I think that that's something that is. pervasive across the field. I know every time I leave a conversation with you, I'm like, Oh my gosh, this is so applicable to everybody. Um, but I wonder if you could talk to us just a little bit more about that shift away from an emphasis on tools to an emphasis on those counseling skills that are so important for the speech language pathologist to have. Nina Reeves:  Yes. Uh, I, I love this topic because, um, I have learned that Those of us who are, you know, supposed leaders. I don't like to call myself a leader, but you know that we're up here talking about this, [00:14:00]  that we have to be okay with having the unpopular opinion. Okay. And we have to say the things that need to be said, even though most people don't want to hear it. And so the, every time when I'm presenting and teaching other SLPs about all of this, I use the word counseling and there's an immediate like reaction, you know, well I'm not a counselor and nobody trained me on this and, and I, and I understand that I really do. I also understand that it is part of our, our, you know, our principles of practice we're supposed to be at least understanding of counseling skills for communication differences. Not that we're supposed to have a counseling, you know, degree. We're not supposed to handle counseling about, you know, a child's issues that are beyond the scope of our practice. But we do, [00:15:00]  we are supposed to be aligned with the idea that people come to us as people and not disorders. They come to us as trying to navigate something that is challenging. Think about stuttering as we're talking about today. Stuttering can be challenging in, especially in society that doesn't get it and wants a quick fix and everybody wants it to just go away because it takes patient listening and understanding, which are not highly valued. or utilized in our society. So counseling skills become a huge part of what we do in stuttering therapy. And that's the bucket I was talking about that we have to continually fill up. And we've been working to do that with professional development and a few university programs around the [00:16:00]  country have been really trying to focus in on that. I believe that that has to be a huge change from the top down in Um, how university programs are designed going forward so that SLPs can at least come out. They don't have to know everything because, you know, university programs can't prepare us for everything, but have those basic clinical counseling skills that will allow us to sit across from a kiddo who stutters, who is crying about being bullied on the playground. And we're not going to give them easy starts. We're going to have to learn how to sit in that moment and discover what, how that is impacting this child and how we can be of support.  Kate Grandbois:  You just said something that was completely parallel to a question that was percolating in my mind as you were [00:17:00]  speaking about the clinical experience, you know, living in our society that doesn't necessarily value. Patience or empathy or, you know, acceptance, you know, our, our society is very ableist and I don't think that anybody who is listening would be surprised to hear me say that. Um, but when you're working clinically with a family or a student or a client individual who comes to your office and says, I don't want to stutter anymore. It's my value to get rid of this. Uh, this is causing me a lot of. Discomfort or pain, um, I would imagine this also come, would come out of the mouths of parents like he's stuttering, she's stuttering and you have to, you have to fix it. So then you're, I have to assume that you're sort of faced with an even larger counseling task. How, how would you recommend that we, you know, resolve some of that tension for families? What do we do in that situation? Well, that brings up, you know, the million  Nina Reeves:  dollar question [00:18:00]  is how, how can we be stutter affirming and not drive an agenda? Eeky beekies. You know, this isn't what, I'm not going to give therapy what I want you to do. Okay, and that's tough because I've seen down the line what You know, that fluency focus has done to people who stutter over the years. Okay. Um, but I also have to let everyone have their process. Okay. So we can't flip from, I need you to be fluent. I will, I'm writing fluency goals for you or at you to, I need you to just accept your stutter. That's not going to fly again. We're turning the culture persistently and patiently. Okay. a little at a time. We can't just flip a switch and now go, it's okay to stutter. So go out there and do your best. There has to be some sort of support and [00:19:00]  middle road that, that addresses those needs and desires of the client. Now we meet people where they are. Yes, but we also have to bring in the evidence base, which does mean we can't cure stuttering. So how do we, how do we balance that? And how do we talk about it with the people surrounding the child and the child? That's where counseling has to come in. We have to be able to perceive what's in front of us, ask deeper questions, and then align ourselves with appropriate expectations. But I'm going to, I'm going to wheel back to something you said that has been on my mind, uh, so, so, um, it's pervasive on my mind all the time. The idea that, of course, people who stutter come and say, I don't want to do this anymore. [00:20:00]  Of course, caregivers, teachers, parents, siblings, everybody wants it to be gone. Because it's a challenge. And it's. uncomfortable, both internally for the person and can be uncomfortable externally until people learn how to desensitize and accept that there are differences in communication. But those initial stages, I just look at people that say, I want fluency and I'm thinking, boy, are you normal? I validate that. Then we have to think about what is the fluency going to get you? Let's think of two things. Number one, has anybody ever given you a different choice? Has anyone ever said out loud that it's okay to stutter and meant it? Not, it's okay to stutter, but make that one smooth, [00:21:00]  right? So, has there been another perspective that has been in the mix of what we might want for kids who stutter? As parents, as teachers, as teachers. as ourselves, as children who stutter. So number one, has there been another perspective even raised? And number two, okay, so if the fluency is what you want, I want fluency because, so what is the value? This would be acceptance and commitment therapy coming through. What are the communication values? What do you want that you don't think you can get? If you stutter and then that list age appropriate as it is becomes what we work towards is working towards the values and I'm going to tell you every single time those things can I want to tell a joke. I want to be able to raise my hand in class and not feel so icky. that I [00:22:00]  might stutter. That doesn't come with fluency. It comes with acceptance and understanding that you are a perfectly great human being and stutter.  Kate Grandbois:  That was so well said, it was so well said. And I also want to mention for people listening who are not familiar with ACT, ACT stands for Acceptance Commitment Therapy. It is a, I don't believe it's considered cognitive behavioral therapy. I think that it's kind of straddles Applied Behavior Analysis and Cognitive Behavioral Therapy. Um, there is a book called The Happiness Trap that was a New York Times bestseller that describes acceptance commitment therapy. Highly recommend. We're all clinicians working with anyone in, in the world. It's, it's a really wonderful strategy. And I'm so glad that you brought that into this conversation to refocus the work we're doing to support someone in their goals and in their [00:23:00]  values and how those values can be uncoupled from the experience of stuttering. It's, it's brilliant, brilliant.  Nina Reeves:  Well, and and listen, there are people that have been writing about this in the stuttering speech pathology community for a long time. Um, the, the idea of there's a book called more than fluency. Which we'll put in the show notes, the idea, uh, there are different chapters in there. Of course, there's a chapter on it, cognitive behavioral acceptance and commitment, avoidance, reduction therapy. There are many ways that speech language pathologists can learn about these aspects of the counseling world that are then brought in and applicable to our work. And I'll, I'll go even farther. I think the happiness trap. And how to talk so kids will listen and listen so kids will talk should be a prerequisite reading, not only for speech pathologists, [00:24:00]  but for educators of all kinds and human beings. I just think it's, it's a helpful way for us to understand the relational part of communication. Because, you know, is communication is the goal of communication to be fluent in any in any way, shape or form. Are we all supposed to be fluent communicators? Because it doesn't exist. Perfect fluency does not exist in the stuttering community or in the, we call them fluenter community. Okay, it's not, it's, it's about being able to get your needs met, to communicate and connect with people. That's what communication is for. And so if we refocus just that shift of the mindset that I'm working on communication therapy with kids who stutter instead of fluency [00:25:00]  therapy, then it brings open everything. And when we talk about it in that way to parents and teachers, it starts to open up the idea that we are not technicians who just focus on the motor behavior. When, when our scope of practice and the ICF model, the International Classification of Functioning model from the World Health Organization, which I'll put some references to, they tell us that it's not just about the impairment. We're not just functioning on our focusing on the functional impairment, we have to be looking at the larger scope of how this communication difference this verbal diversity, as we like to call it, um, how this impacts this. this person who is sitting in front of you. Amy Wonkka:  I wonder if you can give us some examples. [00:26:00]  If you take us back to that child who's sitting in your therapy room with you and they're upset and they just want this to go away and you're talking to them through those components of like, okay, let's get a little bit more information about. The why, um, how, what are some of the next steps? What might that look like in your next few sessions with that student? Who's, you know, who's really upset. You're trying to help them navigate kind of the, the underlying pieces of connection that they're looking for. Um, what other things might you do? Just so SLPs who maybe are still really working on fluency, in their sessions. Like how does, how does that shift look?  Nina Reeves:  Um, wow. I think the, the most major shift would be learning how to listen. Okay. Letting the child tell you the story, learning how to ask probing questions [00:27:00]  that aren't driving an agenda, but are getting curious. We're getting about what that means for you. Um, so listening and validating. Are two things that we can do in those moments where it becomes imperative for us to say, I hear you. I'm sensing that you're upset and, and that how to talk. So kids will listen and listen. So kids will talk book taught me how to say, you know, I'm sensing that, or I, I'm hearing that there might be some upset feelings and if kids aren't feeling upset, they'll let you know. No, I'm not upset. I'm sad or I'm mad or whatever it is. They'll help you out with whatever feeling word. Of course, we want to continually help kids. The underlying message in that is we have to give them some, you know, emotional vocabulary and talking about what they're really feeling. But [00:28:00]  whatever comes out, it's like we validate that. Yeah, that sounds, that sounds like it's okay to be upset by that. And now we're not going to fix it. We don't have to take the next two sections to fix their which is what, in essence, we thought we were trained to do. Right? Let's, you know, I don't want him to cry in my therapy room. It's like, well, then, you know, don't work with people who stutter. I don't know what to tell you because there's gonna be some emotion in this and emotions are okay. It's not that positive emotions are better than negative emotions, right? It's that all emotions are validated. They just are. There's not good or bad emotions. Now. Let's take that further and think about, okay, we're feeling upset. We're feeling like, you know, we have to get this thing to stop. Okay. So let, then we can [00:29:00]  dig deeper about, like you said, the wise. Okay. I need it to stop because. Okay, and then you start hearing of all the impact that's happening, all the things that are happening that because my grandma tells me to slow down and it makes me mad because the kids laugh on the playground. Okay. Now, can I work on environment in the home, can I work on learning how to handle negative listener reactions. Yes. Can I change those people. Okay. No, but I can help them learn to respond in a way that is helpful to the person who stutters instead of trying to help by fixing. Everyone seems to be trying to help by fixing and that is the culture shift. It's the, what do you praise? Do you praise fluency? Well, what if the kid didn't [00:30:00]  say what they wanted to say? They only said two words instead of the 13 words, and we just praised them for that. We just taught them that it's more valuable to appear, let's get that lexicon going, appear fluent. I was writing some of these down. The idea that they're seemingly fluent, apparently fluent, appear to be fluent, which is different than being fluent, than experiencing fluency in their talking. So did, did we, just by praising that fluency. In indirectly and unknowingly praise them for masking themselves in the world. I was just going to bring up the word masking. Kate Grandbois:  I was just going to bring up the word masking asking if that was an applicable description here because I've heard it used in the autistic community as part of this. You know, you mentioned earlier the neuro, um, the, the vocabulary, we have all this [00:31:00]  vocabulary for it now as part of that groundswell groundswell, as part of that wave, as part of that momentum and masking is a huge piece of that. I'm so glad that you use  Nina Reeves:  that word. Well, of course it's applicable in the stuttering community because, um, for all of the decades where people have been trying to help people be fluent, they in turn have had to struggle To use, um, like who wants to sound like a turtle, who wants, I mean, these are just like ways of being fluent that then mask the child's ability to just communicate freely and authentically and spontaneously, you know, if it's okay to stutter, all of them, big, chunky ones, big, you know, um, big ones that, that You know, come out [00:32:00]  and letting them out is an appropriate goal, which it is, by the way, then it becomes a freedom for people who stutter and an allowance for them to say, this is how I talk sometimes. This is, you know, my kindergartners are like, that's how I talk sometimes. And, you know, we just learn to help them say out loud that they are who they are and that you can accept me or not accept me. It's up to you. It's not up to me, but I'm not going to change myself to make you feel more comfortable. Which is what's been happening.  Kate Grandbois:  I have another question that I hope is not a bad question. I know you're never going to yell at me for having, for asking a bad question. I'm, you mentioned, you know, the, that it's perfectly okay to have a goal [00:33:00]  for letting it out. And it made me think about, Being a clinician and listening to you talk, listening to this new paradigm shift, this new lens, this different way of thinking, and thinking about my kid on my caseload who, or my student on my caseload who stutters, and then sitting down to write the goals. And what that, what that process, that overwhelming, how overwhelming that must be. I'm wondering if you can tell us if you have any tips or tricks where, I was going to say where the rubber meets the road, but I'm going to say where the pen meets the paper because we're writing goals in terms of, you know, if we don't have a ton of counseling training, how, how do you write goals that reflect. what you're doing in your therapy session, which is maybe 70, 80 percent counseling focused or defining values or working on self acceptance or self advocacy or You know, being more comfortable unmasking, what, what does that feel like to write goals like [00:34:00]  this, particularly when we, most of us, I'm speaking for myself, but I think it's safe to say most of us don't have that training explicitly. Nina Reeves:  Um, again, we are building the plane while we're flying in it, so let's talk about the shift. But I'm, I do have some pro tips. Number one, you, you asked that question and immediately I'm like, Oh, here comes the gold question. And, but it's valid, right? I'm sorry. Did I give you a lot of anxiety? No, it brings anxiety because here's what happens. Teach me how to write the goals. What does that even mean? If you don't know how to do the therapy, I can, I can give you a goal of amazing stutter, affirming neurodiversity, affirming goals. But if you don't know how to do the therapy, I don't even care if you know how to write the goal. Now, [00:35:00]  unpopular opinion. But I have to write the goal, so teach me how to write the goal. So, you'll, Scott and I have talked about this for decades. You're not going to get a goal bank from us. Everybody says you've got to give a goal bank. There's goal banks on, you know, platforms out there. You know, and of course they make us cringe, right? Because they're not stutter affirming. And the fact is, is that knowing how to write a goal does not help. move us past sitting in front of the child and being able to manifest that goal in a therapy process. So I'm always, you know, one of the, one of the Instagram and Facebook posts I want to do is, um, look beyond the paperwork now on popular opinion. So here are a couple of pro tips. Every goal that you write, If you know the International Classification of Functioning [00:36:00]  Disability and Health, if you know the ICF model, Function, Reactions, Environment, Impact, then you do your, uh, assessment, to find out what's happening in those areas in the child's life, and then you find out the strengths that you can use to address the challenges, um, That they still have in each one of those areas. So let's just say for years and years, function. Okay, we're working on the speech motor, and that was it. We're assessing the speech motor, and that was it. And so we were missing 90 percent of what we were, um, we were supposed to be working on as professional speech language pathologists. So, if you look at the ICF model, it'll help you frame your assessment. which will help you frame [00:37:00]  your therapy planning, which will help you frame your goals and your documentation of those goals. It's like the framework from heaven. I don't know. I don't know how else to put it. It's how I do everything and how I check in with myself to say, have I been, you know, addressing one area more than the other? Cause they all, the beauty of the ICF model, especially the one that is out there for stuttering. Tichenor, Herring, and Yarris, and also Tichenor and Yarris as references. That one is something that you can check in with yourself on. And it just gives you that overwhelming understanding of what you're supposed to be doing. So how do I write the goals? dismisses, did I do an appropriate comprehensive assessment and dismisses, do I know how to do [00:38:00]  the therapy and then how to document it? So we do give sample goals in our books, in our writings. We talk about, you know, everybody knows you have to have that criterion and the setting and, but you don't always have to have percentages, which is another pro tip because everybody likes to count stutters because it's, You know, it's dichotomous. It's like there or not. There's your stutter or not your stutter problem is and you'll hear us, you know, continually talk about this. That's the listeners experience of the speakers stuttering and has nothing to do with how much there was stuttering on the inside that you didn't even see. So read, uh, a point of view about fluency, read the idea that the literature is telling us that the most, uh, utilized definition from people who stutter is the feeling of [00:39:00]  stuckness, which listeners can't always observe. So counting stutters and writing fluency goals is actually. Insane. Oh, she said it. It's like a definition of insanity. You're chasing a grease pig because stuttering is variable always. And so it's never going to be a certain percentage. And then if you, if you write a percentage and the child makes it, you have to understand why did he use a strategy? Did they, um, avoid the word or was it lucky, you know, sort of people who stutter have fluency. So was it just regular fluency? at that moment. It has nothing to do with what you did in therapy. I know paradigm shifting and makes everybody's heads spin off their shoulders. However, most clinicians, when they hear [00:40:00]  that go, Oh my gosh, that's so totally correct. And so when we talk about it in that way, it also helps society see it that way.  Kate Grandbois:  Every time I, every time you come onto this podcast and you talk about something that I don't even do in my clinical life, I have A million light bulbs that go off because I think what you're saying is so, is, is saying that it's liberating, aggressive? I don't know. It's, it's inspiring. It's, it's a different way of thinking about things. And I agree. I think as a, as a working clinician, when you engage this paradigm shift, it is, it feels a little more It feels refocused on the things that matter, which alleviates some of the pressure to do all the extra little things. And I know we have to write goals, and I know we have IEPs, and we have paperwork, and there is things that we're never gonna get rid of. But what matters is the person in front of [00:41:00]  you. What matters is, is how you show up in that therapy room, and, and how you're making space for all that really important, important. Refocused, paradigm shifted counseling work. I, I, it, it's, it's, I'm gonna use the word liberating. I'm gonna double down on it. Nina Reeves:  You know, It's, uh, when I talk with you both, we, we have a lot of fun and there's back backstories and all sorts of fun things. And sometimes I leave a podcast thinking, wow, I just babbled. I have no idea if I said anything appropriate or if I, cause I do, I just did it, I do a thing where I get excited and then I don't finish a sentence. I'll insert an example before I finish the sentence, so I'm hopeful that it, that it, thank you for saying that something's coming through because this is such a passion, um, in my life that [00:42:00]  it, there's so many things in my brain that want to just be spilled out, and I'm hopeful that it comes out in ways that people can grab a hold of and hold on to as they make this shift, because I've been doing a lot of writing and you'll see it in our blogs and in, you know, in social media and in our new books that what we're really shifting. And I wasn't going to talk about this, but I will, because we do this, um, mindset ours. And by the way, others are message. The message is. easier communication, functional communication, free, spontaneous, lovely communication. So that's the message. Then our model changes because our, what, what we model in therapy is not stop and try that one again and make it fluent, right? [00:43:00]   So that changes. Then of course, the meaningfulness, which is what you just said, which sparked my attention to this, the meaningfulness of our therapy changes. It becomes what matters to the student, which is really their value of communication. What do they want to do when they talk with other people? And the values, which are bigger, you know, sort of the overarching understanding. Pretty much when I do values work with kids, I don't think I've ever had a child write down fluency as a value. So I'm thinking that mindset model. message and meaningfulness. Yes, I love alliteration are what we can help ourselves. No, those are the shifts and [00:44:00]  one follows the other. They're very synergistic with each other. So it's not like here are the 3000 things you have to do to do this better or to do this in this way. There are begin with your mindset. If your mindset shift is I always thought that kids who stutter should be allowed to stutter. What I want to help them with is to decrease their struggle. Well why do they struggle? Because internally it's not comfortable and externally they get messages that say this isn't okay. So then they struggle harder, and we've known for decades that the more you try not to stutter, the bigger the stutters become, okay? Not just the motor, but all the stuff that you do around it, the moment becomes longer and bigger because you're [00:45:00]  trying not to stutter. And that is internal. and externalized stigma. We're, we're stigma busters. If you want to really get to it, we're stigma busters. And that is part of our role, um, to align with the stuttering community, their voices elevated and honored to help de stigmatize this verbal diversity. And that, that term came, um, from me. When I was thinking about the neurodiversity and the whole diversity movement that was happening back in 19 and 20, that it, it became apparent to me that if we look at stuttering as verbal diversity, it's just another way of talking, which we've been saying for generations, but nobody got. And now people are looking at it going, Oh my gosh, that's exactly what this is. [00:46:00]  There's a famous line from someone who did from Bill Wade, who did a keynote, he told us about the time that it became apparent that his stuttering was his accent. And it's like, you know, your head just explodes and it's like, wow, but does society accept. You know, stuttering the way they accept accents, probably not. So we have a lot of work to do to turn the tide and there's more responsibility to the listener in the social relational model. It's not all what the stutterer has to do to fit in, which is the masking part, right? Which we've learned it's about. working together to understand that this is a valid and acceptable form of communication. [00:47:00]   Amy Wonkka:  I'm looking at this, um, ASHA landing page about the assessment of fluency disorders in the context of the WHO ICF framework, and there's just So many nice components in here that are so much more broad than this hyper focused lens on fluency. I wonder, because part of, part of what they're talking about in here is just activity and participation restrictions, the importance of the environment for those. People who are working in a school environment, what are some, what are some strategies and things that school based SLPs in particular can do to kind of help shift some of those environmental barriers that don't need to be there?  Nina Reeves:  Yeah. Um, oh, I'm going to be a broken record. Um, teach other people about the ICF and its concepts. Do I take the ICF model related to stuttering [00:48:00]  to my IEPs and my parent meetings? You bet I do. And this is the broad base. This is what we understand about the experience of stuttering, not the moment of stuttering, which we've been hyper focused on, as you said. So this is about the experience of stuttering. I'm looking at your child as a whole child. What parent is going to go, Oh, don't do that. I just want you to fix their stutter. Like, okay. Let's, let's get to the fact that we do have aligned, um, expectations and understandings of this. It's, it's, let's see this child as a bigger picture when, when parents, teachers and others are afraid, they hyper focus because fear makes us do things that when we have a presence of mind, we wouldn't do. So we try to open up the perspective to the experience of stuttering and the communication goals. And that [00:49:00]  does help to begin the process of alleviating the environmental impact. Now, um, another thing that I think, and I'll reference, um, an article that I co wrote with, uh, two guys who stutter. Um, one's a speech language pathologist in the public schools, and one is, you know, like, works for SpaceX. I'm not even sure what he does. It's probably secret. So he's, you know, these brilliant people and I got together in that forum from language, speech and hearing services in the schools, January 2023. The entire issue was focused on ableism. and school based therapy for stuttering and autism. Bam. Boom. Because they're, you know, you can just change the word, you know, back and forth, autism, stuttering, and it probably is applicable in terms [00:50:00]  of ableism and what society expects and how society has to change. Um, so those Institutional roadblocks are discussed in, in that whole issue, but also in, in our, um, our article in specific, we addressed all of that idea. We outlined neurodiversity and understanding, and then we went into case studies. Of what was being done and how the neurodiversity affirming therapist changed it. So I think it's almost like a mini tutorial doesn't give you everything you need to know, but it starts the process of. looking at the institutional structure of school based therapy, um, and saying, okay, these are the barriers and roadblocks, and this is how I'm going to go around them. I'm going to get creative and I'm going to find ways. And [00:51:00]  I'm just going to go, oh no, you can't do that in the public schools. I'm not going to do that. I'm going to say, how do I do it in the public schools? How do I do it better? Because any step along the process of increasing or like raising the bar. is better than no steps at all.  Kate Grandbois:  Earlier, you talked about how you were afraid that you just, you know, went on and on, and it wasn't helpful, and I'm just here to tell you that that was nonsense, and everything you're saying is extremely helpful. Um, And I, I think one of the things as, as a working SLP, you know, thinking about the intersection of, of this paradigm shift in conjunction with our everyday responsibilities, the stress we carry, the caseloads we carry, the lunches that we don't take, et cetera, et cetera. But thinking about realistic changes that we can make and action steps that we can embrace that will make a difference. And I think you've hit a, You've hit a bunch of them just to summarize a [00:52:00]  few and reflect this back to you is talking about things differently thinking about things differently and just talking about them differently. I is a is a very doable action step. So, uh, talking to teachers, talking to parents, bringing these these models to meetings, reviewing them. I know we don't have a lot of spare time, but, you know, reviewing these ICF models. Um, Not thinking about the goals as the end all and be all really focusing on the quality of the therapy and the important and meaningful things that we're doing all of these things are doable. All of these things are action steps that we can bring into our workplaces tomorrow. I'm wondering about any, I know you're full of pro tips and I don't want to, I don't want you to empty your well of pro tips, but how else our roles have changed. How else are. Action steps might change in a realistic, doable way to help shift these paradigms because I have [00:53:00]  to assume that this paradigm shift isn't just about how we think about things internally, but it's also working to shift these paradigms in our workplaces, right? I mean, it's, it's really kind of Embracing a whole new lens everywhere, which is a big task, but it starts somewhere with very realistic doable things. So tell us more.  Nina Reeves:  Okay, Renee Brown, I'll tell you more. Um, say more words. I'm gonna say that. Can I just do the, uh, the ideas around verbal diversity and what it doesn't mean? Because people get very confused. Okay, but this is if it's okay to stutter. This is one of the blogs I'm working on. If it's okay to stutter, then what do I do in therapy? How am I going to tell the parent that it's no longer fluency? How do I explain this? So these are things that we're working through and getting out there to support clinicians. Um, but one of the things that got very confusing right away. Was the idea that oh, then we don't have to [00:54:00]  work if it's if stuttering is verbal diversity. We don't have to work with kids who stutter like yeah, that was cute. That was an adorable idea. Nope, no such luck there person who's really afraid of stuttering therapy and wants to get the kid off your caseload. Um, which of course nobody ever does, but they might think it in their head. Uh, so it does not mean that there's an eligible eligibility change. IDEA reauthorization of 2004 still applies. Does the child have adverse impact in academic, non academic, or extracurricular areas? Which means academic, social, and functional communication. It's all of it. So, If we do a correct assessment of all of the areas of how communication, uh, impact happens for kids who stutter, then they're, they're aligned and they have eligibility. So, they are eligible most, most, most. Kids who [00:55:00]  stutter are eligible for therapy in the public schools. Um, we, we do not shift away and give this to counselors or psychologists. SLPs are still the people to work and help align with neurodiversity affirming principles. This is, you know, if, if a child has An identified anxiety disorder, generalized anxiety, that's for the other person. If the child is anxious because they stutter, that's us, alright? Um, unfortunately, there's not, um, verbal diversity doesn't give you a script of what to say, like it doesn't give you a goal bank of what to write. If you change the mindset, how you say what you say, if you say it, and when you say it becomes very apparent. And I, I start my, [00:56:00]  my presentations now with the idea, give yourself grace, because if you say something or do something that you think, Oh my gosh, what was that? That was from the old thinking. There's the lovely idea of repair. You can repair communication, which I'm going to talk about to give you that pro tip in a second. Okay, so it changes the idea that fluency percentages are gone, but support still happens, and it's documentable support participation goals, um, you know, are they raising their hand? Are they doing what they need to do to access the curriculum? I'm using a lot of IDEA language, by the way. Okay, and that we continually verbal diversity means we as professionals get aligned with the voices of people who stutter and don't just stay out here on our little island of, you know, we know everything about how to help people who stutter. They don't need [00:57:00]  saviors. They need allies. The idea of how can we change the environment as well in the schools, in the home, in society, because that's part of our role in allyship to be a part of that process to raise self advocacy with our kids who stutter and also be advocates. Um, aligning with that. So the idea of how to help other people understand it is not just the ICF model. But that entire refocusing of us, when we refocus our mindset, then we can talk with other people about how that mindset has shifted and how it has been told over decades to be the appropriate mindset and the workable mindset of supporting people who stutter [00:58:00]  instead of trying to fix them. It's It's so obvious when we start to do it, but the people around this child are not in this process with us, right? We're talking about it in professional ways and in, in, you know, this academic way, but we have to be able to say it out loud in functional ways for the parent, the teachers, you know, what do, what do they think fluency will get their child or their, or their student? What are, same thing we started with. In this podcast, what is it about fluency that they think is going to fix whatever they think is broken? What do they think is broken? And what are they worried about? What are they concerned about? Many times it's about their own ability to handle this. They just don't know it. It's all focused on the child. But, um, denial is a crisis of confidence. [00:59:00]  David Luterman, I know you guys are Luterman fans, right? Denial is a crisis of confidence. Denial that the idea that it's okay to stutter is a crisis of confidence of being able to walk with that child over their lifespan and handle the things that are going to come at the teacher and the parents about you aren't doing enough. You aren't enough. You are not fixing this. Did you try this? Did you try that? That that does not just happen to people who stutter. It happens to the people around them, especially the caregivers. So we have to help them with their process as well. But we do it in the same ways that we help our process, help the students process. We can use those same ideas and concepts to help society. Kate Grandbois:  You're a brilliant genius. I've  Nina Reeves:  just [01:00:00]  been doing this a  Kate Grandbois:  really long time. It's, it's just, it's wonderful to hear you, to hear you, I don't know, say all of this in such an organized, passionate way. We do love David Luterman. Um, I love the concept of it being a crisis of confidence. I mean, again, I'm not, I don't work in stuttering clinically, but I'm thinking about this and applying it to my own, to my own caseload. Um, in our last few minutes, do you have any Any last, not last words, that sounds very doom and gloom, but any, any parting thoughts, any, any final words of wisdom for our audience?  Nina Reeves:  You know, the top of mind that always comes when people say, you know, sum this up is the idea to give ourselves grace, but don't give yourself too much grace. Sorry, that just came out. Um, give [01:01:00]  yourself grace that this, if this is new for you, then it's okay to have your own process. Like I said before, we can't flip a switch. Okay. Well, it's okay to stutter. So what the heck am I doing in therapy? We've got to be, you've got to be able to tell yourself, I'm going to take small steps along a hierarchy of difficulty. See how stuttering therapy is life lessons. Like we use hierarchies in all kinds of our therapy. articulation language. We use hierarchies every day. How about we give ourselves a hierarchy of extra learning, finding appropriate places to get this information that is based in evidence, right? And also based in client values, which includes not just the person in front of you, but their entire family and the stuttering [01:02:00]  community. Like there are values out there that we can learn from them. If you've met one person who stutter, you've met one person who stutter. Okay, that's a zeitgeist like in the National Stuttering Association. We talk about that all the time because these are individuals. So just because you did therapy like this with one kid who stutters doesn't mean that's the kind of therapy you'll do with all kids. And that's why we are going to write How to Be a Savvy Consumer of What You See on the Internet. Because, you know, everybody's, you know, looking for that quick fix because we don't have time. So first pro tip, give yourself grace. How to When I said, don't give yourself too much grace. That means you've got to develop a hierarchy of how you're going to go about getting this information and learning to apply it a little at a time. Do no harm because sometimes a little information is deadly. So make sure that you're putting it in context with the entire [01:03:00]  experience and not just one activity on one day. And then just make certain that your work feels, feels like it resonates with you. Because I think we've been for decades, we've been doing work that never resonated with most of us. Yes, there are people that believe behavior is behavior and you just fix the behavior and you'll never, you'll never be worried about it, except that doesn't work because people who stutter have a neurologically based difference in communication. So make certain that it aligns with what you understand and that then can help you align the people around you patiently and persistently. Kate Grandbois:  There's nothing that can be said to follow that up. So I, I [01:04:00]  think the only choice is to just thank you for coming.  Nina Reeves:  Oh, you guys are so fun. Oh, you're so welcome. And, um, you know, Well, I'll try to summarize. I'm not sure what I said anymore. You know, my notes were gone like 40 minutes ago. We took our I'll make show notes and give those citations and make certain that people can get more information that's based. in, um, stutter affirming and evidence based. You're the best. You are the best.  Kate Grandbois:  We will put all of this in the show notes. We've been taking notes the whole time as well. Uh, we will also put a link to everything that stuttering therapy resources has to offer. You guys have lots and lots of free help, so much free helpful content on your website. So we will definitely link that as well. Thank you again so much for being here. You are the [01:05:00]  best. One of our, one of our most Our most prized guests.  Nina Reeves:  So yeah, you know, we were together back in the day, right in those early way that we're developing all of this. It was, it's been fun to watch you guys succeed and you do good work and I'm happy to be a part of it.  Kate Grandbois:  Thank you so much.  Nina Reeves:  All right.  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 [01:06:00]  soon.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerdcast 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 Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are here with two guests today who are in a different time zone, which is always really exciting for us. Welcome, Jacqueline Morton and Ronan Miller. Hello. [00:02:00]  Hello. Thank you for having us. Thank you for being here. You're here today to discuss empowering caregivers in everyday lives of children who stutter. Amy Wonkka:  But before we get started, can you please tell us and our listeners just a little bit about yourselves? Shall I start? Go for it. Um, okay. I'm Jacqueline and I am a speech and language therapist and a mum of two boys. Um, I worked in the NHS. in the northeast of England for a long time. Um, and then when I had my second child, I came out of the NHS and got quite interested in conscious parenting, mindful parenting, respectful parenting, that kind of world, thinking, my goodness, I don't know how to parent. Jaclyn Morton:  What am I going to do here? Um, and so, yeah, so I got into that world a little bit. And [00:03:00]  the reason why that's kind of important, I think, is I really, really care about parents. I really think that we've got a difficult job and being conscious about parenting, I think can be really helpful to ourselves and to our little people. So then I came back into the speech and language therapy world. Um, and I work independently now with families and children who stutter. And I also do workshops for parents around the idea of minding less. So, um, that's, that's kind of me in a nutshell, really. And Ronan, before you tell us about you, for all of our American counterparts and listeners, what is the NHS? Oh yes, the National Health Service. So, um, where people don't have to pay and they come and see us. What is really tricky, that sounds wonderful, doesn't it? But what's very, very tricky about the NHS is we have [00:04:00]  mega long waiting lists. Um, so that kind of timely approach that, you know, All of us therapists would love to give is sometimes not available as, as well as many other positives. But yeah, that's definitely a factor. Interesting. Well, we could have a whole episode on the cultural intersections of, of medicine and therapy, but that's not what we're here to talk about. Um, Ronan, why don't you tell us a little bit about yourself? Yes. So I'm Ronan. I'm a person in stammers and I guess a researcher in some regard. Ronan Miller:  I completed my PhD looking at the experiences of people who stammer, uh, in foreign language learning. Um, and that was in some ways based around my own kind of interest in languages and, uh, experiences teaching English, uh, learning Spanish. [00:05:00]  and finding myself in the stammering community and trying to link all of that up in a, in a way that could potentially be helpful for people. Um, and I'm also a volunteer with Stammer Children, which is another UK organization. And yeah, I've been working with for a bit over a year on some ways. That we can potentially bring help to more parents, more carers of children who stammer. Um, we're aware that that's a challenge that is out there, a challenge not just for speech therapists, but also for the families as well. So we've been trying to do something there. Well, we're very excited for this conversation. Um, just second, before we get into the content, I do have to read our learning objectives and disclosures. I also just want to second, um, what Jacqueline said [00:06:00]  about the, how hard it is to be a parent and how, you know, it, it took me personally becoming a parent to realize all of the horrible things I had said to parents as a therapist, because living it is a really, it's a really unique experience. Kate Grandbois:  So I'm very excited. to center the experiences of parents and have, you know, hold space for that, um, in this conversation. But before we get there, I will read our learning objectives and disclosures. Learning objective number one, describe the importance of caregiver involvement in the therapy process for children who stutter and how this can impact the effectiveness of therapy. Learning objective number two. Describe how technological advancements can facilitate support for families within speech language pathology. And learning objective number three. Describe the collaboration between healthcare professionals and technology developers in creating applications like Penguin Stammering Support.  Disclosures course disclosure. This course focuses on an app called PEnguin Stammering Support. As this app is unique, the course, focuses on [00:07:00]  and only covers information that pertains to this technology. Kate Grandbois:  Jacqueline's Financial Disclosures. Jacqueline is an employee of Benet Talk, the company that builds the penguin and Super Penguin apps. Jacqueline owns an independent practice working with children who stutter and their families. Jacqueline's non financial disclosures. Jacqueline volunteers for the British Stammering Association, also referred to as STAMA, a charity organization. She also runs workshops for parents and SLPs called Minding Less About Stammering. Ronan's financial disclosures, Ronan is an employee of Benitoch, Ronan's non financial disclosures, Ronan volunteers for the British Stammering Association, also referred to as STAMA, a charity organization. Ronan also volunteers for a non profit called Action for Stammering Children. Kate, that's me, my financial disclosures. I am the owner and founder of Grand Blanc Therapy and Consulting 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 [00:08:00]  Behavior Analysis and Therapy.  Amy Wonkka:  Amy's financial disclosures. That's me. I am an employee of a public school system and co founder of SLP Nerdcast. And my non financial disclosures are that I'm a member of the American Speech Language Hearing Association Special Interest Group 12, which is AAC. Um, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, we've made it through the disclosures and the learning objectives. Now onto the good stuff. Jacqueline and Ronan, why don't you So I'm going to start us off just by telling us a little bit about the first learning objective. Why is it important to have caregivers be involved in therapy for children who stutter?  Jaclyn Morton:  Okay, I'll, I'll open this one, Ronan, if that's all right.  Ronan Miller:  Go ahead.  Jaclyn Morton:  Um, oh my goodness. So if we think about stammering. You know, against, say, I don't know, speech sound disorders [00:09:00]  or whatever. We can sort of get little people in, work on their speech, and then they can go. With stammering, we don't know whether that child is going to stop stammering, or if they're going to go on to stammer into adulthood. Lots of children stop, but then we've got a percentage of children who will go and stammer into adulthood. It's very much part of that human, you know, it's a neurological thing, that's the way the brain is wired. Some people are born with stammery brains. And this sense of us as therapists being kind of in charge of therapy, in my mind, just sits really uncomfortably. It's actually not about us. It's about us. If we can take the time with parents. And when I say take the time, sometimes that can be really [00:10:00]  difficult in itself because we have children coming in to the clinic. Sometimes we might have, again, I'm talking about sort of an NHS framework, but sometimes we might just have six sessions. We've got parents coming in with, Potentially expectations of how can you fix my child? And that is because, you know, we look on the internet. We're kind of in this sort of scrambling as a parent of, Oh my goodness, my child just started stammering. What on earth do I do? We come across things like, okay, this is how we overcome stammering. This is how we stop stammering. This is how we cure stammering. It's all there. And it's all very, very attractive to parents. So parents can come in with that, those sort of expectations very, very naturally. And as parents, we don't want to see our little people struggle. If then we kind of turn it on its head and think, okay, parents are actually the most important person for us to be taking the time with at this point. [00:11:00]   Often the little person doesn't have a problem with stammering. That's a generalization. But so often it's the parents who have all of that anxiety. That anxiety, that Those kind of thought processes of how can I make this stop? How can I fix this? They can immediately feed in to the little person inadvertently, you know, we do it with love We say things like slow down or take your time or because we think I can't I don't want to see this struggle so That, the parent is actually the first step on the chain and it is, is the parent who's going to be the supporter of that little person all through their life if they continue to stammer, you know, that advocacy and I'm going to say the word acceptance loosely because We don't necessarily need parents to be, like, flying the Stammering Pride flag. They don't need to [00:12:00]  love it. However, that sense of, okay, this is my stuff as a parent that's going on. I don't like this, or I'm struggling with this. And then separating that from, but actually I think this is the best way for my child to be a confident communicator. So work around that, I think, is, is one of our most important roles. Kate Grandbois:  You just said so many things that made me want to high five you through our zoom screen here  Ronan Miller:  completely  Kate Grandbois:  I that was just so well said and I I wanted to scream, you know here here again multiple times I I think One of the things that struck me most about what you just said was this idea of separating a parent's need, a parent's anxiety, because it's true, I mean, you know, you worry about your kids at night when they're, you know, sick, or when, you know, we, it's our main jobs is to keep children, I always say to my kids, my number one job is [00:13:00]  to keep you safe, and my second job is to keep you happy, right? But when there's something wrong with our kids, It can be a major source of anxiety, and I love the idea of coaching families to identify their anxiety versus their child's experience, right? Because those are two different things, but when your kid is really little, there can be such a blend there. Oh,  Jaclyn Morton:  absolutely. Can I share with you one of my favorite quotes? Always. This is, um, by Alfie Cohn, who wrote the book Unconditional Parenting. I will just double check that, but this is the quote. So, it, he says in his book, Is it possible that what I just did or said to my child had more to do with my needs, my fears, my upbringing, than what's really in their best interest? And that sticks on [00:14:00]  my fridge, like obviously you can't see it, but I have that on my fridge as just a daily reminder because this stuff is difficult and it's not about perfection. It is not, but it's about being conscious and just checking in every day and stuff like that really helps me. Kate Grandbois:  This podcast is not about me, but I feel seen. That's all I want. That's all I want to say. I really, I love this. I love it. And another word that you use in your. Um, in your, the talking points that you sent over was the word stigmatize. And I, I feel like that, that concept, that ableist kind of, you know, cultural concept that we have, it's, is a part of that. Can you talk about that a little bit? Ronan Miller:  Is this for me to pick upon, Jacqueline, you think?  Jaclyn Morton:  This is yours.  Ronan Miller:  Well, it's a big, big topic, and I think there's probably people more qualified to talk on it than me, but [00:15:00]  I think in relation to our objective to try and support parents, um, as Jacqueline said, advocacy is kind of a part of that. So if you're accompanying your child through different stages in their life, you know, moving into school, for example, and then various stages of school, I think being able to understand stammering as what it is rather than maybe how it has been perceived and stigmatized, um, I'm not sure if I've expressed that in the right way, but how it has been perceived and the ways in which it has been stigmatized, um, is helpful for parents to then be able to advocate for their child as they move through these different social spaces. [00:16:00]  Um, and then you can tell me Jacqueline, but I think one of the hopes in therapy is that by equipping parents with that kind of insight and knowledge and understanding and, and powering them in that way, we also setting the stage for the child to kind of take on some of that and be able to build from that place as well. Um, because we're aware, you know, research shows that having a stammer can, uh, impact your life in a variety of ways, whether that's as you move through education or professional opportunities or in social situations. So, I think for parents to be kind of on, on the train, on the boat, not sure the right analogy, in [00:17:00]  the gang, um, and then use some of that knowledge and that insight, uh, in how they bring up their child who stammers could potentially improve the, the situation for that child as they grow up. And not just for them but obviously we're, we're thinking about. broader changes that we can perhaps try and facilitate as well. I hope that makes sense.  Jaclyn Morton:  It really does, and I think what's interesting is, you know, there's a huge movement within the Stammering, Stuttering community around acceptance. When a parent comes into a clinic, they don't want to hear that. They don't want to hear you've just got to accept it. Because this will impact on their child's life. It's not all kind of unicorns and roses. There will be bumps across the road. And I think this is why it's important to speak to parents [00:18:00]  about what their role is as well. You know, we've got a separate role. And as parents, they don't need to fix this, their job in a way is to be able to, as Ronan said, kind of advocate or be the ally or be able to validate those feelings like, yeah, this is just really hard at the minute, but also not for us to necessarily come in with our parenting cape, which again is, mine's always on, and I actually have to take it off sometimes. Well, now my 11 year old tells me, take it off, mom. I don't need it, but, um, you know, it's that this, this is going to be a struggle, but I trust you. And so this is what the kind of app sort of does, tries to set up as well. It's like, we trust you parents for you to trust your child. We can model slowing down [00:19:00]  and making space for stammering for you to model that to your child. And so again, in that chain, that first person is the parent, because then if we miss out the parent and go straight to the child, who's got their back in everyday life, you know, who, who's there. And. Being able to really, really be clear about that role of. You might not like this. It's going to be hard to see a child struggle. I'll just give a quick example. Um, a parent of mine had said, because I talk about being okay with being uncomfortable. It's all right for us to be uncomfortable in this space as a parent of a person who, who stammers. It's okay, actually, just to be comfortable. Therapists to be really uncomfortable in that situation as well, like, that's a whole other thing, but I really like that sense of being uncomfortable. I don't like it at all, but being able to stay in it I think is really important. So this mum, do you have ice cream vans in America? [00:20:00]  We do. Like, yeah. They  Kate Grandbois:  even play a song. Yeah. Well, I won't sing it for you, but there's, there's, there are singing ice cream trucks here.  Jaclyn Morton:  Yeah. Brilliant. So that, that, so the mum was in this massive, massive, massive queue with the child. He had quite a significant stammer, quite a lot of tension going on. There was lots of kind of blocking. This child isn't really that bothered about his stammer. The mum is really, really bothered about the stammer. So we've done quite a bit of work with, with mum. She knew that people were, it was a really hot day and people were getting a bit edgy and everyone was just wanting the ice cream and they were tired. And she's thinking, oh my goodness, he's going to go up there, he's not going to be able to get his words out and people will be even more irate. So all of this kind of reel of information and thoughts were going through her head and she just had, she was incredible and she stuck with it. With that child, the child [00:21:00]  went and asked for a strawberry ice cream, stammered all the way through it. The ice cream man just made space and, um, he got his ice cream, his strawberry ice cream. Not even a flicker. She, the mum was in a mess inside, inside. She'd kept it in, but she was thinking, if I'd gone in and said, I'll just say it for you. This, like, I'm really uncomfortable about all of this queue of people here. I'll just say it for you. We talked about if that had been the situation, which would have been fine. We looked at that other side of the coin of That message would have been, I kind of don't trust you to do this, or you're gonna stammer and it's not okay to stammer in front of lots of people. And so, she had that distinction, which, you know, I think is just a great gift, really. If we can be able to give that, and they can give that to the little people, then I think that's wonderful. [00:22:00]  Have I gone off on?  Kate Grandbois:  That was a wonderful story, and I think a wonderful illustration of an adult being with themselves and making space for their own anxieties and sitting with discomfort, which is, you know, something that culture, at least here in the States, is not easy to do. It's not something that we're taught to do. Um, you know, we've shoved down the feelings and don't ever speak of it again. So having that story really just illustrated the importance of slowing down and self awareness and accepting our own discomfort.  Ronan Miller:  I wanted to check and I wanted to, um, Just come back to something that you mentioned. And I understand that for some parents coming into therapy, um, the ideas around acceptance and things like that are a challenge. Um, and I myself, [00:23:00]  as opposed to stammerers, have found that journey from kind of wanting to stammering and hide as much as possible to slowly kind of becoming more and more, um, accepting of it and meeting all the people who stammer and all of the amazing things that community can bring and being exposed to new ways of thinking about stammering, which I think is the important thing that even if the parents aren't receptive to it in that moment or open or that's not the way they want to go with things. Just being aware that there are other options about how we think about it, you know, because I think, at least for me, and I think people, um, of my age, we were really brought up with only one way of thinking of it, which was, this isn't good, let's try and get rid of it, you know, um, and [00:24:00]  you, I know I did, I needed other. reference points to be, I wasn't able to create a new, uh, theory about stammering from my own experiences, you know, so I needed those external, um, people to kind of bring that in to view for me, and I think it's the same for parents as well, that, you know, we can encourage them to move away from the idea of trying to fix things, but we can also show them that there's, a world in which stammering isn't a problem. It's not something bad. Maybe there's even benefits to it. I know that people I know in the stammering community, myself included, would be able to, uh, identify some. So I think that's an important aspect of it as  Jaclyn Morton:  well. And I think as well, you know, we have lots of parents, I'm saying parents, but you know, I haven't said this, caregivers, anyone [00:25:00]  important in the little person's life, um, who are actually pretty chilled with the stammer. Like I think, I do think society is, you know, there was actually a poll by Stammer from the British Stammering Association and I won't give the number but there was something, some really quite large percentage of children who were actually kind of quite accepting of their stammering from quite a young age. So I do think there is a really positive societal shift and I get a lot of parents who come in and. It is just to get, like, well, I'm, if this is it, I'm fine with it. If it means they're going to stammer, I'm fine with it, but I just need to know that I'm doing my best. And that again is, is a similar concern. So it may not be, Oh, I just want rid of it. I, you know, it's not all like that, you know, parents need to know really [00:26:00]  quite immediately. This is why we've kind of created this app so parents can get the information right from that moment. And then those parents like, ah, okay, right. All I need to do is just continue to see my whole child, have my focus on that kind of. You know, not just on the stammer, but all of the wonderful other things that they're doing. And so, ah, I can rest easy now. That's just as important as those parents who are like, Get rid of it. I just don't want it. I can't handle it. You know, because I think actually that's less and less from all my times of working. So I do think we've got a really positive societal shift, which makes me very, very happy.  Kate Grandbois:  I want to hear more about the app, but before we get there, I want to circle back to one of the things you mentioned, which I think is a really important point, um, in terms of the role of the parents and caregivers, is that we as therapists are transient, and I think this kind of, you know, [00:27:00]  touches on our role and our healthcare systems, which is, you know, different where you are versus where we are, but an SLP is going to be in the life of a child for one school year before they move on, maybe a few, um, if it's through a private care setting, it sounds like you all have long wait lists and short visit limits, but you know, insurance has visit limits. We're transient. We're not a permanent part fixture of a child's life. by design, right? And I think by not centering, I just, I really love the way you're by refocusing on the parent, you're creating an ally for life, you're creating a support person for life, which is so important.  Jaclyn Morton:  Yeah, because without that, we've got a little person who's growing up that could be feeling potentially lonely. And also if mom or dad is saying, you did really well today, you didn't stammer. Oh, that's [00:28:00]  fantastic. But again, with love, again, with real appreciation of when you do this, you don't stammer. And then all of a sudden that little person who wants to please their mum and dad is thinking, mum doesn't like it actually when I stammer. So I'm going to find ways not to stammer. I know ways where I can be fluent. And I know if I don't say that word, or if I don't put my hand up in that class, then you did it. And so it goes on. So a week. To me, it's kind of, well, it's huge. It's huge. And also to empower parents, because parents will be doing some really good stuff already. But they might be thinking, oh, well, what do I need to do with the stammer? So often, they will be making space, but they don't know if that's actually Because actually making space and doing less Is what we're actually presenting to the parents. And so [00:29:00]  we often need to be doing something, you know, give me something to be, to be doing. Um, but actually if we can say to parents that what you are doing, there is a very active way of supporting your little person to be able to say what they want to say and they're like, oh, well I can do that. So if we can find ways that par things that parents are doing already, of which there will be loads, then again, it's. And it is about relate, this is what we talk about in the app as well, it is about relationship and it is about connection and it is about so much more than. You know, the stammer. The stammer is actually a little bit irrelevant, you know, when I speak to some parents and I'll say, they might come in and say, Oh, well, they stammer so much more when they're tired. Or, you know, they just, if we're not in routine and I, and again, I try and maybe take it a little bit away from that stammer talk. Ah, okay. So Katie loves to have routine and she loves to have structure. So it's about what things does Katie [00:30:00]  feel at her most comfortable with? kind of calm or what, what environment does Katie thrive in? Let's do more of that. And they know, we don't know. We don't know the answer to that. So, yeah, to be able to take us out of it, we can sometimes. Especially with these little ones. I think we have a different role with children who are coming in who are really, really struggling with their stammer. We, you know, we're not talking about that at this point. But I think for these kind of younger ones, we maybe need to kind of get down off our box. And put parents up  Kate Grandbois:  there instead. Pick off the expert hat, right? Because we're, we're there to facilitate and support, not be experts full of ego.  Jaclyn Morton:  Yeah. Which is hard again for us therapists sometimes. You know, it's, we need to just, all of this stuff that we're talking about in terms of giving parents, we need to do for ourselves. We need to check in with [00:31:00]  our thinking. And this is why I do a course for therapists. Also can I just say a massive disclaimer, I'm no expert at this. come from lots and lots and lots of mistakes, lots of reflection, lots of goofiness and just tripping up all over the place, you know, and it's not smooth. This is not an easy path. This is a harder path. Um, but I think if we can take the time as therapists to look at our own thinking, to look at our own role. And as I say, I do that workshop for therapists and, um, which talking to 160 therapists is really, really scary. It's the hardest bit of my year, but it's well received, so yeah, all these wonderful open hearted therapists who are willing to look at themselves. It's brilliant.  Kate Grandbois:  That's awesome. I wonder if you could tell us a little bit about the [00:32:00]  role of technology here. So now that we've kind of established the importance of the caregiver, the importance of our own professional humility, centering the needs of the family and the, and the parents, What what role does technology play? I mean, it's, you know, 2024. I don't, you know, I don't spend five minutes of my day without interacting with some piece of technology. So how is how is our current technological climate kind of impacting this work? Ronan Miller:  Go for it. What I should disclaim. I'm not a speech therapist. I have gone back to school to try and join you all in the on the box, but I'm not there yet. Um, hopefully one day soon.  Announcer:  One  Ronan Miller:  day. Okay. Yeah. On the ground. Um, so I can talk to you about this from my perspective, which is kind of from, uh, I put, I'm a person who stammers, which obviously has [00:33:00]  an influence, but also, um, yeah, from a research perspective, I'm just trying to kind of identify problems, I guess, and think of potential solutions. Um, so what we're doing isn't particularly groundbreaking. Um, you know, technology is used across healthcare in lots of ways which we won't go into, but there's, uh, many examples where apps are used to kind of bridge, bridge the gap a little bit between, um, in person sessions with a professional of some kind, and then the everyday life, which is the much more significant portion of time for most people. And I think in lots of areas, the idea of transfer or [00:34:00]  generalization is a challenge, both from a clinical perspective and for the person who's receiving help. So, Um, examples maybe, for example, in mental health support, there are in our context in the UK apps that are used in the NHS to support people who are receiving mental health support from professionals, but in maybe other moments of the day when they when they need support. something, there is an option there for them. So it's about bridging this gap in our, in our world of stammering and speech therapy, a significant challenge in the UK is providing access to support in a timely fashion. So unfortunately there's not [00:35:00]  enough, uh, speech therapy for speech therapy support for the demand. And that means that people can be waiting. anywhere really from six weeks to six months or more, uh, to receive support. So in that period of time, there's a lot of space there for the kind of things we've discussed, the challenges, the anxiety, um, to arise and for parents to be unsure about how, how to support. So technology offers kind of potential solution there. And as you say, we all, well, the vast majority of people now own a smartphone and use apps for various aspects of their everyday life. So having one there for something like this also kind of makes [00:36:00]  practical sense for lots of people. And there's a shift, it seems, with Some healthcare organizations, I'm not sure if it's this way in the U S towards encouraging kind of self management is, is the term people use. So providing people with, uh, resources that can potentially help them on the day to day and reduce their need to access, um, in person support. Obviously we, we want that support to be there. We're not trying to replace that. Um, But we're also aware that maybe with this extra support, we can kind of make space for other people who might be more in need. Um, so it's about finding the balance there. And yeah, just kind [00:37:00]  of does, I mean, I could talk about this for a long time. I'll try not to, but it's about immediacy of information for people. It's about, um, helping them make small changes potentially. every day that will contribute to something greater, and it's about improving access, ultimately. And for people who stammer and their families, there's not been many options for support. In some places, there are no options for support. So bringing another option to the table was, uh, something important, I think, for, for us in this, in our work. As I say, our work is a reflection of a broader. Uh, series of changes that I think are happening across [00:38:00]  healthcare as well. Jaclyn Morton:  We've had some really good feedback from therapists about how it can reduce their, their time, clinical sessions, but also that perhaps parents are already coming with a slightly different mindset through this, the apps kind of just 10 days at like five minute videos. So they're kind of often a bit more in the zone, which can help therapists, um, like, Oh, okay. Right. So you're thinking about that already, which, which is great. And also, I think it's having kind of parents a bit more kind of, I guess, primed or that's a silly word to use, but, um, but maybe even a bit more relaxed or a bit more confident. Like, that's really great for therapists, so I [00:39:00]  feel like this can really be a support for therapists, as well as a support for parents, um, and already we've, we've kind of introduced some certain topics or certain concepts,  Kate Grandbois:  so I, I love that you mention, um, you use the word primed and I could see how that would be a really good word because I'm, I'm thinking about myself. I'm thinking about my own experiences as a parent and how a lot of this is hard emotional work for me. the family for the mom for the dad for the caregiver. And when you're in therapy, as a parent, you know, you've got the therapist there, you've got the kid there, if you have a toddler, you're trying to maybe make sure the toddler isn't climbing on the couch or breaking a toy, I get out, it's it's a there's a lot going on. And I can imagine that by having access to access to technology with short digestible pieces of information, there's a little bit more room for self reflection, [00:40:00]  for quiet thinking, for kind of digesting that information at a pace that feels more personal, um, as opposed to, you know, I've taken my own children to therapy and I'm just thinking, thinking of like, you know, there's not a lot of self reflection when you're listening and digesting and parenting all at the same time. So this kind of gives that nice separation there.  Jaclyn Morton:  Well, that was something that I was a bit reluctant about, actually. I didn't know if it would work. Like, I'm used to working in a clinic setting, or I'm used to working in people's homes, and I ask a lot of questions and be guided by parents. I use a lot of solution focused therapy. I'm thinking, how on earth can we put this into an app? Do you remember, Ronan, right?  Announcer:  Mm hmm. Early  Jaclyn Morton:  stages, I don't know if we can make this happen. Like, how can we have empathy? How can we make it feel nurturing? How can we be able to have that reflective space within the app. And [00:41:00]  you're right, Kate, I feel like I've been very surprised by this, that It actually has allowed more space for that. You know, we're not saying anything so different from what you might see on a sheet, like a handout type thing. Oh, we are, we are actually going a bit deeper actually than what you get off a handout. Um, but I think by, one thing that was really, really important when we were writing this is, Can we make sure, because one size does not fit all, you know, how can we write an app, a generalized app, but really still get deep into that kind of nitty gritty stuff that I think is so important. Um, and I do think we've got it rolling actually. I do feel like we, we, we got that. That was the, one of our most important objectives to be able to have that. [00:42:00]  And in a clinic setting. Unless you've got a whole hour with just the parent, which I do love to do, but I think it can be luxury. I think there is something about the reflective questions and also saying it says things like these are some things that you could try what's best for your family. Like, again, it's that you're in charge here. We'll just suggest a few things. We'll facilitate. I didn't know if that was appable, if that's a word. Um, But I realise now that I think it is. And also, again, it's, it's, it's not about us. It's not us saying, right, again, I'm thinking UK. Your name's now at the top of the waiting list. You come into the clinic. Like, that's us, isn't it? That's us in our terms. Like, oh, we're ready to see you now. Whereas an app goes straight into that parent's, I need some help right now. So they're in charge then of, of, you know, their [00:43:00]  therapy or their situation. And I think technology can do that really, really wonderfully. Ronan Miller:  I agree. And I think just to add on to a couple of things there, one is the, I mean, I can look at this slightly from the outside, but I see Jacqueline's work and the impact that that has. And I think how amazing it is that parents anywhere really around the world could have Jacqueline in their pocket. giving them a bit of a talk and helping them through the day. She will cringe at me for saying that, but I know that's true.  Kate Grandbois:  For those of you who can't see, she is cringing. She's cringing right now.  Ronan Miller:  I know that that's a hugely valuable thing when you don't have. access to any immediate support, to have, you know, someone like Jacqueline who [00:44:00]  thinks about this stuff so, um, in such a way that it's, yeah, I think that's incredible that we can facilitate that to people. And then I like that Jacqueline's brought some examples in from her work. So just an example of a couple of things that we've, we've, we've learned from people who have used the app. One is that we've not designed the app at all for children. It's not, designed at all for children to use, only, uh, the adults who are supporting them. However, had a couple of stories where the app has, we've talked about bridging gaps, the app has bridged gaps between a child who stammers and the parent, um, who weren't able to talk about it. They had become kind of a, uh, abu, um, subject, which, [00:45:00]  can happen with Hammering, you know people who stand there sometimes don't want to talk about it People around them aren't quite sure how to get those conversations happening but we had a great, um piece of feedback a great story of a parent using it with their child and they would Go through The content and then talk about that stuff So that was kind of opening those conversations up and equally um, we've heard about parents kind of Using it as a team, I guess, in a way. So we're really kind of, uh, seeing how people adapt it and use it in ways that make sense for them, you know, and I think that's a really interesting, um, aspect of, of this way of providing help as well. Amy Wonkka:  So when you think about the collaboration between, you know, the healthcare side of things and the technology side of [00:46:00]  things, and kind of how that relationship has worked for you guys as being part of this app development, um, and then using it, Jacqueline, in your practice moving forward, what are some, what are some real press points for you? Pluses or maybe some barriers that you had through that process. I know one of the things you mentioned, Jacqueline was concerned about not being able to have that reflective relationship with your clients. Um, are there any other pieces just having gone through? Because I, I, I wouldn't have the first idea to sign an app as an SLP. So sort of what has that process been like? Yeah. Um, I'm going  Jaclyn Morton:  to say, thank goodness for Ronan. Who, yeah, who is, who is, was able to kind of allow my fluffy, verbose, kind of passionate, all of that stuff. And then we've got a wonderful, wonderful [00:47:00]  software team, wonderful software team. Ronan could just take all of that kind of stuff. Fluffy stuff. Um, and not, not let the passion go from it. And then the, the software team very, very wonderfully put it in. And, um, I think there is a sort of sense of, you know, we, I think there is a little bit of a, um, what's the word kind of, I think speech therapists can be a bit scared of. of technology, actually. Um, I know I was before I came into this. However, I did see it as a wonderful platform to be able to get information so quickly to parents. And that was the thing for me. But I think we can be a bit [00:48:00]  reserved around it and what's going to happen, you know, in the future and what's going to happen to us and what's going to happen to that relationship. And, but I think, as Ronan said, Another option is just wonderful that fits in with parents lives and being able to go on and have workshops and do it on an evening so you don't have, you know, toddlers climbing all over and have all of that come into your own space. I think I'm going to say especially for stammering, but I bet other therapists will be maybe thinking that this could work in their areas too, but for stammering, that sense of us coming to the families rather than the families coming to us, and I think technology is just a wonderful way of doing that. But I do think we still need to keep the heart in, in, in technology. Um, and that was one of my reservations really. [00:49:00]  Um, is there anything else Ronan that. In terms of that.  Ronan Miller:  Yeah, I think the challenge is as you say kind of maintaining that fuzziness and the human aspect of it that is  Jaclyn Morton:  Because if you just said that word that would have been that wouldn't have been okay, but  Ronan Miller:  So, yeah  Kate Grandbois:  It's good. Yeah, you know good it was perfect  Ronan Miller:  maintaining that is the challenge I think and Trying to kind of as you say, maintain empathy and the kind of, I guess, vibe that you might try and create in a therapy room or space. The challenge is trying to create something that approximates that. Because so  Jaclyn Morton:  much in therapy, I think, is about the relationship. Ronan Miller:  Yeah.  Jaclyn Morton:  And we're not trying to replicate that at all. And there are other, as we know, [00:50:00]  other bits of technology that. Don't think about that. And we're certainly not trying to be, although Ronan, you did say therapist in the pocket, but you know, it is just about being able to, to be an adjunct to that, to that therapy and fill those gaps. Um, but also if it means that parents can kind of go into this app and get that reassurance and don't need therapy, you know, winner, winner, chicken dinner. Like I love that expression. That  Kate Grandbois:  was so great.  Jaclyn Morton:  It's great. It's great. Everyone wins, you know, it's great for the service. It means someone who perhaps does need that support can be, it can take that time. So yeah, that's great too.  Ronan Miller:  No, I think thinking about our collaboration and our work, um, I think trust is [00:51:00]  important when you've got these kind of two, you know, potentially, not conflicting, but, you know, not quite sure how these things fit together. And I'd like to give a shout out to Kirsten Howes, who was a big part of this project in linking Jacqueline and I up. She kind of, identified things in both of us that she thought could work together and, um, did that. Hurston is a great, uh, speech therapist, also a person who stammers and is also deputy CEO of Stammer, which is the leading charity in the UK for stammering. Um, so I think that facilitated kind of the the, the trust that we, we built on, um, and [00:52:00]  as Jacqueline said, she wasn't quite sure. Um, I found it a challenge transferring all of those ideas into, as Jacqueline says, like an amplified way. I'm not a technology person, so I'm not, I wasn't responsible for any of the software analysis. Jacqueline said we have a great team around us who have, who have played a vital part in this, but I try to kind of translate the work that Jacqueline did and present it in a way that would in, in the most simple terms, fit on a screen, you know? Um, we're kind of restricted by the, uh, the technology as well as It provides us with opportunities, but it's also restrictive in a way. We have to kind of work within those, uh, spaces. And I [00:53:00]  think we can get a bit carried away with technology and think that's going to fix everything or sort of everything. Some people don't want to receive help in that way and that's completely fine. Some people don't have a phone, you know, Like, we also have to think about the fact that this isn't just, uh, the only way we should be trying to help people. Um, but if there's an opportunity there to provide another option for people, then I think it is, is kind of worth exploring. And I think something that is important as well is the way that you guys as therapists can kind of personalize the experience on the fly, in a way, um, in front of, of a person and adapt with your, um, [00:54:00]  insight and experience and knowledge. And that's very hard to replicate. Um, we, we're working on ways to do that now with kind of the next version. of the Penguin app, which reports to the Penguin now. Um, but yeah, that is a challenge that I think is key and we need to be aware that it's not a one size fits all. Some people benefit from different information at different points in their experience. So yeah, just kind of keeping all of those things in mind as well, I think is uh, an important part of the process. It's a challenge, but the challenges are what makes it rewarding in a way, I think. So that's kind of how we've, we've approached it to now.  Amy Wonkka:  Earlier in our conversation, we were talking about how important it is for caregivers to have the knowledge and with that [00:55:00]  knowledge, it's going to help them in building more positive relationships. I was wondering if you could just tell me and our listeners a little bit about what the Penguin app looks like. So what I'm picturing in my mind is sort of some digestible bits of caregiver information to help give people some of those basics that they might get in an initial few therapy sessions. But I wonder if you can just help us like visualize what it looks like a little bit.  Kate Grandbois:  Yeah. Before you tell us that I'm realizing that we have forgotten to mention something that's very important, which is that this is free. Is that correct?  Ronan Miller:  Yes. So people can find  Kate Grandbois:  free resource for people to download. And I am feeling like we should have mentioned that earlier, but you know, we love free stuff. Ronan Miller:  Yeah. So yeah, you can find it on Android, iOS, all of that stuff. Um, I'll tell you, I think, and then Jacqueline can tell you, and let's see if it matches or not. Um, so we designed it as kind of like a 10, it's a [00:56:00]  10 day thing. So we didn't want people to kind of rush through it. We wanted to kind of. model a bit of, you know, let's slow things down a little bit, get reflective. Um, so we encourage people to take it day by day if that works for them, obviously spread it out further if you'd like. Um, and we were very conscious of time. So we know time is limited. Parents, uh, are particularly under time pressures. Um, so we wanted to keep things kind of short and sweet, but without compromising on the information or the messages that we were giving to people. So another aspect of the challenge was to try and condense things and be quite succinct with how we were, uh, presenting it.  Jaclyn Morton:  Neither Ronan or I are [00:57:00]  succinct.  Ronan Miller:  Yeah,  Jaclyn Morton:  that was a challenge. How could as you  Ronan Miller:  may have as you may have learned from it on this recording, um  Jaclyn Morton:  Each other's work more words out more words out more words,  Ronan Miller:  but that's the trust, you know We're just we're there. So yeah providing that to people And we wanted it to be not overwhelming Want it to be supportive, not time consuming, but give enough, you know, so all of this kind of, um, balancing between these things so it's that's basically How people will experience the app if they if if they have a look I think Um, and we try to order is ordered This is, I guess, in a way I'm contradicting myself because we basically created an order of, in which the information comes, which, this is one of the limitations I think, potentially, with the app, but we were imagining, [00:58:00]  um, people who maybe hadn't had much support before, and were kind of more or less starting from a place of, you know, Not much insight. So we were very careful about the order in which we presented information to people and the things we were suggesting to them and asking them to reflect on as well. So there's, there was that aspect of it as well, which I recognize now might not be the best case for everybody. Um, And that's what we're, we're trying to work out how to kind of, uh, improve that moving forward. But yeah, so there was a flow of things which was also important to us in how we, we created the, the content that was there. Jacqueline, do you want to take over and stop me rambling?  Jaclyn Morton:  So we have this wonderful little character called Bene the penguin, and he's the main, or actually I don't know if it's a he,  Ronan Miller:  I don't know either. Jaclyn Morton:  Um, and [00:59:00]  he's very, very cute and just, it turns out everyone loves a penguin. But Ronan came up with the idea because if you, in the slammering world, we think about icebergs and what we see above the waterline, the bit that you can see is kind of what other people see, but then below the waterline, underneath the water, it can be so much more in terms of emotions and frustrations or excitement or all of these different types of emotions. So, and penguins are on. Icebergs. So, Bene is the star of the show, and then we have a little video, and it's, it is a bit cringe because it's mine and Ronan's voice, so I do day one and he does day two. Um, and it's, it, we've got this kind of lift music behind it, haven't we? It's like all very kind of calming, um, but people seem to like that, they kind of like that, but it's a bit cringey to listen back to. I think it's  Ronan Miller:  worth saying as well, we did this almost as an [01:00:00]  experiment, um.  Announcer:  Yeah,  Ronan Miller:  uh, we didn't really think about it too much. So there's definitely things we would change. Maybe the lift music would  Jaclyn Morton:  Well, you made up that music as well Yeah,  Ronan Miller:  yeah, and now I'm  Jaclyn Morton:  Questioning what I was up  Ronan Miller:  to At that time  Announcer:  I just want to  Ronan Miller:  jump in Jacqueline Because I don't think I can take credit for the penguin Um, our amazing illustrator of Ermine, who you can find on Instagram, her handle is at just ter. She's a person who's ERs as well, and. Just creates the most, most amazing, um, artwork around stuttering and the experience of it as well. Uh, and I was fortunate enough to meet her a few years ago and fortunate enough that she was up for being involved in this project as well. So I think the Penguin [01:01:00]  credit should go, go to her. Just wanted to add that.  Jaclyn Morton:  And so we have these five minute little videos that you can listen to or you can just, you can read. then an activity for parents to kind of reflect on and how it might fit into their lives, then we have like a little takeaway page. And because I'm such a big fan of quotes, we have a quote every day. But again, I think it's another way of parents thinking about things. So it's, it's full of these kind of little sort of mindful quotes, which, um, Yeah, I don't know how people have taken to the quotes, but it's part, part of it, isn't it? Um, and so some of the content includes things like how can you help, um, where is your focus? So we talk about focus being on the stammer or focus on the whole child. Um, a little bit about slowing down your life, if that's applicable to you, or slowing down your pace. [01:02:00]  Um, however you might interpret slowing down. Taking time in talking. Um, and we bring in about kind of the whole family situation and It's, it's not about creating this really artificial situation so the child can just take the whole kind of stage, but about how that can fit in with busy family life. A little bit about talking about stammering with your little person, supporting struggle and then next steps. So it is kind of the basics within that. Um, but I do think because it's a human voice, then it does give that bit of extra rather than say like a handout or something. So yeah, so. Uh, go on and have a look and, and see what you think and see if it's helpful to you, to you,  Ronan Miller:  or, sorry, Jacqueline, I didn't mean to interrupt you, that  Jaclyn Morton:  I, I was just waffling at that  Ronan Miller:  point. Okay. Um, and that, you know, I have to think about the research side of things as well. And [01:03:00]  we, within the app, we've included a self-report, just a really short, kind of five items, self report, uh. assessment. I guess you could call it evaluation, which we modeled on various validated measures, but we decided that we wanted to make something that was a bit more user friendly in that sense and not too overwhelming and not too kind of rough because some of the the way, uh, questions are phrased in, you know, the real Uh, style can be a bit intimidating, I think, which is what we were trying to move away from a little bit with the app. So we do ask parents to, um, reflect on a few things at the beginning, at the end and at the end of their journey with the app. And we've been pleasantly surprised by the outcomes of that. And it, it, [01:04:00]  really seems that I think I'm right in saying that, um, 70 percent of the people who've used the app, which is now, uh, in, in their thousands have seen significant kind of changes to, uh, things like concern about stammering or confidence in the support that they're able to provide for their child and things like this. So that's been, um, A rewarding thing to see as well. And another part of the app, sorry Jacqueline, just to say that, we haven't mentioned it, but another part of the app that we were very conscious about was including a stammering voice as well as a speech therapy voice as a way of kind of, yeah, just giving parents. as much of a big, I don't know if this is the right way to imagine it, but like the [01:05:00]  big picture view, you know, um, and it just so happens that it's us because no one else would do it, but, you know, it would have had the same, maybe not the same impact, but, uh, yeah, we're not voiceover artists by any means, but we tried our best to kind of, uh, present that as well to parents as a way of. showing them that stammering is okay, you know. And  Kate Grandbois:  well, I, I am so excited to share this with our audience. I will say that while you were speaking, I downloaded the app and I can attest that the background music that you used is very relaxing. It's very relaxing. There you are. So I want to say quickly that we will link the app in our show notes. It is free. [01:06:00]  This is a really, it seems like a really wonderful resource for a variety of reasons on only centering caregiver, parent, family perspectives and values, which is part of this speech language pathology evidence based practice model. But another reason it dawned on me while you were speaking is that there are very few instances where Um, parent and caregiver training or parent and caregiver counseling is billable. So we have this really difficult intersection with our infrastructure and our industry as well in terms of parents getting direct access to the care that they need. So, um, we will link all of this in the show notes as we, in our last final minutes. Do you have any, any last, any final thoughts that you would like to share with our audience? Jaclyn Morton:  I wish I could come up with something really wise at this point. You've said so many wise things already. I think you're off the hook.  Ronan Miller:  Winner, winner, chicken  Jaclyn Morton:  dinner. I [01:07:00]  do think as therapists, you know, we're talking about being reflective and we're talking about this kind of different way of working. I think if we can just be curious. And then that will show curiosity to our parents, like with us kind of modeling what we would like our parents to deliver to our little people. And I think that's what we do with the app as well. We, we're modeling within that. And actually, I think I was, again, a little bit worried about that. We wouldn't be able to do that, but I think we have. So I think as long as we are clear in our intentions and what we want to be able to deliver and then, and modeling that, I think. is so much, it's a harder path, but so much more in it than just telling. And I think that in parenting too, which is why parenting is really hard. Ronan Miller:  Um, that was quite wise. I think I am [01:08:00]  struggling to find wise words, but I think what I would like to say is to encourage the professionals that are listening, the speech pathologists who work with children who stammer to really look to the stammering community. And there's so many amazing organizations out there. Um, NSA in the US, Friends, Space, um, to name a few. And I strongly believe that for children who stammer, it's, uh, really important to let them know that there's other people like them out there, um, doing all kinds of things. the stammering, the stammering experience, the stammering experience as a child can be quite [01:09:00]  restrictive, um, if you don't have, you know, the right kind of support perhaps. So yeah, I think that's just, I guess, a personal plea to try and kind of bring, bring that into these children's world and yeah, see how they react to that.  Kate Grandbois:  That was lovely. Thank you both so much for taking the time to come on the show and share all of your knowledge and all of these resources. Everything that you've mentioned will be listed in the show notes as a resource. You've also sent over some literature that is, you know, behind a lot of the concepts and things that you've brought to the table today. So thank you again so much for being here. It was so wonderful having you.  Ronan Miller:  Thank you for having us. It's been a pleasure.  Kate Grandbois:  Thank you so much. Thank you so much for [01:10:00]  joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Kate Grandbois:  Hello everyone, welcome to SLP Nerdcast We are really excited to welcome Kelly Challen here today. Kelly is a local colleague that we have worked with in the past and we are thrilled to welcome her onto the show. [00:02:00]  Welcome Kelly. Thank you so much for inviting me to be here, Kate. I'm really excited to join you and Amy and your nerdcast today. Amy Wonkka:  We're so pumped to have you. Um, and this topic is a really exciting one for me. Um, you are here to discuss the transition from IEP to adulthood. Uh, before we get started, can you tell us a little bit about yourself? Yes. Um, I sometimes have a hard time. Talking about my succinct, myself succinctly, but I will try. So, uh, in terms of the experience that I'm bringing to the show today, I'm a transition specialist and I work as director of transition services at NESCA, which is a private practice here in New England. Um, I conduct and oversee something called transition assessment. And we're going to talk a lot about that today. Um, I also do consultation about a variety of different Transition related topics. Um, we offer planning and coaching services. We offer a lot of professional [00:03:00]  development cause this is a complicated topic. Um, and, um, my educational background is in psychology and school counseling originally, but I've worked in my current capacity as a private transition specialist for the past 11 years. Um, and I do a lot of in person work, but I also do remote work. So I actually have worked with families internationally, um, especially students from other countries transitioning to the United States for education or for post secondary education. Um, and I've worked with students in other regions of the country, um, but I certainly have the most experience and expertise locally. Kate Grandbois:  Well, I, um, I remember meeting you for the first time, I think it was 10 years ago, which is kind of horrifying. Uh, and the first time I heard you speak, it kind of blew my mind. Um, and I'm so excited to share this, as I was saying before we hit the record button, I feel like this topic of transition, transitional services is, is kind of a nebulous professional area where we all know it exists. We kind of have a [00:04:00]  general concept of, of, of what it is, what its purpose is, but. As you have kind of taught us previously, there is a lot more under the surface and it's really important for us to know because as clinicians and SLPs, we are supporting individuals who may benefit from these services or go through these services. So I'm really excited to share all this before we get into, um, the good stuff of today's episode. I do need to read aloud our learning objectives and disclosures. I will try to get through that as quickly as possible. Learning objective number one, list at least three post secondary goal areas required for IEP transition planning. Learning objective number two, identify two components of IDEA that impact transition planning. Learning objectivE number three, define transition assessment and transition services. And learning objective number four, list at least two components of a comprehensive transition assessment process. Disclosures. Kelly's financial [00:05:00]  disclosures. Kelly is an employee of a private clinic. Kelly's non financial disclosures. Kelly has no non financial relationships to disclose. 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'm a member of ASHA SIG 12 and I serve on the AAC advisory group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy Wonkka:  Amy's financial disclosures are that I am an employee of a public school system and co founder of SLP Nerdcast. And my non financial disclosures are that I'm a member of ASHA, Special Interest Group 12, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right. On to the good stuff. Uh, Kelly, why don't you start us off by just telling us a little bit about the first learning objective? What is transition planning? So I think this is actually [00:06:00]  um, Yeah, I mean, it's the most important thing that we're talking about today, right? So transition planning, um, is something that can be done for any human being, right? Transition planning, if we sort of break it down, is thinking about a change in status from whatever's going on now to planning for the future. So for any individual, transition planning might include thinking Long term goals, breaking those down into short term goals, making a plan to be able to progress forward with that. Um, but the type of transition planning that I'm an expert in and that we're here to talk about today is really IEP transition planning. And that has to do with for any student who's on an IEP in the United States, thinking about what are the outcomes that we are all expecting for that student after they finish special education. And we talk about those outcomes sort of in three specific areas. We think about what is the integrated employment experience that student is going to have. After special [00:07:00]  education, and that in itself is really important because we're actually thinking about how is this person going to be included in employment in the real world when they finish education. We also think about what kinds of learning or training experiences. That individual is going to have, so maybe you've got a five year old on an IEP that we need to think about, like, what kinds of learning and training is that kid going to be ready for when they finish public education, and that might be something like college education, but that also might be something like hands on training or technical instruction, and there's different skill sets required for these different things, and then we also think about what is independent living going to look like for this individual, as well. And that is obviously going to be widely different for students who are on IEPs, but we want to be thinking about, you know, quality independent life for an individual. And sometimes within that independent living domain, we think about community engagement. And I shouldn't say sometimes, right? We should [00:08:00]  always be thinking about how is an individual who's on an IEP now going to be included in the greater community in their adult life. Um, so there are sort of these three Buckets of working, learning or training, learning and or training and living for adulthood. And so we look at those areas and then we look at what kinds of skills and strengths and preferences and interests that student has and we start to plan to make sure that we're going to be able to make progress towards those outcomes in adulthood. Um, so that's sort of what is transition planning in a nutshell. Um, but it's not something you just do one time, that's for sure.  Amy Wonkka:  Well, and you mentioned that five year old student who we might be thinking about their employment, and I wanted to ask you because I know at least in Massachusetts, uh, there's a structured transition planning form and transition planning process that takes part as part of the IEP. Um, but it sounds like you're talking about having this transition planning [00:09:00]  mindset much earlier than we start using the form. Can you talk? Absolutely.  Yeah. And so something that I am not sure if you and Kate are aware of is that we're actually getting a totally new IEP in Massachusetts this school year and we are getting rid of that transition planning form. And so transition planning is no longer going to be just a form that we use for students. Sometimes after the IEP was even completed, transition planning is going to be integrated into the IEP process. In Massachusetts, there's going to be a complete transition planning section as part of that process. But there will also be on the new IEP in Massachusetts, questions for kids ages 3 to 14, asking them about their vision for the next few years and some of the things that they're interested in. And so we won't get into formal transition planning for students who are under the age of 13 in Massachusetts, but we will get into this idea of what are [00:10:00]  you interested in? What are your goals? What are your concerns for your IEP process? And that's going to look different for every student. I don't expect that every kid three and up is going to be sitting in team meetings this next school year, but I'm hoping that what we are going to do is be shifting our mindset to number one, If you've got a child on an IEP, the IEP is about the child. And so if we're thinking about goals and objectives and what a kid's going to learn, we need to be thinking about what the kid cares about, right? What's motivating this student? What are they interested in? What do they like about school? What do they hate about school? You know, how do we make this a more kid centered process? How do we help empower kids to have a voice in this process? Which might mean finding other ways to get that voice into the team meeting when they're little. Um, but a five year old can make a PowerPoint, you know, with support, like a Google dot, right, can come up with pictures that were important to them from the year, things like that. Um, and then we also need to be thinking about Like, if we're putting things [00:11:00]  into an IEP for a student this school year, no matter what the school year is, first grade, second grade, third grade, are we helping this student in a functional way so that this student is going to be a more successful adult in the long term? And so where I think of this the most for younger students is certainly goals and objectives, right? Um, communication, um, SLPs who are listening to this, right? Speech language pathologists, you guys have such an important role in transition planning for students. Because one of the ways that students can be safest and most empowered in their adult life is if they have intelligible ways of communicating with other people. Right? So I think about that really early on. Right? For students who are non speaking or have fewer, you know, like, are we getting AAC in their classroom? Really early so that we can empower students to have their own voice like that is so critical as part of transition planning. Um, and then some of this like self advocacy and the social communication pieces, like all of [00:12:00]  that has such a huge impact on being a successful adult. Um, so those are some of the things I think about for students early on. And then just to caveat, cause I assume there will be a speech language pathologist listening to this throughout the like these IEP documents are different in each state. So if we look across states, there are going to be a number of states that have a transition planning section of the IEP. There will be other states that still have that separate transition planning document. Then there are going to be some states that just have it like embedded within and you can't really tell it's happening. Then there's some states that don't totally include it yet or we don't kind of know how that's included based on what's available. But the important thing is like the this mindset, right? This thinking about that. The reason we provide special education services for students is so that they can access education and it's so that they can access education and make progress towards meaningful adulthood, right? We are [00:13:00]  always thinking about students who are going to be workers and learners and active parts of their community. After they exit public education, and I do think about, you know, anytime you're talking about accommodations or support services for a student, are we putting an accommodation in because this kid really needs this accommodation. It's an accommodation. They need to learn how to use and it's an accommodation that they might get later in life. Are we putting an accommodation in because we're sort of avoiding teaching a skill that the student really needs and then the same with when we're at IEP goals to an IEP, you know, like, are we working on a math goal this year because this kid's really going to need this particular math skill in their adult life, or should we actually be going the technology route for that and working on other literacy stuff that's going to be more useful for that student. So it's tough because it is about prioritizing. I certainly don't want to cut any. Um, any potential routes out for a student early in life? But a lot of, I think, early [00:14:00]  IEP development is more around, like, what does this student need to be able to be an active driving force in their life, right? And a lot of times that is communication skills, literacy skills, numeracy skills, um, and certainly life skills for some students. Kate Grandbois:  Um, anyone who's listening to this can't see Amy and I aggressively bobbing our heads. Um, and enthusiastically, I want to, like, give you all the air high fives through, through Zoom. Um, What I love so much about this is the, I think as clinicians we've, Very often, and I'm very guilty of this, move along in our goal development process and our IEP development process kind of just following development. Well, this is what should come next, and so this is what we're going to do. And reframing this and constantly pinging back against what is, what is our long term goal? What is going to happen in the future? And making sure that all of those things are aligned is so critically important. And I just want to emphasize that and how much I. [00:15:00]  wholeheartedly and enthusiastically agree with everything that you're saying. But I also, it's at the same time making me think about the very real and difficult conversations that must end up coming out of those thoughts when you are a clinician working with a five year old who's in kindergarten or in first grade and Trying to find a way to bring this up to families or maybe reach out to the transition specialist because it might feel so premature or, you know, really feel like we're not ready to have that conversation yet. What can you tell us about how to navigate that, that difficulty?  So, I'm going to sidestep just a tiny bit and just point out one thing that's really important to know that's in the law about transition services, which is transition services are mandated to start for students at the age of 16 nationally in Massachusetts, we have stronger protections and they start at 14, but there is [00:16:00]  language in. Um, both federal and local laws wherever you are that also says or earlier if appropriate. And so if you are a speech language pathologist working with a student who is younger who is struggling in whatever domain they might be struggling in that they sort of are working with you to support there's always this question of do you think it's going to take a little bit longer for this student to develop. And if so, you know, how can you start that conversation with a parent? And I think a lot of times, at least if, you know, if a parent is accessing speech language services, They know there's something their kid needs that's outside of general, normative, you know, typical, right? Um, and so, I think sometimes that's your lead in, is like, you know how you knew to come to look for speech language services, or you put your kid through this evaluation? It was because X was taking a little bit longer to develop, or they just needed a specialized way of learning. [00:17:00]  Well, when we think about your child in the future, you know, becoming a successful middle schooler, becoming a successful high schooler, and then eventually becoming a successful adult. I'm thinking that it might take some additional specialized support for them to build those skills, right? I think anytime you can help a parent or family or a student buy into the fact that they've already made these decisions for their child and so it's likely that they're going to have to make some other more unique decisions in the future. Um, I think that's a really helpful approach as a clinician, and one of the things I tend to focus on, both on the professional but also on the parenting side, right, is just getting into the mindset of, like, noticing when you are helping, right? Like, noticing, when have I jumped in and provided a support, as opposed to, Giving the student as much time as possible to [00:18:00]  wiggle through or struggle through whatever the task is in the moment, right? Um, and if we can help parents to start thinking that way at early ages, that is an enormous piece of transition planning. An enormous piece of transition planning as professionals who are helpers, or as parents who love to help and support and prevent trauma. Risk and frustration is just finding opportunities to allow students to struggle to intentionally build skills, um, and trying to maximize those. And there are certainly times in the day, whether it's the school day, you know, the clinical session, the home life that we do have to just help because we got to get through something because we got to be somewhere. But then there are other times that we actually don't need to rush through things, right? And what we are struggling with is our own frustration tolerance or our own anxiety because a kiddo is struggling and trying to find those moments to just allow struggle, allow risk, you know, allow. [00:19:00]  That's when kids develop confidence and confidence and, you know, and coping skills, right? So I think some of it is, is reframing mindset to allow for more independence, more success, more skill building as early as possible. And if we can start building that mindset, um, We don't, I mean, that's just a piece of things. And then it's also when you head into team meetings thinking about that too, right? Like, where have we sort of like over set up the day for success for this kiddo? And where are there opportunities for challenge risk, you know, um, just additional skill building. And it can be, I mean, there's just so many skills that are part of this process. So it is a little bit of a mindset shift. And I think you can have that conversation without. Um, jumping into all of the scary things like you're going to need guardianship eventually, but we don't have to talk about that at five. Although it's interesting. [00:20:00]  I was recently actually over, you know, with a friend who had a child who will need guardianship. guardianship eventually, and they were starting to think about what are the most important pieces to plan. And there is something to be said for consulting with like special needs financial planners and special needs attorneys kind of early. And again, I think you can have that conversation of you've accessed some, some extra support for your child now. You may need to access some extra support for your child legally in the long term. Like, here, if you're somebody who's thinking about working with a financial planner, if you're somebody who's thinking about, you know, setting up, um, any sort of, like, guardianship in your absence as a parent, you may want to be seeking out people who have expertise in working with students with special needs, students with disabilities, as you're making those kinds of decisions. Right? I think just recognizing that you're part of the disability community, and that that means that you want to seek out professional supports from other people who [00:21:00]  understand the disability community is so important.  Kate Grandbois:  That's a great segue into my next question. My next question actually Uh, which is just related to infrastructure and supports. Um, so for anyone listening who might have some light bulbs going off and be thinking, Oh, these are conversations I should be thinking about, or I might want to reflect on the goals I've written a little bit differently and look through what I'm doing clinically. Look at what I'm doing clinically through a transition planning lens. I can imagine myself in those shoes wanting to reach out to someone like you or wanting to find a colleague or work with someone who has specific transitional supports in their skill set, but that would also imply that someone with that skill set is in my workplace and then we start talking about, What infrastructure is really required to execute this? Well, I wonder if you can just talk to us about some of those elements or some of those [00:22:00]  resources that an end infrastructure components that an SLP might seek out or look for to make sure that transition transition planning is supported.  It's a little complicated because obviously speech language pathologists might be working in a variety of different settings. And so the infrastructure that's available or the infrastructure to look for might be a little different. Um, I mean, I think. If folks are in more of like a clinic or a hospital based setting, there may be like social workers or there may actually be somebody in that setting who focuses on, um, like medical transition for students and then they might have access to other kinds of community based resources. If folks are in schools, uh, it's pretty widely discrepant who is in the setting who's going to have any sense of. IEP transition planning, transition services, um, [00:23:00]  how do we sort of seamlessly make the transition from special education to adulthood? Um, but certainly I think there are questions you can ask within a school district setting or questions you can ask families to ask to start to figure out, like, Is there anybody here? Is there anybody who's part of this infrastructure? I mean, I think about, um, something we haven't talked about yet, but part of special education, um, transition planning is that students have access to something called transition assessment eventually. And even if we don't dive into what that is, a question you can ask is like, who does transition assessment in our school district, right? Like you now know, because you're listening to this, that this is a requirement. Somewhere throughout, you know, the K to 12 or post 12th grade process to have transition assessment happen. So a good question to start to assess your infrastructure is like who does transition assessment in our school district who's involved in determining what transition services are part of the students IEP. [00:24:00]   Because the truth is, legally, that could be a lot of different people in different school districts. We are seeing, there are national transition specialist endorsements now. There are some states that have transition specialist endorsements now. Massachusetts is one of them that has a local endorsement. However, there are no rules that say that schools must employ transition specialists. And that's okay. Sometimes there are people with different career titles who might have expertise in this. It might be a special ed administrator. It might be be a special ed teacher. It might be an occupational therapist. We're seeing a lot of occupational therapists, um, in the transition specialist role in certain places. So, um, asking those questions of like, who does transition assessment and who's involved in implementation of transition services will give you a sense of like who in our system is doing this. And there are systems where they're going to turn around and say like, no one, we don't do that. We haven't heard of that. And then, um. Like [00:25:00]  outside of like who's doing this internally, it's a lot about like what's going on in the community, you know, every, every state to some degree is going to have some organization that's involved in advocacy for families, especially families on IEPs, there are usually parent information centers or parent information groups. And so you might also look for in the community, you know, where are. The groups that provide parent information around transition planning, like that's actually part of your, you know, your infrastructure or your ability to sort of bring in those groups for training, bring in those groups to to be able to help parents. I also think about things like if we're talking about employment. Um, states will have vocational rehabilitation agencies. I don't know how often as a speech language pathologist you interface with VR, but it's great to know, like, what does VR do? Because for students who are school aged, there's actually a requirement for voc rehab to provide pre employment transition [00:26:00]  services in every single state in this country, typically 14 and up. If the school doesn't know that, they may not refer the student to do that. Or if you at the hospital don't know that you might not know that, but this is something that's often available. So looking up what are the pre employment transition services in my state? How did, how could a kiddo access that? The truth is that vocational rehabilitation services are all about helping with disabilities, helping people with disabilities to access employment in adult life. They're pretty good at employment. That's, you know, that's what they do. So involving that agency at earlier ages can only be helpful for students. Um, and also in, in a lot of, um, States, there's going to be like a department of developmental services or, you know, somebody who is providing developmental services for students with intellectual disabilities, there are often family support services right before students have exited. So helping, uh, to make sure [00:27:00]  that families know. That there's going to be some agency that can provide them with family support. In some states, there are going to be agencies that can provide them with autism support. I mean, transition planning is all about figuring out like who the kid's going to be in adulthood, but also who their support community is going to be in adulthood. We all have support communities. It's not just for kids with disabilities. And so part of what you can do is if we don't have internal infrastructure, Um, and you're ambitious, right? Like, how do I at least start to figure out who the external resources are? Even if it's just, I mean, one list of like, I know who provides parents support. I know who provides employment support. It's going to be book rehab. I know who provides, um, a little bit more of the family support and case management, you know, it's like, and actually something I haven't mentioned, but it's another great resource in all 50 States are independent living centers. There are independent living centers or centers for independent living in every state and [00:28:00]  their entire purpose and existence is to support adults with disabilities to live in their communities and they will often service any individual with disability any age. And they can provide things like peer mentoring and skill development, but also advocacy and support. And so sometimes families just accessing that one resource or students just accessing that one resource, um, can be really helpful. And those can be accessed during school ages. So there there's kind of like a handful of things you can look for in almost any state that aren't, I mean, there's state infrastructure as opposed to within a school or within a clinic infrastructure, but. That's really what transition planning is, you know, it's not just about like what's in the building. It's about how do I connect this individual to life outside the building. Um, so I, I'm hoping that I'm given enough information to give like starting places for thinking about this.  Kate Grandbois:  Oh, totally. And everything you said also made me think about the intersection of all of this infrastructure or lack of infrastructure. [00:29:00]   And the culture of our workplaces, right? So depending on where we work, we may work in a place that really values EBP. We might work in a place that really values, um, parent, parent centered education. We also might work in a place that doesn't value those things. And I think transition planning sounds like it may fall into one of those categories where your workplace setting either values and centers or doesn't value. And, you know, values, obviously the things that, uh, you know, From a professional standpoint, what kind of resources are allocated? How easy is it to access those resources? And all of this is making me think about, you know, the clinician who's working in a place and then maybe thinking, Oh, I have a few barriers to overcome because my workplace doesn't necessarily center those things. But But if you're working in a school, they may be federally required to provide some of these things. So what can you tell us about IDEA? What the federal requirements are? Um, I'm just thinking, you [00:30:00]  know, an SLP out there who is maybe thinking about some of those barriers that might really help us out to know what those federal requirements are so we can very kindly educate our colleagues, um, about what we must be providing to students on IEPs. Thanks. I think,  I mean, I think that's so important. And I, I think what I am, um, somewhat constantly reminded of as a transition specialist, which is obviously a pretty small profession right now in the United States, who's been doing, you know, who's been working as a transition specialist in the same place, you know, like in a pretty prominent, um, city in Massachusetts for 11 years. I think like, oh, I've been doing this for 11 years here. Everybody must know that I exist and that transition services exist. And, you know, and sometimes I, I walk into team meetings in the same school district that I've been going into for 11 years and I see some, some really similar challenges and I do not at all. Place [00:31:00]  blame on anybody within a school district for this not happening seamlessly, right? Because we have limited budgets and we have increasing numbers of students with special education needs, and especially post pandemic. Now we're seeing students who are just more complex, right? So I'm not saying that it's easy to follow this federal mandate at all. Um, but, but it's, it is, it's sad and fascinating to me that like this has been part of the law for 20 years. And yet, there are so many, um, families, students, and professionals who support the IEP process who don't actually realize that this is such a critical piece of this process, right? So, um, you know, as, as spe as speech language pathologists, related providers, anybody listening to this, like, you're certainly, hopefully, familiar with IDEA, right? You know that this is a federal law that guarantees students with disabilities an equal opportunity to free and appropriate public education. Bye. You may or may not be aware that right within the [00:32:00]  purpose of special education, right, within the law when we talk about what's the purpose of special education, it actually specifically mandates that the purpose of special education and related services is to meet the unique needs of students with disabilities and to prepare them for further education, employment, and independent living. So those are those buckets that I mentioned before. So literally the reason we have special education is so that kids are better prepared for further education or training, employment, and independent living. So just knowing that, and that's one of our learning objectives, that's why I'm sort of hammering it home, but just knowing that and being able to talk about that in your school community, you're like, how are we as a district or as a community, um, using our IEPs to prepare students for these things is a key. Question, you know, so that's one component of idea. That's so important. And I think a lot of times, even in districts where we do transition planning. Well, we may not think about that until students are high school, or it may not be considered at all. Or it's like an [00:33:00]  afterthought. So then we tack on, but really thinking about that when you walk into meetings, right? If you're part of a team, like, did we at all think about. Preparing this kid for life after high school. You know, that's important. Um, and then there's sort of this, like, what's the primary mechanism through which we help to prepare students for life after special education? And that's this, this word we've been talking about, or this phrase we've been talking about, which is transition services. Um, and transition services are described and defined right in IDEA as well. So, uh, this is more within the definition of an IEP, like what has to be in an IEP. The law states that no later than age 16, Or earlier when required. And as I said, Massachusetts is one of these states that starts at 14. There is at least one state that starts at 12, although I don't know which one. And it's interesting, right, like the age ranges, some states offer special education all the way up till age 26 so like there's shorter and longer transition planning periods. [00:34:00]  Mandated by law, depending on what state you're in, but no later than age 16, a student's IEP must include appropriate measurable post secondary goals. So we have to list out exactly what those goals are for after special education and the IEP. Those goals have to be based on age appropriate transition assessment. So there has to be assessment that was done to help determine those goals, and that assessment needs to be documented in the IEP, and the assessments need to be related to training, education, employment, and where appropriate, independent living skills, and then it has to list out transition services. Including the course of study that is needed to assist this child in reaching those goals, right? So we actually have to be listing out. Is this student going to get a diploma? You know, are there certain classes this student needs to have? Is this student, um, going to be sitting for standardized testing if that's required in your state or things like that? Like, that all has to be in there. [00:35:00]  Um, And then I want to break down transition services a little bit more, but it's big, and that's why this is hard to do. So, you know, the transition services have to be part of an IEP, right? You gotta be able to see those in the document annually after the kid's 16, um, after the kid's 14 in Massachusetts. Um, but transition services are a coordinated set of activities. So they can't just be ad hoc. Like, there has to be a way that these things are happening in a coordinated manner. Um, they're designed to be within a results oriented process. So again, It's reasonably calculated that these services are going to help the kid make progress towards their goals, and then they need to be focused on improving the academic and the functional achievement of the child with a disability to facilitate the child's movement from school to post school activities that include, again, post secondary education. Vocational education, um, integrated employment, continuing adult education, adult services, [00:36:00]  independent living, or community participation, right? So the services are going to propel movement forward towards those different outcomes. They're based on the child's needs. That's not a surprise because in special education, we're always looking at the child's needs. But the other thing about transition services is they take into account the child's strengths. The child's preferences and the child's interests. So when I think about, um, transition IEPs or IEPs where you can tell that transition services are being delivered appropriately, it should, there should be documentation of like, what is this kid good at? What are they interested in? What do we know about their preferences that's going to impact their future employment or their future, um, learning or things like that, right? Thanks. And then, okay, so we talked a lot about like the qualifiers for the services, but what are the services? Well, they can be instruction, right? They can be general ed instruction, right? It could be taking a computer science class, if you're a kid who wants to be a computer programmer in the long term. So they can be instruction. They can also be specialized [00:37:00]  instruction. And that's what's interesting is a lot of times kids need very specialized instruction. To develop skills that maybe their peers didn't need very specialized instruction to develop, but their skills that we know are going to be important for employment or for accessing college or training or for living more independently. And so we first need to think about is there instruction or specialized instruction that this kid needs. They can be related services. Like speech language services, uh, like occupational therapy services, which we often don't see at the high school level in Massachusetts, but occupational therapy is critical when sensory, you know, when sensory integration is getting in the way, when there's a motor piece to what's going on, right? So there's, they can be speech language, they can be OT, they can be PT, physical therapy. They can be a lot of things we're used to for related services, but they can also be things like job coaching. If a student needs to be practicing vocational skills, either within a school environment or out in the community setting, um, they could be something like a [00:38:00]  transition specialist as a related service provider, if that exists. You know, they could be, uh, they could actually be voc rehab services. Like, it's interesting because those can be accessed, obviously, um, in a free way, but there can also be ways that those are integrated into the IEP process. Um, they can also be things like community experiences. Right. And if we're talking about students who have trouble with skill generalization, then providing IEP services in the same classroom throughout high school and never seeing if they can generalize those skills to another setting is kind of irrational. So these community experiences, like what are the community experiences a student needs to have this year that would help them to be progressing towards post secondary adult life? One of the things I think is so fascinating is we require the You know, kids to have assessments where they can set goals for life after high school, but half the times the kids don't know what the options are for setting those goals. So sometimes there are community experiences that need to happen [00:39:00]  so that students can better be part of this goal setting process. The other things that can be part of transition services is literally like the development of employment and other post school adult living objectives. So let's say I'm starting transition services. I've got a 13 year old 13 year old is going to turn 14 during this period. Therefore, we need to talk about transition. You know, we need to have transition assessment and talk about transition services at the IEP meeting, but that 13 year old. Doesn't know what they want to do for a job after high school. That's okay. Part of their transition services this year can be thinking about developmentally appropriate career education for that student, right? That could be a student, you know, putting together a PowerPoint over the year of like interviewing their parents and interviewing other people to figure out what they do for work and what their career paths were, right? Like you can think about, um, what are, what's appropriate for this kid this year so that they can have better employment objectives. Next year, right? Um, and then if [00:40:00]  appropriate, it says acquisition of daily living skills and functional vocational evaluation. Those are two very different things, but they're put in one bullet point. So daily living skills to me, um, there are lots of places in the federal law that says transition services. Might include daily living skills. I think historically the percentage of students who are on IEPs that needed help with like ADLs or IADLs, um, was a lot smaller. I think when we think about students who have special education needs now, there are many times they're going to need some level of specialized instruction or a service to be able to have age appropriate daily living skills. Um, What's interesting is, and I know we started this talking about speech language pathologists who might not have the infrastructure around transition services in their school system, one of the things to just note if you're sitting in a team meeting is, you know, is this student, um, is any part of this IEP supporting the student's acquisition of [00:41:00]  daily living skills? And if not, how was that determination to do that? Made, right? Like, did somebody just say, I don't think this kid needs ADLs, or was there some sort of informal or formal assessment tool that helped to define that? I think there are times that students can show up at school looking like they don't have daily living skills, uh, challenges, and it might have been like three hours at home with a parent to get the kid looking like that. And if we don't ask the question or use some sort of standardized measure to figure out if these are sort of age normative skills, um, the team doesn't really have a basis for determining that that's not appropriate for ADLs to be part of this IEP, right? So something to just think about is like, did transition assessment happen? And did we ever talk about whether it was important for this kid to develop daily living skills? If we didn't like, you could raise that question, like, um, you know, depending on, uh, sort of, What your team dynamics are. But just to say like, Oh, I know for transition planning, we're [00:42:00]  supposed to determine if it's appropriate to work on daily living skills, like, does anyone have data to be able to figure that out? Right. Um, there are a lot of kids that we know they're gonna need specialized instruction in that area. And so, um, just making sure that, uh, somebody's done an assessment to, to be able to quantify that and figure out who the best person is to work on that. And how are we integrating that into the IEP process is so important. And I, I don't know, um. Sort of like what percentage of speech language pathologists would be working on executive functioning skills in school. But certainly if a kid has executive dysfunction, that is going to impact their ability to carry out daily living skills. And so that's important. Um, and then the last piece of transition services. that I mentioned was that functional vocational evaluation, some students really need to go through more of a hands on evaluation process with a rehab specialist or an occupational therapist or transition specialist to be able to figure out more about what accommodations they might need for work, what technologies need to be in place to support [00:43:00]  them. And like, what kinds of jobs are going to be sort of reasonable or that they need to be trialing over time. So that is also something that can be a transition service, right? We did a career interest at, you know, inventory for this kid, but that's not really the best way to evaluate vocational skills for this student. So functional vocational evaluation is going to happen this school year. And It's going to be, you know, over X amount of time or it's going to be a couple of days or but that can be a transition service for a student. So it's a little odd because you're supposed to do assessment to be able to name the goals to then figure out the services. But sometimes what you figure out is that we actually need more assessment over the course of the next year to be able to do the transition planning better next year. And that's okay. If you have started this process on time or early enough for the student. It's a problem when it's 12th grade, you know. So. Um, that's the piece. So hopefully I just gave again enough information to  Kate Grandbois:  it's no, this is great. And I, I, you know, [00:44:00]  as you were talking, one of the things that stood out to me was if we don't ask the question, then we don't have the reason we don't have the space to. We don't have the information we need to move forward. I think is you said something. I'm paraphrasing and botching all of the brilliance that you just shared. But I think that is such an important point. And it's something that we talk about on this podcast a lot is that Uh, the importance of asking those questions, the importance of measurement, the importance of measurement, and then the relationship between how we measure things and how we move forward. So what kind of goals do we write? What kind of targets are we choosing? Um, I'm thinking about SLPs listening to this and absorbing it, understanding that it's, you know, related to what we're doing every single day, even though it may not be the central focus of what we're doing every single day. I'm thinking about SLPs who might be. starting to have these conversations with administrators or parents, um, and making referrals. So finding those resources, um, or, [00:45:00]  you know, asking for some of these assessments. Are there things that an SLP can look for in a transition assessment that would make it a good transition assessment? Are there things other, before we start talking about goals and the connection between assessment and goal writing and how we move forward, Are there things other than what you've already listed that would be really critically important to look for in a trans in a comprehensive transitional assessment? Yeah, I think what is complicated and actually I haven't defined transition assessment yet. So when I kind of step back. And provide a definition of it, but it's not going to be that helpful, but, but I want to make sure you know, as someone's listening to this and they're thinking about it, you need to know what it is to be able to share. It will be very helpful.  Kate Grandbois:  You're not giving it. So, so  the funny thing about transition assessment is it's absolutely in idea. It says we have to determine post secondary [00:46:00]  goals based on age appropriate transition assessment. Um, I think speech language, you know, assessment is defined in IDEA. Occupational therapy assessment is defined in IDEA. Transition assessment is not defined in the federal law. Uh, but, um, we do have a commonly accepted definition of transition assessment that has sort of been utilized, um, in various ways legally over the years. And that comes from the Division on Career Development and Transition, Which is called DCDT, which is out of the Council for Exceptional Children, um, CEC. So DCDT wrote a position paper that defines transition assessment. And the way that they define it is an ongoing process of collecting data on the individual's needs, preferences, and interests. As they relate to the demands of current and future working, educational, educational, living, and personal and social environments. So, it's a broad, vague definition, but the whole point is, [00:47:00]  the way you know if you've, if you have enough data, if you've seen a comprehensive transition assessment for a student, or if you've seen enough different evaluations that we are sort of coordinating in a comprehensive way for a student, is. Do we have information about what the student's goals are going to be after high school? And do we have information about what the student's needs and strengths and preferences are right now that can help us to define annual goals and objectives for this year and figure out what services are needed and figure out if we need to do more assessments. So it's a little bit of a reverse, you know, reverse thinking in terms of the way you know you had good transition assessment as you have the information you need to develop the IEP. Right. Um, and You know, then it's sort of like, do I also have information about what I suspect would be challenging for this kid when we think about the transition planning process? One of the questions that I like to ask as an evaluator, um, to professionals working [00:48:00]  with the student at school, to the parents, to the student themselves, is like, what are you most worried about when this kid exits public education and enters into adulthood? Right, if I ask everyone who knows this kid what they're most worried about, what could go wrong, what are the obstacles here, I'm gonna know if there's something I need to evaluate or dig into more. And if you're reading, um, if you are lucky enough to actually be looking at a transition assessment report, um, that was either done school based or done by a collaborative or an organization outside of the school, um, Then the question is like if you read that report, do you clearly see what the goals are for the student after special education? I see a lot of really thorough transition assessments that give a lot of information about these domains of transition planning, but never actually get to the point of saying here are the post secondary goals that should be in this kid's IEP and that we should be aiming for. And so if that's not in the report, [00:49:00]  Then, like, what are, how are we coming up with those for the team meeting? How are we then creating an IEP? So that's one thing to look for is, like, Did we, you know, sort of flesh out what the kids goals are, or if if the goals were vague, did we say here's the goals right now and a recommendation for this year is going to be sort of working with the student to participate in some activities that they're learning more about themselves so that these goals can be better defined next year when we meet as a team. Um, and then the other thing is just are there sort of clear recommendations around again in those different buckets of have we thought about employment for this student? Were there assessments and recommendations related to employment for this kid? Career planning, career development, vocational aptitude, vocational interests, you know, like, did we learn something about employment for this student through this evaluation process? And, um, you know, are there recommendations in that area? Certainly, um, Are there like assessments that are helping to formulate what that kid's going to do for learning and training [00:50:00]  after high school and whether they have the skills to be able to progress in that path. And I'm sort of smiling as I say this because I see so many times in Massachusetts in particular we are very college focused. And I think there are other states that are very much like that. And, um, so often it's like the kid's going to go to college, you know, but then when you look at IEP objectives that did not, the kid's not going to college, right? And so there's either a mismatch between we have a post secondary goal here that's unachievable for this student, or we haven't set up annual objectives to be, um, Ambitious enough for the student to actually be able to bridge that transition. And what's wonderful in the United States right now is like, there's a lot of different ways to go to college. There are a lot of different support services available to make that transition. But again, the IEP has to be setting the student up to access those, right? Um, if a student's going to need disability services or need an executive function coach or need, need a support, then they have to know they have a diagnosis and they have [00:51:00]  to have the skills to be able to disclose and use that resource. So. So sometimes it's, it's like self advocacy skills that are needed. Um, and then the other thing with the transition assessment, and this is so important is like, did anybody bother to check if life skills are needed for this student? Right. I think that's the one you're, you're going to look for the most of, like, if we don't have life skills data in this transition assessment, was it evaluated somewhere else in the student's career? And if not, we're really missing out on an important domain for a student. Um, And some of the other things that I look for, or that I strongly recommend looking for when you're thinking about was this comprehensive, are sort of, where did the data come from? You know, did we get data from a variety of sources? Number one, did we get data from the student themselves? Right? Uh, that is important. But if that's all the data we got, that's probably not super valid. Um, there are a couple students that might be valid for, but, but really it's not just, The student, but also did we get information from the parent or guardians [00:52:00]  or did we get information from school providers? If there's a really important related provider out there in the universe of the kids got a therapist, you know, if the kids got like, is there some data coming in from people who know this student really well, so that we are certainly. So we have the most appropriate post secondary goals for the student, and so that we have the most appropriate information in terms of what transition services are needed for this year. So I like to see data from multiple sources. I also like to see, as part of transition assessment, like one, I'm going to say transition planning inventory and it's funny because there is a tool that's called the transition planning inventory. It's the third edition now and it's like a 57 item checklist, but there are a number of other like transition activities transition inventories. There's even like Washington State has this life skills inventory. That's actually like pretty broad. It covers all the transition planning areas. I like to see one. Checklist that's across all the areas. Um, you know, [00:53:00]  almost as that like quick check to make sure that we haven't missed something. And if that's done, then it's like, I don't need like a big Vinelander at a bath if I did a transition planning checklist, and that has a couple of life skills questions on it. Like, you'll be able to flag areas that need to be part of transition planning just by doing that.  Amy Wonkka:  As you're speaking, I'm listening to you talking about it and I'm listening to, you know, sort of the piece about this transition as a process that's happening, if I'm an SLP, who's working with a middle school age student or a high school age student, uh, but I do keep coming back to, it can also sort of be a shift in mindset for those of us who are working with younger age students. You know, I think about in, in my career, I've mostly worked with I previously worked with early intervention up through high school age students, and my focus for my younger students on my caseload has been about access to school and not really broadening that vision to think that far into the full into the future. [00:54:00]   About what some of those skills are and I wonder if you can talk to us Like I think if you're working with the later age students You actually have the benefit of hopefully having somebody who has done the transition assessment So now, you know all of these areas that you should be more thoughtful about I wonder if you can talk to us a little bit about how we might see the transition planning reflected in a course In some IEP goals, both for those older age students, but also, you know, for those of us who are working with younger preschool, elementary school age students, how we might also sort of broaden our mindset, have those bigger conversations with families, you know, thinking back to the comment you made about, is this something that is a skill deficit versus an accommodation? Um, and just how we can be thoughtful across the entire. age spectrum of school aged, um, individuals who are going to receive some sort of IEP transition supports.  Yeah. I think for the younger students in particular, um, [00:55:00]  I mean, access to school is important, right? Like, an integration into the community is important. Like, those are skills that we want for students lifelong. We want them to be able to access learning and be part of their communities lifelong. So, that focus is quite important. I think these self advocacy and the self determination skills are really what I would just encourage Anybody working with a preschool student and elementary school student and middle school student to make sure that that is embedded in this IEP process and that we aren't circumventing those skills for students. And so, you know, when I just gave my sort of lengthy description of transition assessment and transition services, one of the things I talked about is that this process is based on the students needs, but it is also based on their strengths. And their interests and their preferences. And the most ideal way for that to be part of this process is because the student has [00:56:00]  learned what their strengths and their interests and their preferences are and how to communicate those to other people. And so I think, um, you know, like, Those self advocacy kinds of skills, the self awareness, um, the perspective taking in terms of how are my strengths different than somebody else's strengths or how are my needs different, you know, like the ownership of like the some things are hard for me, um, that is all critical and and Honestly, I mean, that's what often prevents teenage students from participating in this process is either, um, I am not willing or able to acknowledge that I have a disability, I am not willing or able to acknowledge that anything is hard for me. So like, if we could work on those skills earlier if we had that mindset of not just does this kid need a math goal or reading a writing goal. Um, a fluency goal, you know, an audiology, sort of like a listening, [00:57:00]  right? Like, like, if we're thinking about, like, does this kid need to be able to talk about themselves? Does this kid need to be able to compare different parts of their own sort of skill set, right? Like those kinds of things early on would empower students to be so much more successful as part of this transition planning process. And I think about, um, and I, I wrote like a blog post or not just like a LinkedIn post about this recently, but just having a conversation at, uh, my son was at the dinner table and like I was standing, my son eats for a very long time, so the dinner table and we were just talking about, um, memory, right? And. He made some comment and I was like, and, uh, he noticed that his dad had gotten a haircut and he made the comment of like, dad, did you cut your hair this morning? And my husband said, actually, I cut my hair last night and my son looks at me. He goes, mom, did you notice that dad got a haircut? I'm like, no, no, I did not notice that dad got a haircut. And I said, but that's one of the things I love about [00:58:00]  you. You have you pay very close attention to your environment. You look really closely at what's going on visually in your environment, and you have an amazing visual memory, so you will notice if something in your environment changed from yesterday to today. My brain's not like that. I'm not paying attention to the world around me. I walk into walls and doors frequently, right? Like literally I'm just, I'm in such a hurry. I don't, I don't, you know, position myself correctly, but I remember everything that is said in my environment, right? Like my, my listening memory is really strong. And then my son said, mine's not, you know, and, and just being able to say like, Hey, my visual memory is really great. My auditory memory. It's pretty terrible. Um, and being okay with that, just that it was a matter of fact discussion, like that's what we want for younger students, is that like, it is okay that different parts of my cognitive profile are different from one another. It is okay that I can learn [00:59:00]  math faster than I can learn reading and writing, right? Like just being able to engage in discussions about that meaningfully Like that is transition planning and that is what enables kids to be part of this process and set goals and then be willing to work hard on certain things and also like students getting acknowledgement for the hard things that they've learned to do and like this was harder for you to learn but like you were you worked really hard and you got that and you can do that because that is going to also be a big part of transition planning is being willing to work hard at the stuff that you're not so good at. Kate Grandbois:  I love this so much because what you've just described is a conversation with another human being, not because they have a disability, but because they are a human, right? That's, that is a, that is a condition of human existence is to have some things that are easier and some things that are more challenging. Not everyone is good at everything. And I love the example you've given of sharing something about yourself, making it very [01:00:00]  normalized, creating a space in your professional and, you know, your professional relationship with your client where they don't feel othered. Well, we're here to work on something because it's really hard for you. You know, that, that is not the environment that is, that is going to be therapeutic or helpful. Um, it was just a really great example. And I, I, I thank you for sharing that. That was awesome.  Yeah, I think that's just, um, I mean, again, it's this shift in mindset. Like, I'm lucky because I do this professionally. So, so in some ways, you know, like, I'm up in the middle of the night thinking about, like, planning for adulthood for my own family or for my students. But it really is. It's just thinking about like, when can we be working on goal setting? When can we be working on self awareness? You know, how do you embed that? And then I also think, and unfortunately I don't think this is something you guys struggle with professionally, but I think really thinking about communication for students early, um, not waiting on AAC, you [01:01:00]  know, it's so frustrating working with these like 17 or 18 year olds who are just not intelligible to anybody, but. their parent. And, um, like that's a wonderful thing. And I'm super happy for that parent that they have a communication method that's working for them. But that means that their kid can't access the world without their parent right next to them. And I do, I have a student who actually is like out shopping. And if the sort of clerk doesn't understand what he's saying, he knows enough to call mom, get mom on the phone. She interprets in the moment. But then if mom is busy, That's no longer a functional way for that student to be able to make a purchase, right? So I think you guys have such, um, an important role in making sure that students can self advocate, making sure that students can be safe because they can communicate with other people. And especially making sure that students are set up with the right. Low tech, high tech, whatever kind of tech support is going to work for them. Um, so that they, again, can be more independent in adulthood. So I think [01:02:00]  there's, there's no, I would never sell a student short on that being really important for them early in life. And I do think, you know, the other thing that, um, To give you more food for thought, which isn't always helpful, but I think is really important, special education is about education. And so I don't, I don't want the transition planning mindset to take over the fact that there are skills that kids need to learn through special education, through education, that there's no other opportunity for them to learn later in life. I have a number of families that get to my office because they're worried about planning for life. After special education, and I start to look through and I'm like, Oh my goodness, we need to be so much more focused on reading, writing and math, because the reality is what we know from research what we know, you know, no looking at like our economy and other things is that your sort of foundational literacy skills and numeracy skills like that is that is your earning power right like that has such an [01:03:00]  impact on being able to obtain Integrated employment, which is what we should be aiming for, for everybody. Um, and being able to make the most money in employment is like reading, writing, math, you know, and if, uh, if that needs to be done through accommodations, you're going to be able to use those accommodations extremely fluidly to be able to do that out in the real world. So I am not a proponent of like, we got to get this fifth grader out, you know, doing volunteer work. I mean, that would be great. Doing that with your family is great, but I'm not a fan. I've taken instructional time just to say we're doing community experiences if they're not age normative community experiences, and that student really needs two hours of reading every day, you know, if you have a kid who is Still motivated to be working on their reading skills, whether it's middle school or high school, and can continue to progress with those and is going to be able to get to a point where those reading skills will be either functional for daily life or [01:04:00]  functional for community college, or, you know, functional for them to read their medical paperwork. The time is better spent on. reading, you know, like that is absolutely what we should be getting out of special education. We have, you know, voc rehab services are great at supporting students with employment. So I don't just want a kid going out doing a volunteer job that isn't actually related to competitive employment, where they're maybe not being held to appropriate competitive work standards in lieu of education. So that we're saying we've got this great Transition services, you know, it's really helping that student to build skills, um, and have the experiences and activities that are going to be most functional for them so that they can be most successful when they transition eventually. And, um, so that's also something you can notice in team meetings. It's like, Whoa, did we go way too far towards functional for this kid? And there's still untapped learning here. Kate Grandbois:  I feel like you've mentioned a few things that are really important to focus on when we [01:05:00]  were thinking about that forward thinking. So you've talked a lot about self advocacy, obviously literacy and math. Are there any other, um, goal areas that a speech language pathologist could really focus on or consider when working with their clients or students in projecting forward, doing that forward thinking and considering transition planning? I mean, depending on what age you're working with the students, executive functioning is one of the areas that certainly has come up and we've talked about. And I think, uh, one of the things that is really hard with executive functioning. Is, you know, it develops through obviously direct instruction, but also opportunities to practice with and without support. And so sometimes it's almost thinking about like, where is this kid practicing some of these skills in more functional way? You know, like, is it executive functioning for recess or exactly? You're like this stuff that [01:06:00]  happens overnight in terms of like, uh, do they need goals around getting themselves ready for school in the morning, right? Like, like where, where can we be a little bit more functional? Functional and are thinking about that skill set. Um, but a lot of what we've already talked about. I mean, this, this self advocacy and self awareness and, and, and knowing what resources are available to me and being willing to ask for help. Like, that is huge. Right? Communication is huge. Um, some of these foundational academic skills are huge, but certainly like. Being able to implement those in real time, being able to generalize, having strategies and supports to keep myself organized, to be able to plan, to be able to set goals, to be able to break goals down into manageable steps. Um, those are a lot of the most important skills that are part of transition planning. Um, and then the other thing, uh, it would really be for people working later in life, but it's just a sort of check mark, and it might be something to talk with clients about if you're working with middle school or high school clients, is just thinking about like, When is this kid going to have their first [01:07:00]  paid community based work experience? And I know I'm like throwing in an extra, but that's one of the most important things is for students to actually have meaningful employment activities at some point before they've exited public education. And so I'm always talking with families about that. If you've got a family that's like over programming their student over the summer, or if a student's got IEP services during the summer, and then that's preventing them from like maybe doing a CIT position or getting a job. Um, and I think it's really important to think about, you know, when you're planning a job at market basket, uh, which is a local grocery store, you know, it, it's thinking about like, have we put enough time into this kid's schedule and enough support so that they can start their, their work experiences early? Because we do know that those paid integrated work experiences. Um, while in high school are enormous predictors of success post high school. So. That's not a goal area. It's not an objective, but it is sort of something you can have in your mind if you just, if you really want to have that transition planning mindset. And if you happen to have an older student. Um, and then, you know, [01:08:00]  the access to community resources, that being part of, um, our thinking, uh, a lot of times it's just, it's, um, who's in your network, right? Like, you know, if you have a family that you notice is a little bit more isolated, um, like, who's in their network? Can we introduce other people into this network? Life is absolutely all about networking. Transition planning is about having that supportive community and getting a job eventually is about, about who you know, like, just like it is for any of us. I think sometimes we think, like, sometimes we think work works differently when you have a disability, but there are so many pieces of this process that are exactly the same. Like, it's who you know, and it's being willing to, like, you know, make a lot of phone calls. It's being able to deal with rejection. You know, it's being able to sell yourself to other people, which is a hard skill that you Students should be practicing with you guys, right? Can I talk about myself comfortably, right? Can I, can I talk, you know, can I talk about something that I, is an area of challenge without giving way too much detail, [01:09:00]  right? So there's a lot to this that's just, um, similar stuff to when any of us, you know, started adulting.  Kate Grandbois:  We both appreciate this so much. And I wonder in our last couple of minutes, if there's anything you haven't shared that you want to share or anything that you'd really like to leave our listeners with. I think, um, what I like to share is like it's never too late or too early to start thinking about transition planning. You haven't missed the boat because you have like a 25 year old speech client who is still living at home, right? Like it's never too late to think about a young person setting goals for themselves, making a little bit of progress, taking a few steps. And it's also not too early to start thinking about how is this student going to be independent and integrated in their adult life. Thanks. And then the other thing I just want to say is I'm sure I've shared a lot of information. Like for me, this is obviously what I do day in, day out. So I just talk about it. Like it's common knowledge, you know, really easy. And I know it's not [01:10:00]  easy. And so like, don't try to process everything from this particular session and memorize it all and do it all. Like pick that up. One thing and do it a little differently in your clinical practice tomorrow, right? Like it's just or in your educational practice tomorrow. It's like, if you're just doing one thing that's going to support transition planning, like that's more than yesterday. And like, that's important. And then you can learn more knowledge over time. I, for families, um, uh, in Massachusetts, like there are certain. workshops or conferences that are all about transition planning. And I tell people like, go early because you're going to be overwhelmed, right? Like, go when your kid is 12, because it's all going to feel like, Jar, you know, like jargon and jumble and it's good. You're going to be so overwhelmed, but then you go again every year. And like you, you know, like your child is different every year. You learn something different every year. And I feel like professionally too. It's like transition planning is complicated. I feel super lucky that I get to specialize in this area. There are so many professionals working in transition where it's a small piece of what they do. And that is not [01:11:00]  easy to stay on top of this. If it's a small piece of what you do. So just take one thing away, listen to this again later, you know, like Do some other transition planning workshops, um. There are some great, you know, again, like local and national resources if you want to learn more about it, but don't try to do it all at once. I've been doing this intensively for 11 years, and there's still so much to learn. Kate Grandbois:  Well, we can tell that you've been doing this intensively for 11 years. You're brilliant, and you've just shared so much information with us in an hour. We're so grateful for your time. Thank you so much for being here. Thank you so much for having me. This was wonderful. Thank you so much.  so much.  Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, [01:12:00]   www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

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 EpisodeSponsor 1 Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. I am very, very excited about this evening's, uh, or today's episode. I am here with the most people we have ever hosted on this podcast, ever in the history of this podcast, [00:02:00] which is really exciting. Today, we have the pleasure of welcoming the heads and members of the Multicultural Constituency Groups from ASHA, also known as the MCCGs. Does everyone want to say a collective hello? Hi! So great! Alright, so today we are going to discuss allyship and cultural humility. Which is something that we've mentioned on this podcast in the past here and there, but I'm very much looking forward to unpacking these concepts and going a little bit deeper with all of you. Um, especially how these concepts relate to our field, both speech language pathology and audiology. But before we get started, I was wondering if each of you would like to briefly introduce yourself so that our audience knows who is with us today. I can go first. Um, I am Gregory Robinson. My pronouns are they, them, and um, [00:03:00] I am the chair of LAGASP, the LGBTQ Caucus of ASHA. Hi, good evening. My name is Sophia Carias. Sofia Carias:  I'm a bilingual service provider, an SLP in the Los Angeles area, and I'm the, uh, past president of the Hispanic Caucus. Hi, my name is Xin Hui Xin Cho, and my pronouns is she and her. I'm a professor at Minnesota State University, Mankato, and I co lead the Asian Pacific Islander Speech Language Hearing Caucus with Archie, and this is my fifth year leading the caucus, and we're very excited. Archie Soelaeman:  Hello, my name is Archie Sulaiman, and I am the co president of the Asian Pacific Islander Speech Language Hearing Caucus with Xin, and if you hear cooing, that's the Hi,  Brittani Hightower:  everyone. I'm Brittany Hightower. I'm the chair of the National Black Association of Speech, Language, and Hearing, also known as NBASLA, and I'm an [00:04:00] SLP in Texas. Ranjini Mohan:  Hi, everyone. I'm Ranjani Mohan. My pronouns are she, her. I am an associate professor at Texas State University. And, um, the president of the South Asian Caucus of ASHA. Shine Burnette:  Good evening. My name is Aletha Shine Burnett. I'm half White Mountain Apache, half Navajo. I'm the president of the Native American Caucus. I'm a speech language pathologist in Arizona, and I work in the schools. Kate Grandbois:  And that is everyone. I've never felt more part of a group here. Usually it's just me, Amy, and one other individual, or maybe two, but this is very exciting and lots of fun. Um, and before we get into the content of the episode, I do need to read our learning objectives and our disclosures, which are lengthy because we have a panel of people here and I'm going to try and get through them as quickly as possible. Learning objective number one, define allyship and list [00:05:00] two reasons why allyship is not a selfless endeavor. Learning objective number two, describe the importance of allyship in speech language pathology. Learning objective number three, list at least two action steps that clinicians can take to show professional allyship. Disclosures. Sheen's financial disclosures. Sheen is a full time employee at Minnesota State University, Mankato. Sheen is receiving an honorarium for participating in this course. Sheen's non financial disclosures. Sheen has a professional affiliation with the Academy of Neurologic Communication Disorders and Sciences. Sheen Asian Pacific Islander Speech Language Hearing Caucus, the American Speech and Hearing Association, Mankato North Mankato Act on Alzheimer's Action Team, Minnesota Connect, Aphasia Now, Minnesota Speech Language Hearing Association, Sophia's Financial Disclosures, Sophia is receiving an honorarium for participating in this course. Of course, Sophia's non financial disclosures. Sophia has no non financial relationships to disclose. Shine's financial disclosures. Shine is self employed and [00:06:00] receiving an honorarium for participating in this course, Shine's non financial disclosures. Shine is the president of the Native American caucus. Gregory's financial disclosures. Gregory is receiving an honorarium for participating in this course and has a full time associate professor at the University of Arkansas for medical sciences, and is also a contract employee for prismatic speech services. Gregory's non financial disclosures. Gregory is the president of Legasp, the LGBTQ plus caucus of ASHA. Archie's financial disclosures. Archie is receiving an honorarium for participating in this course. Archie's non financial disclosures. Archie is the co president of the Asian Pacific Islander Speech Language Hearing Caucus, a member of ASHA SIG 12 and SIG 14. Brittany's financial disclosures. Brittany is an employee of a public school system. Brittany is also receiving an honorarium for participating in this course. Brittany's non financial disclosures. Brittany is the chair of the board of directors of the National Black Association for Speech, Language, and Hearing, also referred to as NBASLA. school system. Brittany is also receiving an honorarium for [00:07:00] participating in this course. Brittany's non financial disclosures. Brittany is the chair of the board of directors of the National Black Association for Speech, Language, and Hearing, also referred to as NBASLA. Kate, that's me. Most people who are listening likely know that I am Kate, that's me. Most people who are listening likely know that I am the regular co host here. My pronouns are she, her. I didn't even introduce myself. My financial disclosures. I am the owner and founder of Grand Blanc Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosure is I'm a member of ASHIC 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. That was, I'm very impressed with, with, with myself for getting, if everybody's still here and with us, we've done it. Everybody's clapping. Hooray. Now, let's get into the fun stuff. I would really like to start this conversation by talking a little generally about allyship. [00:08:00] Um, I wonder if any of you can sort of kick this conversation off by telling us what an ally is. How would you define an ally?  H Sheen Chiou:  I can start, or Brittany, would you like to start? Sure. You can go ahead. I'll jump right in. Sure. Um, so an ally is a person who is not a member of an underrepresented individual or group, but wants to support and take action to help others. So that targeted individual or group is typically underrepresented, marginalized, or discriminated. Um, in general, an ally will build. A supportive relationship with the individual and group and works in solidarity in partnership with them so their voices can be heard.  Brittani Hightower:  I 100 percent agree with that definition of an ally. I think, um, just to add to it. Being an ally is, [00:09:00] is more of a, and I know we're going to touch on it probably as we keep going through the conversation, but it is, um, something that you do almost, I feel like it's more from the heart. It's not a, it's not something that you're doing to show just because, Hey, I can help out with this group and help out with that group, but you genuinely want to support those who are underrepresented and want to, uh, help with promoting their agendas or their, their missions and visions to make sure that their groups are, uh, represented in the larger majority. Kate Grandbois:  This definition is bringing to mind two other terms I have heard used adjacent to the concept of allyship, which are performative allyship and also virtue signaling. Can any of you walk us through what those concepts are and how they are related to allyship? Okay.  Gregory C. Robinson:  [00:10:00] I mean, I can talk a little bit about, um, about performative allyship, um, as this is something that's very common that we see, um, that we talk about in the, um, LGBTQ community, um, because it's, uh, you know, it's sort of like, Um, there are a lot of like, uh, I don't know, big companies or something like that that during Pride Month, you know, they're, they're out there and they've got their rainbows up and they've got their, uh, they've got their, um, their packaging and it's very clear in those situations that they're not in it. really for the community, but they're in it for them, for, for themselves. Like they're, they're in it because they think that that's going to sell more, um, more things. They're, they're, they're going to sell more if they, if they seem to show that they are Like an ally to the community during this pride month kind of a thing. And you know, that it's performative [00:11:00] because once that, uh, currency runs out and the climate changes, as we are seeing in here in Arkansas, where I am, um, you know, suddenly everybody starts to backtrack and they're just like, Oh, wait a minute. Like, um, now we don't actually. need to, um, support the LGBTQ community or now we need to be like suddenly quiet about it or we don't need to be loud and it's like, Oh, okay. So when it was benefiting you, um, then you were like all loud and proud, but then when suddenly the risk got high and, um, you started to feel like there was something at stake or you might. You might get in trouble for being an ally. Suddenly you backed off and that's, that's what we call performative allyship. Now, um, I think we have to be a little careful about that because I think a lot of people get called out for, for being performative. Um, but there is a [00:12:00] place for it. Like, okay, so, you know, if, if we, if we have some anti trans legislation that's going down across the country and we have like people that are being attacked, um. I'm like, please do not, if you are actually an ally, please don't care about being performative or seeming performative. I was like, you know, honey, the stage is out, the lights are up, the curtains are open, perform now. Okay. Now is the time we need you to perform. It's not like you don't need to be like, oh, I don't want to seem performative. Like. I think you missed the point and we need you out there on stage now because there are people that are being harmed and there are, uh, we need the voice. We need the voices of support during the times when it's critical. So I think that, um, I think that we have to be careful, like people don't need to be concerned or scared about like seeming performative. I don't know.  Brittani Hightower:  I think, I almost think if you are [00:13:00] in that mindset, Then you're, you're probably not being a performative ally. You're probably a true ally and just go ahead and. Be, be that, be an ally.  Sofia Carias:  That's right. People. Um, I think we're going to talk about that too, as we talk about this, uh, topic throughout this hour about, um, that kind of allyship, maybe they just don't know what to do to be a good ally. And so it comes off like you're giving a performance to somebody. Um, but they don't mean to, I think that's what Brittany and Gregory were touching. Um, they don't know what to do to be an ally. They're like, how can I help that kind of thing? And I think that's, that's important to talk about too. It's like what could they do and feel like they're genuinely being an ally and not putting on a performance  Ranjini Mohan:  and I think sometimes, um, with social media, there is a pressure to seem like you need to contribute to creating awareness, but I think that's where it stops there. performance or their virtual, virtual signaling is it stops with [00:14:00] sharing a hashtag or, um, you know, the, there was the, um, during the Black Lives Matter movement, um, there was the, um, what was that? The Blackout Tuesday Square? Um. Mm hmm. So people would share that, but then not actually take any action. They wouldn't, um, you know, uh, donate or sponsor. They wouldn't actually do anything more than that. And they'd think, well, I contributed to creating awareness. Well, we were all aware. I don't think that one action necessarily did anything. much to benefit the community. Um, and even if it did, it's a very small act. And then to think that you're an ally because you, um, shared something online is, it just means that, well, yes, that's like maybe valuable in some way, but that's not enough. And it's, it's, we can't assume that. Um, I mean, there is this idea that It's about, um, you know, a previous act of solidarity [00:15:00] does not guarantee a future act of solidarity. And so, um, I think sometimes it's just as Sophia said, it might also be, they don't know what else to do and they feel the pressure. Um, they want to be seen as someone who's supportive. And so there's that one little thing, but that's where it stops.  Gregory C. Robinson:  Yeah. And I think it comes with an awareness of the fact that being an ally is dangerous. Like, it should be dangerous, like there is a risk to being an ally, um, because there is a risk to being a part of the marginalized community as well. And so, um, by being an ally, you, you are, you are, you are taking a risk. And so to only Only do that work when it's not risky is, is, um, it's a little bit, I don't know, fake, I guess.  Brittani Hightower:  And then also I think allyship is, it's not a one time thing. And I think Rangini was touching on that, but it's, [00:16:00] it's truly like a, it's almost like in your daily life. Um, you may not do something every single day, but at some point in the course of your life, you, you be shown that you are an ally to a particular group. More than just that one share on Instagram, or, you know, and more than just in social media also like in your physical workplace in just the community at large, it trend, it transpires through all aspects of life. H Sheen Chiou:  And I, one thing I really love about, like, getting together with our multicultural constituency groups is, like, each group has their work  Announcer:  group,  H Sheen Chiou:  like, um, focusing on how, like, how to work together and make our voices heard. So, like, my example is, like, my, for the APA caucus, we have an anti [00:17:00] racism learning community, and It's kind of like we have different issues, different concerns that we like members bring up and then we host a plat. We have a platform for people to talk about it and to talk about it. Generate actions and on how to work on things that we would like to work on, like, uh, for asset modification and for a, uh, code of ethics. And, uh, recently we have, uh, to, like Archie and I, and a lot of our members work down like how to remove, uh, um, an articulation. book treatment material from the market just because they, uh, for some members, it's a racist, uh, image. So, like, I really appreciate having to be part of this group because, and with MCCGs, because [00:18:00] there's so much that we can do and there are so many allies that they are not, like, They are not Asians, they are not Pacific Islanders, they are not native Hawaiians, but they are here for us, um, and just, I, I just feel very blessed to be in my caucus and in this group. Kate Grandbois:  This conversation about allyship and and performative allyship is making me think of something that someone said to me once a long time ago, and I'm interested to hear your perspective on the statement. It was that allyship requires an exchange. So the person who is. actively trying to be an ally is giving some form of their privilege, time, money, activism. There is an active exchange happening. It's not a passive, Activity like an Instagram square. Would you say, does that resonate with any of you as, as a decent [00:19:00] description? Gregory C. Robinson:  I think it's, I think that's interesting. I've never, I've never thought about that. And I, I like that. It's a, um, it's a rule of thumb that I think is. Good.  Kate Grandbois:  And I know we're going to be talking a lot about action steps that clinicians can take later on in this hour as we move through this. So, um, I think we can maybe ping back to that later on as people who are listening are reflecting on things that they can do and how that exchange might play out. I had also been told at one point that a person in a position of privilege doesn't really, can't really call themselves an ally. And the term ally is something that is given to you by another individual. Is that true? What are your thoughts on that as a concept? Ranjini Mohan:  So I do, um, align with that idea, um, a little bit. And I think it comes [00:20:00] from a lot of the marginalized people being slighted. Um, uh, throughout history by trusting allies, people who claim to be allies, and then finding out that it was not genuine or that we can't count on them. Um, and because, uh, in the beginning, when, um, Brittany and Sheen were talking about the definition of allyship, they talked about action, right? So, allyship is, In the moment of the action, but unfortunately, a lot of people claim it to be their part of their personality like it's an identity. And the downfall with that is that when they are silent in a specific situation, or they act in misalignment with their proclaimed allyship. and they're called out on it, it hurts their ego because they say, well, I'm an ally. Someone questioned [00:21:00] their identity. And, um, that can have a negative effect on, um, on, on the group that the community that they intend to be. Um, I can give an example. So I have a, a colleague, a friend who, uh, is, uh, is her back. She's Indian and she worked at pediatric clinic and she loved her boss because her boss claimed he loved Indian food. organize, you know, cultural events, uh, like Diwali parties and always insisted that everybody, all their employees receive, um, diversity training. But it was that same boss who consistently made multiple recommendations to my colleague to, um, risk to seek accent modification services, which she consistently refused. And none of her colleagues or her clients had ever complained about it. And, um, when she called out her boss on it, he said, Well, but I, [00:22:00] you know, I'm just learning. I, I, I, you know, I need more information. You need to tell me when, when I'm doing something that's wrong. And then again, that comes to this idea of is it our response? Is it the, the marginalized person's responsibility to teach someone what, um, is acceptable and what is, uh, discriminatory or not. And, and that person clearly that boss's ego was hurt because he thought he was an ally. So it, when people use these like one off moments to claim or prove allyship, it becomes about them and not about the community that they are, uh, they aim to support. Because people don't realize that it's a lifelong process. And there's a lot of, you know, Um, time and, uh, energy and emotions in practicing lifelong allyship. Um, and so, um, I think, uh, by and also, I mean, the other idea is that by calling yourself an ally, it implies that your [00:23:00] journey is over, that you're already completed that process and you're an ally now. But as long as, uh, systematic oppression exists, the process can never be complete. And that goes for all of us, right? Where just because we are part of, um, someone is part of a marginalized community doesn't mean that there isn't room to learn and support other communities. And so it goes for all of us. We've all made mistakes, but it continues to be where you, it has to be about, Continuing to acknowledge those mistakes and learn and, um, and, and actually take action. So you're only an ally in that moment of action. Um, and not, and it's not necessarily, uh, something that is something that we can count on. Gregory C. Robinson:  Yeah, I would, I would agree with Ranjini a hundred percent. And, um, I think that. I think that, um, I think that people might benefit from being more descriptive with their language a little [00:24:00] bit, so rather than, you know, when people are referring, like, to the LGBTQ community, um, to, that they are an ally. So a lot of times what they're saying is that they are a safe space. So they're saying that you can feel safe with me. I am an accepting person. And that's very beneficial. Like I need to know where those safe spaces are and I need to know, um, uh, you know, that, that those exist, but, um, perhaps, you know, um, staying away from I'm an ally as if that is something that has been now achieved and now it's done and set and and everything like that. I think that that's different. I think that it's, it's interesting because like, um, We all have, we all have identities, right? We all have identities that we claim and we have ownership over those identities and what the name is we give ourselves. But there are some identities that are really more about relationships [00:25:00] than they are about your own personal identity. So like I have The sole authority to say that my gender is non binary, that is it. I am the only person who can say that. And, um, and that's it. I am the sole expert on that. However, to say that I'm an ally is actually a different kind of term because that's about my relationship With another group or another person and it's more akin to a word like friend so, um, you know, so I Can can you ever say that you're somebody else's best friend like that's a weird sort of thing Like why would you can I say that I am? Oh, I am her best friend. Well, no, I can say she's my best friend But, like, for me to be so presumptive to say that I am her best friend, it requires a little bit of a, wait, you don't have the authority to [00:26:00] say that. That's, that's their authority to say that. Um, and I don't know, maybe their relationship is such that, that she's okay with me saying that, you know, that, uh, I'm her best friend or, or something like that. But, um, nevertheless, it's a, it's a little bit of a different kind of, you know. Identity term ally is not like all of the other terms of identity that we have. It's different. Kate Grandbois:  I love that, um, description of making it akin to saying, Oh, well, I'm her best friend. I think that's a real that clicked. I think that was a really, um, clear parallel. And I really appreciate that. Um, in the conversation that we had, uh, I think the last time I spoke with all of you was about six months ago for anyone listening, and this is being recorded. So this is odd nebulous of time. You don't know when that was. We do have a previous recorded course with all of these lovely humans, um, specifically talking about the resources [00:27:00] that are available through the multicultural caucuses at ASHA. And I. You know, you all, your groups, the organizations that you're leading and that you're a part of, have so much to offer our field. You all have talked about continuing education opportunities, community outreach, and it's, we all know by now, That the field of speech pathology is incredibly homogenous. I don't have the exact statistic in front of me, but I can safely say it's around 92%, 92 point something percent of white women. And that leads me to make the assumption that a lot of people who are listening fit that demographic. And I'm wondering, For those of us who identify as white, cisgender, heterosexual might be listening to this conversation and thinking about the multicultural constituency groups and thinking this does not apply to me. I don't [00:28:00] belong in one of these groups because those are not my identity. Um, and. In our previous conversations, you all had talked about not only the resources that the groups offer, but that your doors are open. You are wanting people to be involved, and for anyone who is listening, who is in, who is not part of a marginalized group, why should a white cisgender woman join one of these groups? What are the Um, emotional barriers that they may need to overcome to feel comfortable approaching one of these groups and, and taking, taking action to join them. Sofia Carias:  Chances are that in our profession. You will be working with somebody in a marginalized group. Um, the chances are very high considering the um, educational disadvantages and the um, disparities in healthcare.  Shine Burnette:  Like,  Sofia Carias:  um, you will [00:29:00] most likely be working with somebody from a marginalized group. And I think you have to have um, information to do that. And that's why I think we exist. Part of the reason we exist is to give that information. You don't have to be, you know, Hispanic to be in the Hispanic Caucus, um, you just have to work with that population or be interested in working with that population. Um, yeah, I  Gregory C. Robinson:  mean, none of us exist in a silo, like everybody, everybody is connected, like we're all connected and I would ask anybody out there. Are you interested in making the world a better place? Like, are you interested in making it a more inclusive place for everybody? And like, that means you too, because by making the world a better place for, um, marginalized people, you're making it a better place for everybody. And I, I love this quote that, um, that I came across, uh, from Lilla Watson. Um, and it says, If you have come here to help me, you are wasting your [00:30:00] time. But if you have come because your liberation is bound up with mine, then let us work together. And I just love that because, um, You are, you enter into these relationships with groups because you realize that you are a part of helping to make the world a better place. And also it's an acknowledgement of the fact that the very oppression that people of color are facing is the result. Of white history. And so is it only up to the people of color to address the discrimination that is actually caused by, and it originates from, um, the, the people in power. And so it's, you know, it's, I think that it's an acknowledgement that, that we are all a part. Of this together and we are all here [00:31:00] little fishes swimming in a swimming in a in a fishbowl and we are, um, and, uh, we all need to work together to make sure that it's a pleasant place to be for everybody.  Brittani Hightower:  Right. I think also. Um, like, I think we mentioned before, like, yes, we have all these resources that would be beneficial to people who are not of our, uh, identify as a person of our groups. But, um, I think that research that we offer the resources that we offer. They just help to make you a better and more well rounded clinician. So if you're able to join our groups and one, like we've said before, you don't have to look like us or identify as how we identify to be a part of our groups. Um, we're in Basel. We always say if you align with our mission, our vision, and you want to support [00:32:00] our, our efforts, come on in, like our doors wide open. We do have members who are not black. I know a lot of people don't think that, but we do have members who are not black, um, and we welcome them and they are right in the fold, uh, on serving on committees, um, putting the initiatives into place. So. I think that you should not feel, uh, there should be no emotional barrier, uh, if you have a genuine want to support any of our groups. Come on in. We're here. We're welcome. We want you to join us. We're happy to share our knowledge with you and then whatever questions you may have. It's a, we are those safe spaces. Shine Burnette:  I also think that. You know, when, um, when they come in that they could get a feel for some of maybe our cultural, our cultural [00:33:00] identities, the things that we kind of value. And, you know, not just as each, you know, Each of our ethnic groups, but also as a person, you know, today I was asking my kids. Hey, what are you guys doing for Christmas and they all had different, you know, um, Things that they do with their families, which was all different. Whereas, you know, for us, they could get a little bit of of history of background of the reasons why we do certain things, you know, going back to the ally thing, you know, very, um, Um, difficult for some groups to really trust others to really believe that if they say they are allied do you really mean it or not, you know, but also we've gotten a lot of questions like hey, I work in this population. Is there anything that you that you can help us with or that I should know which is great because you know then we can kind of give an insight but [00:34:00] also it's so diverse just even for us to cover every You know, tribe, but I think for people to at least come and say, Hey, can I just hang out with you or come to your meeting so I can get a little bit of understanding of why certain things are the way they are. Gregory C. Robinson:  I think that's really important. I think that it's something to circle back to something that Kate, you said in the question was that you said, you know, how do you, um, how do you feel comfortable going to these groups? Maybe you don't feel comfortable. Maybe it's not about being comfortable. Maybe that's the big thing. Maybe you need to not be comfortable for a minute.  Ranjini Mohan:  And, you know, Asha talks about providing culturally responsible, um, services, and, uh, one of the first steps is to acknowledge your own privilege and then to learn about other, um, others [00:35:00] experiences. And one of the best ways to learn is to, um, hear from others about their lived experiences. And, um, what better place than a group that is, um, is, is working so hard to. Uh, support their community. And, um, so, and, you know, your question did ask about what can a white, cis gendered person do, but I would say that it doesn't matter what your um, race or ethnicity is, um, there is so much intersectionality even, um, across communities and I think learning from people who are learning more about it is very valuable. So for example, like when I was, you know, a few years ago, when I was learning about trans rights, um, I, it made me reflect on, you know, like body autonomy and, and my experiences as a cisgendered female. And, you know, when I was learning about Black Lives Matter, it showed [00:36:00] me like concrete examples of potentially how I could, um, Um, advocate as a South Asian. So not to say that I'm making it about myself and my identity, but it made me more invested in there, in these movements because I was able to relate to it. So it, it taught me about where I had privilege and where I didn't. And for the longest time, when I moved to the United States and I was South Asian, I thought, well, I'm part of the marginalized group. But I didn't recognize my own privileges also as someone who is highly educated, someone who is, um, female, cisgender. And so I think, um, it, it shouldn't matter what your, um, your race, ethnicity or specific identities are. It's important for us to learn about people who are different from us. People who don't share those same identities because we might find that it's actually mutually beneficial. We might learn things we about ourselves that we hadn't before. So I think it goes along with what Gregory was saying earlier about building a world that you build a better world. [00:37:00] But also, there are very specific things that you can take away from it that's beneficial for us also, as well as the community that. Archie Soelaeman:  And I just want to add to that a part of it is essentially just being vulnerable. Um, so join and be vulnerable. Um, learn from us. Um, and, you know, just like what everyone else has been saying.  Shine Burnette:  And, and who knows, we could learn from you as well, you know, so like how, you know, to approach. Different topics or different things, you know, sometimes we kind of think like, oh, this is how they need to know or learn, but then they may come back and say, hey, this, you know, for us. You know, could you kind of present it in a certain way just by different cultural things that we kind of present? You know, some people could be very straightforward and forceful with some things about the past history and of what has happened to our [00:38:00] people, but maybe that's not the way to approach some of these things Kate Grandbois:  for anyone who is listening and is. not only interested in joining, but would like to take some action in joining. I'm sure each of your groups has a different website and a different, you know, email signup process or whatever. So what we will do is link, um, we will put links in the show notes and on the website for each of the individual caucuses so that anyone listening has that information right at their fingertips and can, um, move through the process of joining. I do want to take a second to unpack a little further the concept of discomfort. Um, I have, I really appreciate that, you know, several of you have talked about your own experiences with learning about other cultures. You know, one of the, in the title of this course is, and we've talked about it a little bit, this concept of cultural humility. And. The, that what [00:39:00] goes along with that is something that you brought up, which is this concept of intersectionality. So there is no monolith. Everyone is their own individual person with different levels of, of privilege. Um, and I want to take a second just to talk a little bit about those uncomfortable feelings and what a person can do when they have those uncomfortable feelings. If it's fear of hurting someone's feelings or. You know, I don't want to say the wrong thing and offend anyone. So I'm not going to join because I just don't want to put my foot in my mouth. Um, or I feel so guilty about my privilege that I am just not going to join or I'm going to stay within my own group because I feel more comfortable. What are some of the, you, you've talked about this a little bit, um, but what are some of the action steps that a clinician could take if they want to show they have a [00:40:00] value to show some of this professional allyship or get involved in an MCCG, but there are still some emotional barriers or still some of those feelings of, um, guilt or shame or fear. Which are very powerful feelings that will definitely stop action from happening. And I think it's important to talk about it a little bit more. Gregory C. Robinson:  Um, I can start, I guess. Um, I think that it is important to, um, to remember that, uh, that this is not, this is not about you. It's not necessarily about you. Um, and so that's something that, um, I, it is, it is about you and it's not about you. So like, I always try to go, okay, wait, are these feelings I'm having from ego? Like, is it, is that, is that where these are originating? Um, because if that's the case, maybe I can do some internal work to try to like, okay, let's calm that. And let's focus a little bit more on the harm [00:41:00] that. Um, is happening over here. And let's see what we can do to mitigate that harm. Um, but, but also to, to recognize that, that it, it is a little bit about you as well. Um, and, and to acknowledge that your, your place in that mix. Um, And sometimes like people will, I, I, I encourage some people to, if you're having uncomfortable feelings, because like, Oh, you said the wrong thing. Or like you, you, you, you did something that might've hurt somebody's feelings. And then they told you about that. Like, um, I, um, I try and I'm not always successful, but I try to, to look at those moments as. Moments of celebration rather than moments of shame. And what I mean by that is like, I, it's a life work. We all have our biases. We all have our prejudices. We all have places where we [00:42:00] are potentially discriminatory. And it is a life's work to constantly, constantly be looking and self reflecting and trying to find those places that could be potentially harmful. So when you find one, it is not a time to be upset at yourself because you're not a good person. It is a time for you to be Very happy because you discovered another thing for you to work on. Like you made something that was secretive and possibly harmful, obvious, and something that you can definitely address. And like that flip In the switch is something that I think is really is sometimes very helpful. Um, and regarding being called out or called in, I saw a little acronym. Um, I shared this with the group and they thought, Oh yeah, you better share that because it was, um, I don't know where I found it and I tried to Google it and I couldn't find it anymore. So if anybody [00:43:00] out there knows where it is fine, you know, um, shoot us the, the, the citation or the credit, but, um, it was an acronym that was called claim. Claim responsibility. So C, the C stands for center yourself. So if I'm being called out or called in, I'm being told that I've done something that was potentially harmful. The first thing that you need to do is center yourself, like breathe, like, whoa, whoa, whoa, you're about to have some pretty intense emotions because that happens anytime anybody gets called out or called in. That's a natural thing. So center yourself. Let's breathe. Now, L stands for listen. Listen to what it is that is the problem. Listen to the person. Don't talk, listen. Then A is accept responsibility for what you did. And then I is inquire or investigate how [00:44:00] you can do better next time. And then M is move on. Don't over apologize. Don't make it about yourself. move on and commit to doing a little bit better next time. So C. L. A. I. M. And I just love that little acronym. And it's hard to remember in the moment, but, um, it's, it's great to, um, to kind of aspire to anyway. Kate Grandbois:  That was awesome. That's a great acronym. Another thing that I think can sometimes be helpful is practicing some self compassion and some self forgiveness, just like you said, because no one is perfect. And we all carry biases and, um, everyone makes mistakes. And just because you've made a mistake doesn't mean that you are a terrible person. Uh, it's an opportunity. It's an opportunity to, to learn and to do better next time. Uh, I want to. Maybe spend the rest of our, the rest of our episode talking a little bit about action [00:45:00] steps. So we've laid the groundwork for what true allyship is. Um, we've talked about how it's very action oriented that we've mentioned this component of exchange. Um, we've talked about the resources out there, all of these wonderful groups that you all lead and are a part of. within our field to show and hold up professional allyship or create opportunities for professional allyship. Aside from joining one of these groups or becoming active in one of these groups, what are some additional action steps that clinicians can take to, to become a professional ally or get on a journey to become a professional ally? Archie Soelaeman:  I would say one of the things is just kind of take different opportunities to learn, um, be in the moment and just, you know, if you're, if you mess up, that's fine. Use that as basically a learning opportunity. Um, and, [00:46:00] you know, there are all of these, uh, all of our groups where you can, um, come and join us. And then also. learn from the different constituencies and um, essentially like what Gregory said, just move forward, right? So learn, um, and use that as a learning opportunity. Ranjini Mohan:  I think another, um, thing that kind of goes with what you had, the real previous question is, you know, rather than coming with this, um, intention of, hey, I'm an ally, this is what I can do to help you. is ask a community. How can I help? So don't come with any idea. You can have ideas of different ways that you can use your privilege, but just asking, how can I help? How can I, what can I do to support your mission? What can I do to support your agenda is just as simple as that. And it could be something as simple as, [00:47:00] can you help me create a week? I mean, the response could be, Can you help me create this flyer? Here is the information I want you to put on that flyer. Or it could be as, as big as, uh, would you be able to join me in this protest? Um, or would you be able to sign off on this letter that we want to send to, uh, another organization to support our cause? So it just asking, and I think that, that sometimes the fear that people have is I don't know what to do. I you have good intentions. But I don't know what to do, and I don't want to overstep, um, my boundaries. So just ask, how can I help? And accept whatever help they, they request. And if you're able to do that, then do it.  Brittani Hightower:  I think that piece is important, uh, just so that you're, you're not unintentionally offending anybody, because I know, um, and even I might do it. Like, I might think, oh, this is a good idea. This might be helpful for this [00:48:00] particular group. But in reality, it's far from what they need help with at that time. That might be a great, like, a couple months down the line, but right now, the help is something that's smaller that, that is more actionable for them in that moment. So that ask, and I know we've mentioned having those feelings of uncomfortable, but, or uncomfortability, but I think if you can, Center yourself, find that, that inward, um, I don't know, motivation just to say, okay, let me put myself aside. I know that I want to help this particular group. Let me seek the person that may be able to help and also. Anybody in our marginalized groups, we're not the expert on our marginalized groups. So we know what we need, but there's, we're not the only ones who can, [00:49:00] um, I don't know if I'm wording this correctly, but y'all know what I'm trying to, trying to say, but just like, because I'm a black woman does not mean that I know what all black women need, um, or want or desire and need help with. So that's, I think that's something just to be aware of. We are not the experts on our particular group.  H Sheen Chiou:  Yeah, exactly. Brittany, there's no way that we know everything. And it's no way that we, I think it's important to acknowledge that it's okay that we don't know everything we don't know how people live their life, and how to what their lived experiences are. I think, uh, Ranjini touched on that earlier too, like, it's okay not to know everything and what do you do about it, uh, by joining us, uh, the Multicultural Constituency Group by, uh, uh, supporting our mission, our vision, [00:50:00] supporting our, Uh, what our tasks, uh, whatever we are doing at this at the time. Um, and, um, and usually an ally probably will be someone with power, right? Uh, just that they are supporting a marginalized group. Because, so an ally probably has more power than an ally. a marginalized individual, what can they do to support, um, a marginalized individual or group? I think that's very important to consider, um, and lots of, like, those unconscious biases that are hard to identify, to be identified until there's a specific scenario happened. And then you're like, Oh my God, that's my unconscious bias. And so it's okay to feel uncomfortable and to be able to kind of acknowledge, Oh, I didn't know this. And Oh, what did I say? That is very harmful to have that, um, [00:51:00] to feel comfortable being in a comfortable position. I think it's What's the term like to be comfortable with the, um, I think Brittany was trying to, uh, talk about that. Um, yeah, what's that phrase? Being comfortable being uncomfortable?  Sofia Carias:  Somebody Google it. Google it because I don't know. Um, I wanted to touch, uh, upon that, uh, I think I would suggest to people as a, an action step is to do some self reflection about the concept of like other, the otherness of other people. Um, if that makes sense. Um, I think that we think a lot about other, like, like we're, we call ourselves marginalized groups and we're other. And I think people doing some self reflection about how much we have in common, not so much our differences, but thinking about what we all have in common. Um, so it doesn't seem like so other, like when you talk to people that you've never known or you don't know anything about, like, they don't seem like aliens anymore, you know, like, we won't seem like other those [00:52:00] other people over there. Those over there. I think self reflection is an important part of that. I think that again, thinking about our commonalities and not so much of our differences. Gregory C. Robinson:  I'd like to add that, um, and so I'm about to make some pretty bold statements. So, um, so, um, so the, the, the disability community has, um, has a phrase, uh, nothing about us without us. Okay. And so that's, I think a super important thing to remember when we're dealing with, um, all of our marginalized communities and, um, we as a profession of speech language pathology have a long history of doing a lot of. Things that we think would benefit other groups, but then not actually including anybody from those other groups on the planning board or the, um, the thing, um, that is out there, um, to find out if that's actually what they actually need or actually want or, or anything like that, or if we're even doing the right thing. [00:53:00] Um, and so to, to include if, and this means, this is where I'm getting bold, like, We have a whole bunch of research, like, a lot of research that's going on in our profession. And the researchers are often not a part of the groups that are being researched. And I mean even the people with disabilities. So, like, actually, like, getting the input of the people with disabilities, or the, the communities, or the, the populations, and finding out what is it that you want to know. me as a researcher to, to, to research. Like what do your, what does your community need? Is there any way that I can use my power to empower you instead of always trying to get acclaim and acknowledgement for myself? So like, you know, if, um, And so I think that that's, I think that's just really, really super important is to remember that. And, and that also involves [00:54:00] like therapy, um, therapy endeavors that we are doing. I mean, if you're starting a new, um, I don't know, stroke support group in the nursing home, which is something I did when I first started my practice, I had a whole little stroke support group. Like bringing in the actual people in the group and co creating that together. Um, but, but the big thing about this and the big caveat with this is a little bit, um, about like what Brittany was talking about is that, um, you don't lean on One member of that group as the expert and you don't If you are relying on the expertise of somebody else in the community Then that person should be getting something for that like that should be Compensated it should be an authorship an authorship like a co author on the paper that you're writing Yeah, they may not be [00:55:00] a researcher and they may just be a trans woman and you are researching trans women and then you bring on this person to help you write your dang paper and give them authorship because then they can put that on their resume and possibly get something from that. Like that is important. Um, so it's just important to bring in the people from the community and make sure that we are actually doing. The work that we do, because like, it's really terrible allyship to just be assuming that you know best. What some other group needs and unfortunately that's what the history of our profession and the history of our country has been doing for a very long time. Um, to the great detriment of, um, lots of, um, indigenous people, lots of, um, black, uh, other people of color. Like it is, it is, that is what the, um, This whole, uh, issue, and believe me, I have a lot of [00:56:00] lawmakers down the street here who think they know exactly what trans children need, and they've never met a trans child in their life. And so, um, it's, it's very damaging, um, and I think that that's one of the biggest things that we as a profession really need to, to watch. And I think the disability rights movement with a nothing about us without us, if you can just plug that in repeat in your brain as you are going about your allyship work, like that will do a lot, I think. Shine Burnette:  And  Archie Soelaeman:  I also just want to add, um, as we mentioned very early in this conversation, um, the field of speech language pathology and audiology is very, um, white. So when you. When you're in all of these spaces and listening to different conversations, [00:57:00] if you hear something that doesn't sound quite right, get uncomfortable and speak up. That's how you can also help us is speaking out in those spaces where we are not there, because there's only 8 percent of us. Versus the 92% of everyone else. So if you hear something and you think that doesn't sound quite right, um, be the one that calls it out and get uncomfortable, I would to even add onto  Brittani Hightower:  that part, in those spaces where you don't see us, if there's a way to include us, reach out and get us in there because like, like we said before, ne, none of us are experts on our own. In our own group. However, that voice still needs to be heard. So if you're in those spaces where we're not represented yet you're talking about a [00:58:00] topic that directly affects that particular group. Ask why is that person or why somebody who represents that group is not there. And if there's a way to get someone in there, get them in there, let their voices be heard, get it straight from the source, if you will. Ranjini Mohan:  And going back to what Gregory was saying, which is really important, you know, having representation in leadership or in policymaking, but that there's the other side of it, which is sometimes there is this. Um, there is a token minority person that you always go to and you want, and that person then gets overburdened because they're in all these committees. And it's also important to know that that one person is, does not necessarily represent their entire group and has perspectives that may, um, not necessarily be the collective voice. And so those are also opportunities where I think they can reach out to the multicultural constituency groups, because we do.[00:59:00]  Aim to represent collective voices. Um, and we have experience hearing multiple perspectives within our communities. And so, um, we can offer, um, advice. We can be consultants. We can, um, uh, uh, refer you to other people who have better expertise potentially, if you just want to listen, if you just need some additional help. H Sheen Chiou:  Yeah, I agree. I think like everybody has something to offer. Um, like in our field, like we have most of. Our, uh, certified speech language pathologists are all monolingual, uh, English speaking, female, and do we know that there are 350 languages spoken in the U. S., and if we can only serve one, we have problems. So to be able to connect with multicultural constituency groups, you get resources, you [01:00:00] get support, you, even if we cannot figure it out, we can help connect you with someone who can help you. Um, again, like we don't know everything we are, like, if we are Um, if you let us show you the rope, we can support you, we can support our ally and our ally can support us. I think it goes both ways.  Ranjini Mohan:  Yeah. And, and, you know, some of, um, uh, the, these multicultural constituency groups, they, um, include languages or ethnicities and nationalities outside of the United States. And so we have relationships with, um, the speech language, um, and hearing associations from these other community, from these other countries, um, or states. And so, um, if, if like we were talking about, like what, what do we, um, what are some of the services we offer? What are some of the resources we have? Um, if you have a client [01:01:00] that, uh, speaks a specific language and you don't know what standardized tests are available in that language. Um, you can reach out to us and we can, uh, help you find those resources or connect you to people who can share those resources with you. Sofia Carias:  I think like the title of this presentation and the one we did before, it's stronger together. Like, it sounds like a kitsch phrase, but it's absolutely true. We are all stronger together. And that's why we've made it a point at these groups lately, the last couple of years to work together on things. We've made it a point to, you know, present and to disseminate information and to be seen You know, not just again, each other's like group over here and I'm over there and you're over there, like we've made it a point to be working together with each other so that we can do it because we have so many things in common. We have more in common than we do not. And I think if we can generalize that, like, can you tell I work at a school I need to generalize those skills. We need to generalize that to the greater population of our profession. [01:02:00] We need to do that. 'cause Yeah, Gregory C. Robinson:  I'm really having a hard time not singing the high school musical song. We're all in this together. .  Sofia Carias:  You can play us out. Kate, can you play us out with that song? I was gonna say, I put it over Wish  Announcer:  I wish someone had warned me. I'd cue it up and we would just play it. The exit music copy you should do in editing. Sofia Carias:  You should do it. Can you do it in  Announcer:  post? Can you put that in? Post  Kate Grandbois:  I, I'll, I'll do my best. I'll do my best. Um, this has been such a wonderful conversation and I'm incredibly grateful to all of you for spending your time and your energy walking us through these concepts, unpacking all of this for anyone listening. We encourage you to use the links in the show notes to learn more about the MCCGs, the multicultural constituency groups at ASHA. If you are sitting and listening to this or watching on YouTube and you're biking or walking or folding your laundry and you're having some [01:03:00] feelings that I have feelings too. We all do. That's okay. Um, and we will link all of the additional resources in the show notes for further learning. Thank you all of you for being here with us. I really, really appreciate it.  Brittani Hightower:  Thanks for having us. so  Ranjini Mohan:  much. This was a great opportunity.  Sofia Carias:  Thank you for the platform.  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 [01:04:00] joining us and we hope to welcome you back here again soon.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]  Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Sponsor 1 Announcer:  This episode is brought to you in part by listeners like you and by our corporate sponsor Practice Perfect EMR. Billing, scheduling, documentation, patient communication, business metrics, and more. Practice Perfect EMR [00:02:00] specializes in speech therapy practices like yours, connecting everything. Check them out at www. practiceperfectemr. com.  Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. I am Kate Granbois, and usually I am joined by my co host, Amy Wonka. Uh, she is not here today, but I am not alone. I have the pleasure of welcoming a repeat guest, Martin Holland. Welcome, Martin. Hi, Kate, how are you? I am fine. I am very excited to have the second conversation with you today. You've been on our show once before talking about private practice, um, and today's episode is going to be a slight extension of that. Um, I have a cute little story I want to tell about how we met, but I will save that for a few minutes from now. Why don't you start by telling us a little bit about yourself? Where did you acquire the knowledge that you have and where are you coming from [00:03:00] today?  Martin Holland:  Well, I'm coming from Norman, Oklahoma. . I've been in private business for 49 years, uh, soon to be 50. I've started eight businesses from scratch or reorganized, reorganized one. Uh, two of them failed, sold four of them and still active involved, actively involved in one or two, one of which is my wife's pediatric SLP OT. Physical therapy and feeding therapy business, which she started in 2014, after teaching speech language pathology at the university level. So, uh, my experience comes from having lived it after I sold my last business in 2011, I decided I didn't want to do that again, because as your listeners might understand, business can be a strenuous exercise, thought I might be able to help other people. With my, uh, history and found out it took a couple of years [00:04:00] to find out how to be a business coach. But eventually, I kind of figured it out. And that's what I've been doing since 2011  Kate Grandbois:  and onto my cute little story. I guess it's I'm not sure. Cute is the right word, but you and I got connected. Sort of by happenstance. So you wrote a book. I know we're going to be referencing this book quite a bit today. Your book is called the profit problem. They say I make money. So why don't I have any? And as our listeners know, I'm a business owner. I've been in private practice for about 12 years. And there have been some fundamental components of business that have always eluded me. And my brother in law, who knows very little about speech therapy, he's in a completely different field, said to me, hey, I just read this book and I really think that you would like it. So he gave me a copy of his book and lo and behold, this is the way I describe your book that I hope you take as a compliment, is it's business, it's a business book meets beach read. So I was able to finally understand some of these very complex components of [00:05:00] accounting of business strategy. Um, I, and it was just such a great book. I have recommended it to probably 10. I'm like your best saleswoman. I 10 or 15 recommendations I've made for this book and I connected with you on LinkedIn. And lo and behold, you messaged me back and said, Hey, are you a speech therapist? And so the story goes, we got to chatting and now you're here on our podcast. And, um, just to sort of preface this conversation with you have a very good book that's out there. Our link to it will be in the show notes. Uh, and before we get onto today's topic, which is the four fundamentals of business, I do need to read our learning objectives and disclosures. So I will get that over with quickly and then we'll jump right in. Learning objective number one. Describe the four fundamentals of every business. Learning objective number two, list two strategies for getting started in business. Financial disclosures, Martin's financial disclosures. Martin is the author of a book titled The Profit Problem. They say I make money, so why don't I have any? Martin also runs a business [00:06:00] coaching firm called Aneal Business Coaching. Martin's non financial disclosures. Martin has no non financial relationships to disclose. Kate, that's me. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and 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. Okay, we got that over with. Let's move on to the fun stuff. Can you start by telling us a little bit about the four fundamentals of business? Sure.  Martin Holland:  Uh, as I said, when I started coaching, it took me a while to learn how to, to be a coach. And what I came up with was a construct, a mental construct, um, that has borne up over time. I've worked with over 500 individual business owners since I began coaching, and I found this to be true. That there are four fundamentals of every business, [00:07:00] regardless of what it is. I've had contractors, I've had psychiatrists, publishers, retailers, SLPs. Manufacturing and these four fundamentals hold up the way I use them is that I'm always cycling through the four fundamentals of business and saying, where's the weak point? Where's the thing that if we started today, if we improve that, stop doing it, started doing it would make the most impact on our business. So it's a mental construct for me, but the four fundamentals of business are guiding the business, getting the business, doing the business. and administering the business. And I think I talked to you before we started recording that most people start business to do something they're good at and know how to deliver and are passionate about. But what most don't realize, and I say most based on my experience is that being in the business of [00:08:00] doing something is a completely different animal than doing it. Speaking to SLPs and perhaps other therapists, most of you will not. Go out of business or suffer terribly because you don't know how to apply your trade because you don't know how to be a good speech path. it will be something else. It will be something in one of those other three. So there's guiding the business, getting the business, doing the businesses, delivering whatever you sold, which being a speech path, delivering therapy or administration, it will be in one of those other three areas that it will get you. And if, if it's okay, maybe we dive into what are in there.  Kate Grandbois:  Yeah, I, I, absolutely. I just, I'm having a lot of personal reflection as we have this conversation as a business owner. who got into business to work. My particular patient population is [00:09:00] pediatrics. I wanted to work with, with a pediatric population. I wanted to provide therapy in the homes way back in the day when I first opened my practice. Um, I still don't know very much about marketing and it's my biggest, my biggest weak point. So I'm looking forward to sort of unpacking all these different areas outside of my clinical expertise.  Martin Holland:  Well, let's start with leadership, um, or guiding the business, which is leadership. And so what, what's that, you know, leadership word. If you Google it, you'll get 800 million hits. What's leadership. But leadership includes things like having a vision for your business. Matter of fact, that's number one. Number two in leadership is having a culture for your business. If you're a solo practitioner, culture, It's a little bit easy, but you're starting at it. People. It's how do you hold people accountable? How do you incentivize people? How do you organize yourself in your company? So it's all these matters of leadership that people have all heard about. But in my [00:10:00] experience, very few people have done anything. Um, but it begins with having a vision or am I going to be a solopreneur? Or do I intend to bring people in? Do I want to be at multiple locations? You, and why am I doing this? I'm very proud of, uh, the vision for my wife's company, which is two, two items. And one is to be the clinic of choice for moms. And the second one is to be the clinic of choice for the finest pediatric therapists. And that sounds like something you might want to put on your website, which I think she does, but it is who she is. It guides everything she does. And just as anecdotally, she hired an SLP that we needed last week. And she said, I don't want you to come here because you're running away from something. I want you to come here because it's your dream job. Take some time. And make sure that this is where you want to be. [00:11:00] And the young lady said, I already know this is where I want to be. I got goosebumps when you told me what your vision was. Okay. So what's the vision for that company, right? What's your culture again, you can culture a bad culture in a business. We'll blow up the business more quickly than running out of cash, and I just won't be a whole lesson on that. But we can talk about that at great length. So that's that's a little bit about what the leadership is. Where are we going? Which direction? What's my purpose? Why am I doing this? Um, that should be articulated not only for you, so you know what you're doing in the morning, but for anybody you bring on board, they need to buy in to your vision and your culture or there will be trouble. Okay. The next one that was guiding, getting the business is marketing and sales and marketing, of course, is generating leads. Sales is closing the deal. It's a little bit, um, [00:12:00] different in an SLP practice than it is for a contractor because you're not really selling people. But the most important question in marketing is to whom am I speaking? Okay. So what jumps out at me immediately. Is, um, in SLP, or at least in my environment here, I know they're different one, different types of environments is who is my target audience and a lot of times you can spend tens of thousands of dollars a month with like digital, uh, Marketing and being in magazines and maybe billboard. I don't know. I've seen any billboards, but what you're really after is the doctor, the referring doctor, at least in our case. So, 1 of the 1st questions is what do doctors want and more particularly, the doctor scheduling nurse. What do they want? They want to know you received the facts. They want to know the [00:13:00] status. There are some reports you can send back to them unsolicited that they can just look at and know that you haven't forgotten them. And that doesn't cost nearly as much as 5, 000 a month for AdWords, right? And besides that, if a mom fives you on AdWords, that's no guarantee that you're going. If you're insurance, that's no guarantee that you're going to get a referral. So when it comes to marketing and sales. Sales, uh, doing the evals quickly and things like that, but marketing, where you get enough clients, uh, referrals, your role in it. Isn't necessarily to be really good at social media. It has to be really good at understanding what your target market wants. That target market is the scheduling nurse, right? So guiding the business marketing and sales is getting the business, doing the business. I'll drop off a little bit, but I will say doing the business. Which is what you're already good at is [00:14:00] really having processes so that you repeat it. That's oftentimes guided by, by rules, uh, with insurance company is guided by software, uh, that if you have a practice management software, it kind of creates those for you. So that takes us to the fourth one, guiding, getting, doing, and administration administration. I tell people, Uh, who have started their own business. I describe administrative matters as all those things you had never even heard of when you started business. It's finance, it's bookkeeping, it's HR issues, it's IT issues. You know, your software management, it's legal issues, it's regulatory or I'll call it regulatory ASHA. You know, what do you have to do? Schedule, credentialing, insurance. It's just like, oh, my gosh, it's a never ending stream of things, uh, it's corporate governments. Do you have an [00:15:00] operating agreement in your, in your new LLC? And are you current? I don't know. Everywhere, but where we have a, it's not really a franchise tax, but you have to pay a fee every year. Nobody tells you to pay it, but if you don't pay it, you're out of standing. And if something happened, you're in trouble,  Kate Grandbois:  right? I recently learned that I was supposed to have a business, several very specific business permits in my town hall. I mean, here in Massachusetts, we do everything by individual town, not county. And I was registered with the county. I was registered with the state. And it came up that because I do work at home and I have a home office that I was, you know, nobody had ever told me, but I, and I came across this information accidentally and panicked. I had to write my 40 check. I had to go get this application notarized. It was like a whole 18 hours of, of panic around this one. This one piece of paper I hadn't filed with my town clerk. So there are so many loose ends like that in my personal experience that have come [00:16:00] up. And I, I really appreciate taking a minute to highlight all of these things because I feel so many of us and I'm only speaking for myself and my colleagues, I suppose, but we go into this business for the primary purpose of doing, doing the business, the category of doing the business, doing the clinical work. Working with families, doing the counseling. Um, and I think many of us, we go into private practice, we're solo preneurs, we get some of the basics ironed out, we have our malpractice insurance and some things that are obvious that we know about. And then as business grows, it becomes this snowball effect of, Oh, but there are all of these other things that I. That I forgot to do, or I think I need to hire someone. Is it an independent contractor or an employee? And how, how on earth do I do payroll? You know, it becomes this domino effect of questions. That's extremely overwhelming. One of the things I loved about your book, and one of the things I love about this, this explanation is that it is [00:17:00] compartmentalizing all of these loose ends into these very easily digestible buckets,  Martin Holland:  I'll call them. And that's, that's why I came up with it as much for me as my clients. But my, it resonates with my clients. They know what we're doing and you're always, I'm always cycling through all the, is we've got an issue. Is that a leadership issue? Is that a culture issue? Is that a sales issue? Is there a marketing issue? Is it, we ran out of cash. Is it, you know, you mentioned insurance, which you got all the ones you need. How do you remember? To renew them next, next year, right? Hopefully your agent calls you, but how do you, I mean, getting organized as a whole kind of a, it runs through all four areas, but how do you remember that? How do you remember to pay that little franchise fee and that town hall fee? And I'll just give you one story, uh, because if people need to be terrified. Kate Grandbois:  It's being a good terrified. It's healthy fear. [00:18:00]  Martin Holland:  It's a healthy, healthy fear. But I have a lady, she's not a speech path. She's in the home care business and she's the most wonderful, kind, Generous person you will ever meet. She is all give, but she decided on her own that she would do her workers compliment comp through her 10 99, have her 10 99, uh, workers, which really aren't IRS issue. She would have them get their own workers comp. Well, she called me one day and she'd received a letter from the Oklahoma, whatever Bureau of workers compensation. And it announced a fine of 1, 470, 000 because she was out of compliance. And this lady's sales were 500, 000 annually. We negotiated that down to 43, 000. Oh my God. My stomach just  Kate Grandbois:  dap, just  Martin Holland:  dipped out. Yeah. That's my point. That's my point. What you don't know about these [00:19:00] things can really get you. I am not trying to scare people off from going into business. I think we had a discussion before we got on that, talked to people I know, I said, had you known everything that you were going to have to do, would you have ever started your business? And the honest answer was no. Well, I certainly don't want that. I want people who are so inclined to do it. Business owners are the backbone of the country that everything originates with small business owners, in my opinion, but I want them to go in and not have the terror of receiving a letter that finds you for over a million dollars. And by the way, the last. Sentence of that letter was, please enclose your payment or please return your payment in the enclosing of low.  Kate Grandbois:  Oh, that's hilarious. And  Martin Holland:  absurd. Yeah, we got it worked  Kate Grandbois:  out. So any anybody who is listening or any speech pathologist who is [00:20:00] interested in opening a small business or is already operating in a small business. Listening to this episode. I think you mentioned this maybe before we hit the record button. You also say this in your book, no one is good at all four of these things out of the gate. So if you, you know, if you're listening and you have this pit in your stomach, I don't know these things. That's okay. I think that that's, you know, we go into these business to do the business, to work with the work with our clients and patients to, um, maybe have more flexibility, maybe to be self employed because we can operate our own schedules. There are a lot of wonderful things that come with being self employed. And one of the points that you make in the book that I really appreciate is when you identify an area that is a weak spot, there are things you can do to mitigate those, those, those weaknesses.  Martin Holland:  Absolutely. And almost universally, or at least the place to start is get help. And I'm not pitching business coaching here. I'm pitching, [00:21:00] if you're in business and you don't have a CPA, then you need to get one this afternoon. Right. And there are, I talk about different kinds of CPAs or CPAs who just do taxes and they're not of that much help. You do need to pay your taxes, but there are CPAs who will help you keep good books so that you know, if you made money last month, , I make a grand statement, but I'll stick by it. That 90 percent of the businesses in the United States do not know if they made money last month or last quarter, or even last year. Until they get their tax return. And if says some number that they don't understand because it has depreciation and cash basis and all these things, you must know, you must know. If you're making money and if you're not, you must know what to do about it. Specifically, is it in our area? My wife's [00:22:00] issue is not finding referrals. We have a huge backlog. It's finding the therapist, right? So there's always something, but you need to know what it is that's holding you back, fix that and then move on. And if you don't know how to fix it, get an advisor and the minimum, uh, you You should have a bookkeeper, which is not the same thing as a CPA, somebody who can help you with HR, like the lady with a million dollar fine. If she had had an HR person, she had known you can't do that, which she just decided to do. Uh, you need somebody who can deal with benefits, uh, somebody who can help you. With leadership and developing a culture and recognizing what those things are, but you are exactly right. Nobody is good at all of those things. And even if you're that 1 in a 1, 000, 000, who [00:23:00] is pretty good at him 1, it's not the best use of your time in 2, you can easily get somebody who's a lot better. If you can keep books, you can for 3, 400 a month. It's somebody who can do a much better job than you.  Kate Grandbois:  I think this is, you know, something that I want to expand on a little bit, I suppose selfishly from my own learning experience. Before I launch into my, my comment though, I want to say that our first episode that we did went deep into accounting and how to use your book. So if you are listening and you want to learn more about that. Please feel free to go earlier into the season. Um, in our episode with Martin, I believe it's called, you can't run your business from your cell phone. So go back in time and your podcast player and find it and to learn more about, um, accounting and using your books to make sure that you know, if you're making money. The second, the comment that I was going to make selfishly about my own learning experience is that delineated, that [00:24:00] deciding factor. So that moment where you're trying to decide whether or not to hire someone and go get help, right? Because help costs money. And as you're growing a very small business, at first, many of us are doing, we're wearing all the hats. So we'll wear the clinician or the business owner or the administrator or the marketer or the salesperson. We're the HR compliance officer. We're, you know, we're, we're making all of the decisions, particularly as solopreneurs. And at some point the hats need to start coming off because nobody can do all the things forever, a hundred percent of the time and trying to decide when to make yourself better at something or when to hire out or bring in a specialist and how to make that decision. Can you tell us a little bit about  Martin Holland:  that? Sure. Two, two things. One, you can hire somebody without having to hire them, right? In other words, you can get somebody to help you with marketing without making them an [00:25:00] employee, right? Or you can get a rental bookkeeper. I mean, I have a number that I've put together who work with a lot of my companies and they only cost them some fraction of what an employee would. Would cost, um, but you're kind of bringing me to the, uh, point we would like to talk about is how do you get started on this? Okay. And I described you before we got on, you just draw a line on a whiteboard and put 3, a horizontal line, put 3. Vertical lines in there, and you've written out 4 quarters for the year. Right 3 month quarters, and you can sit and say, you know what? After listening today, I haven't emphasized it enough, but if you're not there, you need to start with good books. Okay. So, uh, everybody should start with books. If you don't have good books, you need to have, well, for the first quarter of this year, the next three months, whatever, wherever we start, I am going to do something about [00:26:00] books. I'm going to call a CPA. I'm going to call a bookkeeper. I'm going to find something out and I haven't spent a penny yet. And what else could I do? I can buy books, meaning paper, audible books, such as mine. I can watch YouTube videos. I can go to webinars. And so what I do is commit a little bit of time each week for three months to learn about books so that your role in the world. As the owner is very seldom the one who does it, your role will be to recognize if you're being well served. Okay. Marketing is a key place for that applies. There are countless people. You probably get inundated I do every day. They're going to do your SEO, or they're going to do your social media, or they'll design a website. And there's no doubt they can do all those things. But do they generate leads? And I mean, I measure marketing. [00:27:00] You can measure marketing and bounce rate and hits rates and all this. I measure markets. Have they brought in for sure identifiably, have they brought in more money than they cost me? If not, I'm going, eh, well, it's brand awareness. I go, you know, the best brand awareness is a satisfied paying customer doing referrals, right? So you can take three months and say, I need to explore this idea of marketing. And I can recommend some books and read, read a book or two. And matter of fact, I just have to mention Donald Miller marketing made simple, so the best there is he is by that book and do what it says. Okay. And we'll put the link  Kate Grandbois:  in the show notes.  Martin Holland:  Yeah. Yeah. He's just, he's brilliant. Oh, I can learn some things about marketing and I can learn to recognize what Martin said. The most important thing is to whom am I speaking with my marketing? So why, you know, why [00:28:00] advertise to a mom's group, although they, they matter until you've advertised to that scheduler at the doctor's office. Again, presuming that you're, Need referrals for insurance, right? So you spend three months thinking about that stuff and take a step get an advisor Maybe you're maybe you are doing some of it yourself. Maybe you take doughnuts to the doctor's office those kinds of things But do that and concentrate on that for three months. Then the next thing might be whatever the next thing  Kate Grandbois:  is Again, not to keep using the analogy of a beach read, but I really love how compartmentalized this is, this approach is in terms of professional development, identifying something that you're, that you're not great at, giving yourself a goal. You know, giving yourself a finite period of time, breaking things up to feel slightly more manageable. So instead of, Oh my gosh, I'm so overwhelmed. And believe me, as an entrepreneur, as a business owner overwhelmed, sometimes just [00:29:00] becomes your baseline, just becomes like your status quo, because there are always so many things going on. But being able to compartmentalize things and break it down to more digestible, approachable goals is a really wonderful strategy and it makes things feel so much more  Martin Holland:  manageable. There's you can only, you know, there is no such thing as multitasking. I've read a lot of research on that. There's fast switching, but when you've got when you've got to, I mean, that's literally what they found. You cannot. Well, nevermind that's another subject you cannot do all these things. I just mentioned, you can write out all the topics I mentioned. You can download that. Advisor and mentor checklist mentors checklist from my website and have them there, but you pick one, you pick one and you get better at that one. And you still have to do your speech, your [00:30:00] therapy, and you still have to pay the bills. Yes, you do. You still have to do that. It's the chaos of transition. But pick one and get better. And then pick another one and get better. And if you use my quarterly thing, by the end of the year, you've done four major things. And you look back and you go, wow, I know, I am a different person. And I thought I than I was at the beginning of the year, there's a lot more. I can learn about marketing. There's a lot more. I can learn about books. There's a lot more. I can learn about time management, which I threw up under the leadership thing. There's a lot more. I can learn about how to maintain a healthy culture, but you are making progress. You're always looking for the short stave in the barrel that limits how full it can get. Once you've shorn one up, go look for the next one. Work on that one. But constantly making progress, one thing at a time. Kate Grandbois:  So one of the things that I have found to be really helpful in my own development as a [00:31:00] business owner, and I don't know if you have comments of, you know, something to say about this. When you're in that early development phase, learning something for the first time, trying to get better, better at marketing for the first time. That's just the example I'm going to use because I'm still terrible. I'm still terrible at it. I think there are a lot of very low cost things you can do to teach yourself. You've already mentioned YouTube videos, um, having some good books at your fingertips, something, some sort of self study. Um, there's some continuing education about these kinds of things in our fields. I personally have found looking outside of our field to be most helpful in terms of learning about business. But the other thing that I've found is you, Loosely mentioned coaching, coaching and consultation. So I, for example, earlier in my career, knew someone through a friend who was an accountant and I didn't necessarily have the capital to pay for a weekly bookkeeper, to [00:32:00] pay for a monthly bookkeeper, but this lovely accountant, I paid her for an hour of her time or two hours of her time. I can't remember, which was much lower cost, lower barrier of entry for me. And she sat down with me. with my books for an hour and taught me some there. It was a class of one on one. She taught me a couple of things about how to use QuickBooks. She taught me some basic fundamentals. I didn't quite understand all of it, but I got, I had some, some guardrails. I had some, for taxes, definitely don't XYZ. I would definitely do XYZ, some black and white rules I could follow just as guideposts until I got to a point in my business where I could hire a weekly bookkeeper or could hire a CPA. How do you feel like that's a reasonable  Martin Holland:  suggestion? 100%. The other thing that you have is a phone number and a relationship, right? So something happens, you go, whoa. You have somebody to call. That's a good point. They might charge a 75. They might charge you 100 now or something, but that's better than a million dollar [00:33:00] fine. HR is that way too. People make HR human resource decisions all the time. I'm going to hire him. I'm going to do this. I'm going to do that. And I'm going to do that. Well, you know what? There's just a whole lot of things you can't do right now. And it behooves you to know what they are. So maybe you get a stab at a, an HR manual, you know, something very bare bones, but you have a relationship. And if you've got an employee who is presenting issues, you have somebody to call rather than just say, well, I'm going to fire you. That doesn't always go that far, but you have somebody to call. So build those relationships. Another one is a banker. Maybe you don't need money or don't anticipate needing money or scared to borrow money, have a relationship with a banker who can tell you, yes, I can give you a line of credit if you need that because of cashflow issues. What's cashflow issues? [00:34:00] Well, we're going to call that bookkeeper back, right? Everybody knows what that is, but maybe they don't know how to track it and so on. But, uh, yeah, it's, it's. Establishing the relationship, picking somebody out. That's something you should do in every one of those quarters is who can help me with this. Can I take somebody to lunch? Can I buy an hour of time and say, can you tell me what things I need to work on? The unfortunate thing is the 1st person you pick all the time may not be the right  Kate Grandbois:  one. I am definitely around. Yep. I've had to shop around a lot. Um, I think another. Another thing I found, I don't know if you have. Anything to say about this, but working with someone who's local. So I know, for example, here in Massachusetts, we have a lot of regulation around a handful of things. We have very strict laws on what constitutes an employee versus an independent contractor. And it's very different in New Hampshire, which is, you know, you know, An hour and a half drive from [00:35:00] my house So I think there is also something to be said for reaching out to a local bookkeeper accountant attorney somebody who knows What regulatory body bodies you're beholden to? And I say that only because you know now in our digital age with electronic medical records and electronic payroll systems There are Many blanket companies that will give you a service for a low cost subscription and you get quote, you know, HR HR advice at the click of a button, but you're getting an HR specialist who could be in a completely different state who maybe isn't well versed in the nuances of the regulatory bodies in your in your local jurisdiction, for example. My, the, one of those companies would never had known, have known that I needed to go drop off that duly notarized, tiny piece of paper to my town clerk after being in business, you know, so I, I think there's something to be said for that too.  Martin Holland:  Yes, and I, uh, certainly do a lot. I mean, more [00:36:00] than half of my, Coaching sessions are around the country and on zoom and so on, but I like a personal relationship. I really do. You can call up and say, man, and you anyway, I, that's still me. I think a lot of people are still that way too. I'm not dealing with a computer screen and a website.  Kate Grandbois:  In our last couple of minutes, I wonder if you have any additional guiding principles or words of advice for anyone who's listening, who's maybe hearing about the importance of fundamentals of business for the first time. Martin Holland:  I'm going to quote it, quote a guy. Who's, who's book I read recently, uh, he's talking about contractors, but he said, these things that we've just touched on today, you must do, okay, you must do them. You don't have to do them in one day, but you have to make that quarterly progress. [00:37:00] You must do them if you are unwilling to do them. Don't be in business. Okay. That's a harsh message and I don't want to run anybody off. But by the way, if me saying that runs you off, you probably weren't going to make it through the there are 30 million businesses in the United States. So it can be done. It's tremendously worthwhile in my, but be aware of these things. So you don't get ambushed and then do them. Because otherwise, the way the guy described it, whose book I'm quoting, he said, everybody wanted to be out for football because you got the uniform. But if you weren't willing to do the work, you weren't playing. Right. And said, you're just better to not do it. So anyway, that, you know, everybody thinks it's freedom. And, you know, I get set my own hours. I set my own wages. And I take, I had somebody, uh, tell me, oh, you and Diane both own your own businesses. That's so great. You can take off 6 months a year if you want. And [00:38:00] we were at a football game in another state. And both of us had our computers out. Right. And I said, you know, No clue, but we love it. We love it. Um, most of the time, sometimes it's, it's terrible on the overall it's, we love it. So take the time to figure these things out. And educate yourself and do not expect to become an expert immediately, but educate. Do you've heard what you've heard about bookkeeping and break even? Maybe you'll start hearing those words. You'll hear people say, wow, and you'll, you just grow like a weed. So I don't know if that was helpful or not, but that's  Kate Grandbois:  my closing. It was very, very helpful. And I, every time I speak with you, I feel a wave of, of inspiration that, you know, we can continue to learn and grow. And for those of us who are business owners, this is professional development. It's outside of what we typically think of in speech therapy as professional development. We think so much about professional [00:39:00] development in a clinical sense. Learning a new therapy technique, reading about a new research article in some sort of assessment method. Um, but as business owners, this definitely is a different kind of professional development where we're constantly learning and growing and improving our skills. And I just really appreciate you. And I can't, I can't say enough about your book. I know I'm like a broken record at this point, but I appreciate it. Thank you. Anybody who is listening, all of the references and resources that we mentioned during today's episode will be in the show notes as well as on our website. Um, a link to Martin's book will be on our website. And as a matter of fact, you have a blog post, um, and free download about this exact topic available on your website as well. So if anybody would like to print it, save it. We will link, um, we'll send a link over to your website for that as well. Thank you again so much for being here. It's always a pleasure to [00:40:00] have you.  Sponsor 2 Announcer:  Thank you again to our corporate sponsor, Practice Perfect EMR. Billing, scheduling, documentation, patient communication, business metrics, and more. Practice Perfect EMR specializes in speech therapy practices like yours, connecting everything. Check them out at www. practiceperfectemr. com. Outro Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the 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 [00:41:00] so much for joining us and we hope to welcome you back here again soon. .

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]  Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are here today to talk about a topic that we have mentioned many times on the show, but we have two expert guests here to walk us through a lot of the detail. Welcome Danica Pfeiffer and Helen Long. [00:02:00] Thanks so much for having us. We're excited to be here. Thank you, Danica and Helen. Amy Wonkka:  You are both here to discuss ways to access research beyond the paywall. I'm super pumped about this topic, um, but before we get started, can you please tell us a little bit about yourselves? Sure. So my name is Danica Pfeiffer. I am an SLP and an assistant professor at Old Dominion University. And my research is in enhancing children's early language and literacy skills by building collaborative school based partnerships. Danika Pfeiffer:  But I'm also a volunteer with CS Disseminate with Helen and that's a group dedicated to promoting research accessibility in our field and so really excited to be here today to talk more about that. Yeah, and I'm Helen Long. I'm a postdoctoral researcher at the University of Wisconsin Madison. Um, my primary line of research studies early vocal development in kids at risk for [00:03:00] cerebral palsy. Helen Long:  Uh, and I'm also a collaborator with CS Disseminate, um, and I'm happy to be here. We're so happy to have you. The research practice gap is a massive problem, uh, that we've addressed in a few other episodes, but we've never had the opportunity to talk specifically about the paywall problem and how difficult it is for clinicians to access research. Kate Grandbois:  So we're really excited to get into this before we do get into this conversation. I do need to read our learning objectives and disclosures. So I will get through that as quickly as I can. Learning objective number one, describe five free and legal strategies for accessing research articles. Learning objective number two, identify common myths about accessing research articles. And learning objective number three, explain the different versions of research articles that authors may share. Disclosures, Danica's financial disclosures. Danica receives a salary from Old Dominion University. Danica also received an honorarium for participating in this [00:04:00] course. Danica's non financial disclosures. She is that Danica is a collaborator with CS disseminate and open CSD groups of volunteer CSD scientists and clinicians passionate about bridging the gap between scientific research and clinical practice, Helen's financial disclosures, Helen receives a salary from university of Wisconsin, Madison. Helen also received an honorarium for participating in this course. Helen's non financial disclosures. Helen is a collaborator with CS Disseminate and OpenCST, groups of volunteer CSD scientists and clinicians passionate about bridging the gap between scientific research and clinical practice. 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 serve on the AAC advisory group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Amy, that's me. Amy Wonkka:  My financial disclosures are that I'm an [00:05:00] 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, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, on to the good stuff. Uh, Danica and Helen, as, as somebody who has personally struggled to access articles that are behind a paywall, I'm really excited to learn about free and legal ways to access this information. Uh, before we get into that though, could you start us off with just a quick overview of some of the current problems and misconceptions related to accessing research? Danika Pfeiffer:  Sure. So I think one of the big problems that our group really works to try to help solve is that it takes on average 17 years for research evidence to be used in clinical practice. And this is So much time. Um, and it's really unfortunate because in the research we find that these interventions are working and [00:06:00] we can't, they don't get implemented for so many years. And so that's one of the biggest problems that our group is trying to help tackle, but we really need all of us clinicians and researchers to work together to tackle that one. We also know that there's a lot of misconceptions around publishing in general, and so, um, one of them is that Researchers are not allowed to share their work for free. Um, there's a misconception there that clinicians are not able to reach out to researchers to ask them for their articles when they can. We actually can, as researchers, share our work. If clinicians email us and ask us for a copy of our work, we can send it to them. Um, and so that's one of the things that we'll get into a little bit more today. Helen, do you want to share some other misconceptions? Helen Long:  Man, that was like a really great summary. Um, yeah, I think a huge misconception is [00:07:00] that, um, gosh, I think you actually covered it. I don't know. I think I'm, I'm definitely going to skip ahead because I'm, I'm thinking about emailing the corresponding author, but there, there seems to be just a misconception about, um, Like if if you can't access the article directly through the publisher, then it's just unavailable to you. And I think, like so many of our suggestions that we'll have for you today are that that's just not true. And I think one of the easiest ways to do it is emailing. Uh, the corresponding author, which you can usually view on the publisher website or the first page of the PDF, um, and don't be afraid to do it. Kate Grandbois:  I just want to second that because I, I mentioned this to you all before we hit the record button, but as part of this little nerdy project, we have to cold call and reach out to people way more frequently than I do in [00:08:00] my personal life. Um, and I am repeatedly. Surprised by the kindness and enthusiasm that comes with the reply that I receive. So. I'd say eight times out of 10, I get not only a reply, but, oh, and here's another article that you might like, or I've cc'd my colleague on this email who does adjacent research that you might be interested in. There is a tremendous amount of transparency and enthusiasm in my, in my experience and both Amy and ours experience about what kind of information you can get just when you reach out. Um, I think that there is. You know, this conception from the clinician's end that researchers are sort of, they're exclusive, they're elusive, they're, but they're people, they're, you know, people just like me, you know, it's like a celebrity kind of thing. I, and every single piece of contact that we've made with a researcher, the response has been warm and welcoming. So I [00:09:00] just want to second that, um, if you're listening and that is a conception that you have, give it a shot. It's, it's really worked out well for us. Yeah,  Helen Long:  yeah, I just I bring that one up first because I think there's just a misconception that if you email the author then they're like going to be offended in some way that you're wasting their time, but it's like, so the opposite of that. This is one of the biggest interests in their world and it's so exciting. Knowing that someone is interested in your work and they want to apply what you've written about into practice and like these are the emails that we want to be answering every day. So do it.  Amy Wonkka:  I think connected with that is also something that I didn't realize until I was, I was involved in some work in this area, which is. The authors aren't getting paid if you pay for the article, right? Like they're not getting paid. And when you see those articles that are open access [00:10:00] articles, the authors had to pay for that. I was  Kate Grandbois:  just, when I was just going to say this, yes,  Amy Wonkka:  this is another, like you're not skirting around the author getting paid by you buying the article. And emailing them, they're not getting paid at  Helen Long:  all. I  Kate Grandbois:  was just going to piggyback on, just to piggyback on what you said, and I'm sorry I interrupted you, but it was astonishing when Amy and I had the opportunity to do some of this work and collaborate with publishers and work on a piece together, a manuscript. The publishing process. Was very in order to publish something as open access was going to cost money out of the author's pockets and I have had people, you know, I have heard some of the misconceptions before that if a piece of work isn't published as open access, then the authors had some choice in that, right? Like they're going to profit, um, but it's the actual, it's completely the opposite. Can you talk to us a little bit more, like, just a peek behind the curtain, [00:11:00] what is that process like if an author wants to publish something as open access?  Danika Pfeiffer:  Yeah, so when we start a research project, one of the things that we do right away is choose what's the potential journal that this piece, this study could fit in, and so when we are deciding where do we want to submit this work and where do we want to write this up to go, We, one of the big things that we look at is, is there an open access fee, or there's different kinds of open access in some journals. One in our field is teaching and learning and communication sciences and disorders. They do not charge authors to publish their work open access. So it's completely free for researchers and it's completely free for clinicians. So you can go onto their website and find all of the articles there for free. So, When we're deciding where to publish, that's something that we definitely consider. Other places have those [00:12:00] article processing charges, is what they're called, APCs, and those can be thousands of dollars. So usually if you don't have a grant that's funding your work, then that's not really doable for many researchers. Some researchers are starting to put them in their startup packages when they first start at a new university to try to cover some of those costs. But otherwise, it's usually just grant funds that that money comes from. So especially for new researchers in the field like myself, we don't have thousands of dollars to be putting towards publishing our work. Kate Grandbois:  That makes a lot of sense. And, you know, there are, there are a lot of people. Well, maybe not. I'm actually not sure how many, but there are individuals that don't have any grant money who are publishing like Amy and myself. And in those instances, if the manuscript that you've Written and you're shopping around for journals does have a fee. When we had our conversation with our coauthors, we were discussing taking it out of our own pockets at one point, [00:13:00] because there really aren't, there is a whole web of industry around this. And if the journal doesn't have. A no fee or low fee open access entry point, then that money does need to come from somewhere or clinicians have the option to access it through other legal ways if it's not already open access. Can you tell us a little bit about other ways, other legal ways to access an article if it is behind a paywall? Danika Pfeiffer:  Yes, so we have compiled a few different ways that clinicians can access this research. One of them is going through the ASHA journals. So if you're an ASHA member, then you can access these articles for free, which is great. But sometimes when you go onto the website and you So if you are looking at an article that's been published in one of the ASHA journals, you'll see that it immediately says no access, and something that we just want to remind you is that you have to [00:14:00] log in. So make sure that you have put in all of your login information, because if you haven't, then it will tell you that you can't access the article. So it's really easy. All you have to do is log in, and then you have access to all of the articles in that five different ASHA journals, which is really great. Um, another. One that you can use is called Unpaywall, which is a browser plugin. So all you have to do is you go into the Unpaywall website, and it's an online database that has over 47 million open access journals. So they scour the internet, they find all of the free versions of articles that have been published. And when you go on the website, you just Click, um, to add this browser extension to your Chrome browser, and then when you're searching online for an article, it will show this little green icon that shows you if there's any free versions available of it online. It's really quick, really [00:15:00] easy, and on their website, they report that 52 percent of users of this unpaywall extension can access research papers for free, so they do a lot of digging themselves, which makes it much quicker for you to know if there is any of these free versions available, and it helps you find them really quickly. The next one that I'll share is something that I think many of us are pretty familiar with using Google or Google Scholar. So Google Scholar is a great place to find research. It's a free search engine similar to Google, but it can help you find those academic papers. And when you go on to Google Scholar, you can either type in the article title or the author's names, and that can help you to find the article. And once you've found the one that you're looking for, on the right hand side in the column next to the article's title, sometimes you'll see a link that says PDF. And that means that [00:16:00] there is a free PDF version that has been linked in Google Scholar for you. So you just click on that link PDF right there, and you can pull up that free version. If that doesn't work, you can try looking to see, when you look at the article title, it'll have the author's name linked to it. And if the author's names are underlined in blue, that means that they have a Google Scholar profile. And a Google Scholar profile is for academics, and it basically compiles all of their work in one place. So if you click on their name, and it will populate all of the work that they have done, all of their articles, all together on one webpage. And that's another place that you can look to see if, um, there's a free version of the article there on their Google Scholar profile. What you'll often see on Google Scholar, too, is that it might say underneath the article title that there's several versions. So it might say seven versions of the article [00:17:00] are available. So you also want to check there, because it might be that there's several paywall links, but then there might be a free version linked under that as well. So you want to definitely try all of those options, kind of click around and see if you can find a free version that way as well. That's awesome. Um, as far as the finding the different versions of the articles, I know before we hit record on here, you had all mentioned that there are actually all these different types of articles, which Was sort of new information to me. I don't know if you want to talk a little bit about that too. Amy Wonkka:  So part of what somebody might see on that Google Scholar is a few different types of articles. Helen Long:  Yeah, so one of the things, so kind of going back to our earlier conversation of when authors are deciding on what. journal to submit your paper to. So I'm going to talk just a little bit through the process of submitting your articles, [00:18:00] um, and then just the pipeline that it goes through because this relates to all these different kinds of articles that might be available to you as you are looking through these. You know, new and exciting ways that, um, will make research available to you. Um, so once authors submit their paper to journals, Um, more and more journals are allowing paper, are allowing authors to share their articles as submitted versions. These are also known as preprints. There's also some, like, a lot of other terms that you might see floating around. I think submitted version and preprint are the two most common terms. And preprints are becoming increasingly common. For authors to share their work before it's been peer reviewed because the peer reviewed process just takes so long. I mean, some, it usually doesn't take [00:19:00] less than two months, but sometimes it can take up to a year or more. I've had a paper that was under review for two years. because it's just sometimes takes a long time to find a qualified peer reviewer to, you know, have the time to peer review your work. And so one of the ways I think it was, um, it really started growing in, uh, the field of psychology. But people started sharing their, um, submitted versions of manuscripts before they were peer reviewed because of this peer reviewed problem. Um, and so there are a growing number of repositories online that people are able to share their pre prints. So again, these are the non peer reviewed versions of papers that are currently under peer review. Um, Just so that people can have access to these papers, at least in an initial draft. [00:20:00] Um, and of course, you know, this is not, I think there's a little bit of a misconception around preprints that, um, some people are worried that people are going to stop trying to get their work peer reviewed at all. And I don't think that's what's happening at all. And it definitely shouldn't be what's happening. Um, but the point is that you can at least view a first draft of the work. While it's in the process of being peer reviewed. Um, and then the goal, of course, is that once it is peer reviewed, uh, then once it's accepted for publication, that then becomes the postprint or the accepted version of the manuscript, and then you end up replacing your earlier preprint version with that accepted version. So now the version that's available of the manuscript. If you've shared it on one of these repositories, um, that is now the peer reviewed version, um, that's available and, and that one you can view with, um, a little bit more confidence than the pre print in terms [00:21:00] of, um, you know, this has been peer reviewed, it's been vetted by So, other experts in this area. Um, and so the accepted version is kind of a unique version where it's the exact same copy as the published PDF, except it's just not as pretty. Um, it's just another like double spaced Word document that's kind of boring, but it's the exact same words and it's the exact same manuscript as the published version. And it's the accepted version that, um, authors have a lot more freedom. For most publishers, I mean, of course, it really depends on what journal you go through. Some are a little more strict with what authors can do with accepted versions, but more and more, um, it's really only the, the publisher PDF that you can download straight from the website. That's the version that the publishers own the copyright for, and that's the version that they're able to pay wall. But for most publishers, [00:22:00] authors can share their accepted versions just like they can their submitted versions. I have a question about the preprints. So if, let's say, someone were to find a preprint in one of these websites or through Google Scholar or wherever they find it, To what degree of caution does someone need to approach a preprint. Kate Grandbois:  In other words, we know that the peer review process is a gold standard of science. We know that once something has gone through the peer review process, many eyeballs have gone through it, and it really is as good as it could be. To what degree does someone need to be very wary of a preprint? In other words, is there a chance there is a preprint out there that is someone's musings and ramblings? That is very far from, from something that would be accepted through peer review. Yeah, I do think clinicians and, and researchers too. I mean, I think anyone who's reading [00:23:00] a preprint who is knowingly reading a preprint should absolutely use an extremely critical eye. Um, but very much I think, uh, you know, the same critical eye that you would read, even just a regular peer reviewed article where you're judging the quality of the article is this something that I think I can legitimately apply to my Clinical practice. Helen Long:  Um, but, but I do. I absolutely think that pre prints should be judged even more critically because like you say, it could very much. It could very well be just a using and rambling and extremely biased piece of work that maybe all of those. Things will be weeded out by the time the peer review process is over. Um, you know, you know, it's just a reflection of the unfortunate problem with the peer review process right now is that it's all in the hands of. Volunteers and just reviewers who are, you know, yes, this is a piece of work that interests me and [00:24:00] that I have no relationship with these people. And I want to see this piece of work. out there, and I want to spend time reviewing this work. And, um, it, unfortunately, that's, um, really reliant on a lot of volunteers, just kind of, Giving their time to support the advancement of science, which is, of course, a necessary part of our job. But, um, yeah, I'm not sure if I answered your question. No, you did. Kate Grandbois:  You did. It makes me it brings me to another question about the self archive process. So I think which I think you mentioned briefly, um, I wonder if you could tell us about the self archive process and whether or not. Um, which is essentially for those who don't know when an author publishes on their own website, um, or makes it independently available from a publisher. And I know you'll walk us through those details and correct me if I'm wrong, but to what degree a self archived process needs to be approached with caution? [00:25:00] That's a great question. So self archiving is something that researchers can do in a few different ways. And it's just a way of sharing our work more openly, more effectively, more quickly with clinicians and others that want to read our work. Danika Pfeiffer:  So one way that we can do that is putting establishing for ourselves our own personal website. So we can create our own website, or sometimes if you work at a university, you should have a webpage that's established for you. Sometimes, if you would be surprised, we aren't able to access our own websites that are available through our university, and someone else actually manages them. So that's not a great tool for some researchers, which is why they might establish their own personal website. Um, or you could, at a lot of universities, have repositories, which is the central place for uploading your work. And that way, um, usually, [00:26:00] if it's within your university, then other researchers within your university can access your work very easily. Um, there are more central open, um, repositories as well, like the Open Science Framework. There's a ton out there of places where you can also share your work, so lots of different places. Sometimes it's just hard to find the information, but again, if you just plug in that information in Google, Google Scholar, usually they will link for you and you can easily get there. So when we want to self archive our work , there's really a lot of steps that we have to go through. So first is figuring out what the journal's policy is on self archiving. So each journal has a different policy. So as a researcher, when I wanna share my work on my personal website, I first have to go. to the journal's website to figure out what is their policy. And this will outline which version of the work I can share, as well as when I can share that work. [00:27:00] So some journals place what's called an embargo on sharing the work, which means there's this set period of time after the article has been published by the publisher that I cannot share my work. So they want to make sure that people are going on to their website and purchasing the article before I share it myself for free. So often that's six months. It could be for some journals I published in a year, maybe two years before I'm allowed to self archive and share that free version on my own website. So we have to check and make sure that we're following those policies for each journal that we publish in. And so that can be very time consuming, which is why a lot of researchers choose not to do this process because it's very time consuming. You almost need someone, maybe a research assistant who is just dedicated to self archiving and helping you guide, guide through that process. But once you figure it out, When you can share it, you also want to look at which version you can [00:28:00] share. Oftentimes, that will be like Helen talked about earlier, the accepted version. That's the unformatted but peer reviewed version of the manuscript. That's basically just a Word document. And then we put a license at the top, which is just really a disclaimer to say that this is the accepted version. It's just unformatted and we're following the journal's policies for sharing this work. And then we just upload that onto whichever website, our own website or our institution's website that's been created for us so that clinicians or anyone can easily access the work. So to sort of reflect on this process, it's less likely if something that is labeled as a self archived manuscript or article, less likely for a clinician to stumble on that and have it be like a blog or someone's, you know, ramblings and musings and biased work. Kate Grandbois:  Is that inaccurate? Is that an accurate description? Yes, and it will say [00:29:00] at the top which version it is. So it will say exactly where it is in the peer review process, so it'll be very clear. And if there's any questions, just reach out to, to the author and they'll be able to tell you. But it should say right at the top there, which version it is. I have to say, listening to all of this, I'm getting a lot of frustrated feelings about the publishing industry, who is really profiting off of a lot of free labor across this entire process, but that's probably a whole other episode. I'll just leave that there for everyone to, to think about. Um, what are some of the other. Processes through which someone might be able to access an article legally that's behind a paywall. Do you have any other suggestions? Yeah, um, we mentioned emailing the corresponding author earlier. I think that is probably the easiest way if you've stumbled across an article through the publisher that [00:30:00] is, um, you know, directly inaccessible through that publisher emailing is probably the easiest way. Helen Long:  But I think another one that we haven't yet mentioned is PubMed Central. I think this is one that I think a lot of clinicians. Are still really familiar with from, uh, like grad school. Um, I remember both in undergrad and grad school, the, you know, when you're trying to write your, your research papers in your different classes. And you raise your hand and you ask your professor I'm not able to access any of these articles. They always say we'll just go look on pub med. And it is true that PubMed is probably the next. Um, easiest option than if it's not directly open through the publisher that, um, if, if, if that paper has received any funding from the NIH, [00:31:00] um, the National Institutes of Health, which is a major funding organization in, um, in the US, um, the, The government I don't know what the best term. I guess it was actually the White House that started a policy and 2008 that recognized the problem that a lot of taxpayer money. Was funding research. Many, many researchers in the U. S. are funded through the NIH, um, but all of this subsequent research coming from this funding is being paywalled. And so the White House, I think in 2008, built PubMed Central, which is essentially a repository that houses, uh, openly accessible versions of any NIH funded papers. I believe that's correct. I'm not like a hundred percent sure that that's super accurate, but, [00:32:00] um,  Kate Grandbois:  we won't quote you. It's  Helen Long:  okay. Okay. Okay. Um, but it really is. It's, it's another, usually if you're looking for a paper online, uh, sometimes you come up with the PubMed version of that paper. And that is basically just another accepted version of the paper, and you'll even find a little user license on the top that says this is the accepted version of this paper, you'll find, you know, it was originally published in whatever journal that it was published in. And so, that is a really great option. Um, and I wish that that was kind of an end all be all to like, okay, great, the, the American government has solved all our problems, but unfortunately, they, they, they had written in their original, um, policy that, Publishers were allowed to place up to a 12 month embargo, which means that's [00:33:00] yet another, that's more time that papers are still not available through PubMed. And so if you're trying to do up to date evidence based practice you're basically if you're only relying on PubMed, you're really always going to be 12 months behind because you can't access it for 12 months through PubMed, which is a big reason why a lot of scientists are starting to self archive their own research on their websites so that It's more accessible, uh, sooner after publication. Amy Wonkka:  Yeah. I mean, all of that is so helpful. And I think as a clinician who's looking for these free articles online, one thing I'm taking away is that if I can find an accepted version, that makes me feel more confident, whether I'm finding it on PubMed, whether I'm finding it with my browser plugin, or I emailed the author, the corresponding author, they sent it to me. That makes me feel better about it, even if it might not be the [00:34:00] very prettiest version of the paper. The content is solid. Um, in our, in our last couple of minutes, I know one other piece that we had talked about before we hit record was just Twitter. Um, and Twitter is being a potential place to get some of this information. I didn't know if you guys wanted to talk a little bit about Twitter as a potential resource.  Helen Long:  Yeah, I've noticed more and more through Twitter that there are actually a lot more browser plugins than just on paywall. I'm just scanning Twitter you'll find different threads, discussing different. Plugins that allow you to access papers. I found one recently called Paper Panda. It's very similar to Unpaywall. Uh, you just install it. I think it, it might just be required in Chrome, but you just install it and it's just another plugin that you can select when you're trying to access a paper. Um, I also found another one recently called [00:35:00] 12 foot ladder that bypasses news outlet paywalls, which I didn't realize I needed until I installed it. Um, and so that I could access, uh, news articles.  Danika Pfeiffer:  Um. Yeah, and I'll even say as an author of research, um, I collaborated with some of our CS Disseminate collaborators on an article for an ideology journal, and once it was published, I wasn't even able to access it myself as an SLP, so these are things that clinicians are facing, these are things that researchers are also facing, and we don't have all the answers, but hopefully these will be a few quick solutions that will help you get by If not, you can also always go to your public library or a university library if there's one near you. Typically they will have subscriptions to these journals, so you can go in, find the PDF and print it out, take it home, email it to yourself. So that's just [00:36:00] one other way without having to pay for the article. All of this information has been incredibly helpful. I think a big takeaway for me is there should be no, no clinician should be experiencing any guilt around not being able to access the literature that you need to access. Kate Grandbois:  We had, um, one of our previous guests, Natalie Douglas, said this beautifully that she had no. She had no higher power whatsoever, but she absolved everyone from all of their guilt around not being to not being able to access the science that they needed to do their jobs. If there is any takeaway from all of these wonderful information that you've given us, it's that this industry is incredibly complex. It is not working in our favor, and these, these barriers are very legitimate. So if you are feeling frustrated, if you are feeling irritated by all of this. You should be. Those are very valid feelings and all of these strategies [00:37:00] are incredibly helpful to get us over those barriers so that we can access the research that we need to do our jobs successfully. Do you have any final words of advice for our audience?  Helen Long:  I just want to commend clinicians who are going through all of these, you know, you have to admit we've gone through like so many options to try to just do our jobs, you know, and I just have to commend clinicians out there for if you are using any of these strategies when you're just trying to, you know, do evidence based practice. Thank you for your work.  Danika Pfeiffer:  Yeah, absolutely. I agree. It is, it can be very frustrating, very difficult to find this information, but I hope that you'll take away that at least reaching out to the researcher, we are very open to sharing our work. And as I mentioned earlier, always excited to talk about our work and what we're doing. And so [00:38:00] please just reach out if you are hitting those paywalls. Um, and we're happy to share our work.  Kate Grandbois:  Thank you so much for everything. It was really wonderful having you here. We really appreciate it.  Danika Pfeiffer:  Yeah. Thanks so much for having me.  Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00] Kate Grandbois: Welcome to SLP nerd cast the number one professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  [00:00:09] Amy Wonkka: Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  [00:00:16] 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 . [00:00:41] 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  [00:00:53] Kate Grandbois: specified. We hope you enjoy  [00:00:55] 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. [00:01:43] Kate Grandbois: Welcome everyone. We're. So looking forward to today's conversation, this episode is about language skills in youth offenders. We came across this topic from a research article that we read and really enjoyed, titled a systematic review and meta-analysis [00:02:00] of the language skills of youth offenders by chow at all. And we are lucky enough to have one of the authors Dr. Reed center. Join us today for this discussion. Welcome Dr. Reed center.  [00:02:10] Reed Senter: Welcome Reed. Thank you so much. It's a pleasure to be here and it's an honor that you invited me.  [00:02:16] Amy Wonkka: We're, we're so grateful that you joined us. Um, and you are here today to discuss language disorders in youth offenders, which I think is a really important topic. Um, for speech language pathologists to hear about before we get started. Can you just tell us a little bit about.  [00:02:32] Reed Senter: Absolutely. Yes, I'm a speech language pathologist. I worked, uh, clinically for, I guess, five years. Um, mostly in school based settings, middle and high schools. Um, after five years I realized I enjoy this work. I like the kids that I'm working with. Um, but my interests and skills were, uh, more suited for, uh, research in academia. So I went back, uh, to pursue a PhD. Um, that's how I got involved in this article, working with my advisor, Dr. Jason cha. [00:03:00] Um, and then I, uh, got my PhD in may of 2022. I'm now working as an assistant professor at desal university in cider valley, Pennsylvania. And, um, I'm really enjoying, researching, uh, you know, developmental language disorder and, uh, finding ways for especially school based SLPs to, uh, really make the most of their services.  [00:03:24] Kate Grandbois: Well, congratulations on your recent graduation. First and foremost, that's a huge accomplishment. Uh, and we are really excited to learn from you today and take some, you know, unpack everything that we found in this article, um, that we will include a reference to in the show notes and encourage everyone to read even after this today's discussion. So before we get into all the fun stuff, um, I wanna make sure that we have read our learning objectives and our financial and non-financial disclosures. So go ahead and get those out of the way.  Learning Objectives [00:03:57] Kate Grandbois: Learning objective. Number one, describe the prevalence [00:04:00] of language disorders and youth offenders learning. Objective number two, describe the relationship between language ability and behavior problems that pave the way for delinquency and learning. Objective number three, describe at least two targeted linguistic and behavioral supports to reduce the risk of incarceration. , disclosures, read centers, financial disclosures read, received, and honorarium for participation in this course read centers. Non-financial disclosures read previously served as vice president of governmental and professional affairs for the speech language hearing association of Virginia Kate that's me financial disclosures. I am the owner and founder of grand wa therapy and consulting LLC, and co-founder of SLP nerd cast. My non-financial disclosures. I'm a member of Asha CIG 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 and the association for applied behavior analysis international and the corresponding speech pathology applied behavior analysis, special interest group. [00:04:59] Amy Wonkka: [00:05:00] Amy that's me. Uh, my financial disclosures are that I'm an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I am a member of Asha, CIG 12, and I serve on the AAC advisory group for Massachusetts advocates, for children. All right. Made it through the disclosure portion of this, of this episode. So Reed, we found out about your work with Dr. Chow, um, looking at language disorders and youth offenders. Can you talk to us a little bit about why that's a research question your team was exploring? Is there a relationship between language disorders and youth offenders? Because if there is, that seems like something that SLP should be aware of. [00:05:44] Reed Senter: Absolutely. So, um, just to set the stage for a second, um, rewind back to 2019, um, at the time I was blissfully unaware of the speech language pathologist's role in, uh, um, you know, [00:06:00] Understanding and diverting the, the school to confinement pipeline. Um, I was unaware of the connection between language disorders and youth offenders. Um, but in 2019, I think it started to become a, uh, bit of a more mainstream, uh, hot topic within our field. I remember, um, Dr. Shamika Stanford, she, uh, published an article in the Asha leader. Um, and that was the first time that I had seen it. I imagine the same is true for, uh, you know, many of your listeners. Um, she appeared on a podcast, the Asha voices later that year. Um, and then there were, uh, you know, other researchers across the globe, including, uh, One prominent article from Dr. Uh, Pamela Snow. Um, she published that in 2019 as well. Turns out there has been a research about language ability in youth offenders, going back, as far as I think we found them going back as far as 1991. Um, but it was just very scattered. There was one in 1991, there was one in 1993, um, one in [00:07:00] 1997 and then no more until the two thousands, um, around 2011, things started to pick up. Um, but really we just wanted to take all of these isolated studies, um, you know, a study of. Say maybe 20 youth offenders here, um, maybe 34 youth offenders there. We wanted to take all of these isolated studies, uh, compile them into a single meta-analysis, um, where we can take all of their data and kind of synthesize it together and come up with, uh, the most comprehensive view yet of the language ability of youth offenders. And what we found, um, is essentially that language disorders are extremely prevalent in that population. [00:07:43] Kate Grandbois: And  [00:07:44] Amy Wonkka: we were rereading your article this morning before hopping on this zoom with you. And I think I, I wrote down it's like you found 63%.  [00:07:53] Reed Senter: Yeah. So, um,  [00:07:56] Amy Wonkka: really high percent relative. Yeah. To, to what we find in the [00:08:00] general population. Right, right. And that, that  [00:08:01] Kate Grandbois: was gonna leave me into our, my next question is, can you tell us a little bit about the prevalence of language disorders in youth offenders and how it compares. To the general population.  [00:08:14] Reed Senter: Yeah. So when we think of a developmental language disorder, DLD, um, those are children who have language disorders that aren't associated with secondary con uh, condition like autism or intellectual disability. Um, developmental language disorder is prevalent in about, you know, maybe six to 8% of children, um, about one in 13 kids. Um, so you're thinking, you know, your average classroom of 26 children, maybe two of them will have DLD. They might be diagnosed. They might be undiagnosed. Um, Within the specific subset population of youth offenders. Um, it's not one in 13 it's, uh, like you said, just about 60%. Um, when [00:09:00] we, uh, look at children with, uh, language deficits, um, you know, greater than one standard deviation, about half of them, uh, 50%, um, had, uh, you know, language deficits of more than one standard deviation and an additional 10% of, uh, children had language deficits greater than two standard deviations below the mean, um, so again, more than half of youth offenders presented with, uh, developmental language disorder. [00:09:31] Kate Grandbois: And to your point about, I'm going to use your words being blissfully unaware. This is something that. I think you're right has come slightly more to the forefront in terms of our responsibilities as professionals, but is nowhere near the actual forefront of what we are learning in graduate school. What we are, what our ethical code directs us towards. It just doesn't seem to be, I [00:10:00] mean, as, as, as prominent of an issue as it, maybe it should be based on the numbers that you are giving us and how, how much higher that prevalence  [00:10:11] Reed Senter: is. Yeah, absolutely. If, um, if children with language disorders are that drastically overrepresented within the population of youth offenders, um, then that's something that, you know, we're coming into contact with these children before they even enter that school, the confinement pipeline, um, that's something that we can help with. We can, uh, um, help divert that pipeline. Um, and you know, should, unfortunately they enter that pipeline. Um, that's something that we, we can help support those children even, um, you know, once and during their, uh, confinements, um, You know, a large part of that is tracking those children with behavior problems and a lot of SLPs, I think, um, kind of push back on behavior. I remember my first year in the school system, [00:11:00] um, I got a transfer student, uh, who's IEP. Um, they were, uh, eligible for services under the category of emotional and behavioral, uh, disability, E B D. Um, and I thought to myself, what are they doing? Assigning an SL P to a kid with E B D while it turns out 80 per or yeah, 81% of children with, uh, E B D have undiagnosed language disorders. Um, undiagnosed is many as, uh, 97% of kids with EBD have language disorders, but 81% of those are undiagnosed. So SLPs really need to be at the forefront of that conversation. They need to be there in the room. They need to be working with those children and they need to be, uh, You know, empowering them with the, the language and behavioral skills. They need to make sure they don't end up in confinement a couple years down the road. I mean,  [00:11:50] Amy Wonkka: that's just a staggering number 80, I mean, 81% is a, is a huge number. And so one thing it makes me think about, [00:12:00] and we talk a lot about on the show, it's just trying to connect to what can that clinician do with the information they learn in the podcast. And that makes me think one of the things you can do, particularly if you're a school based SLP is, is get involved in your. Referral teams at your school when kids are coming up and your school based team is talking about these behavioral concerns, be aware of that percentage and advocate for appropriate assessment for these students. You know, don't, I, I think you make a really great point where you just about, like, we get kind of uncomfortable with behavior and what is the overlap there? And that's not, you know, my role. Um, but obviously it is right for 81% of these undiagnosed students. That's  [00:12:47] Reed Senter: huge. Absolutely. And I'm probably not making any friends among the school based SLPs out there right now, who are, you know, saying, why are you piling this extra work on me? I can't handle anymore, uh, children on my caseload. Um, but [00:13:00] absolutely proper screening, proper assessment procedures, um, especially for children, um, with behavioral concerns, EBD diagnoses, um, it's essential.  [00:13:10] Kate Grandbois: So I can feel myself wanting to go down like four rabbit holes with more questions and comments, because my, what I'm hearing is that this is touching so many aspects of our job and it's all very, it's all critically important. Um, and before we get into some of those more detailed conversations about the role of the SLP, just to set the stage for our listeners, what else can you tell us about what your research found, um, what the meta analysis revealed?  [00:13:43] Reed Senter: Absolutely. So, um, just a little background on the meta analysis, um, you know, it's regarded typically is one of the highest levels of research evidence because it takes high quality, you know, randomized control trials, or, um, quasi experimental trials. It takes [00:14:00] all of those and kind. Puts it in a blender and spits out the best available information. Um, it synthesizes all of the, um, high quality research that we have available our particular meta-analysis. Um, we found 18 studies, uh, that included data from youth offenders, um, under the age of 18. Um, and it also included, you know, quantitative. Language data on those students, um, that we could compare in some way, whether the study compared them to, um, their typical peers or whether we could use norm reference assessments. Um, we were able to compare data from 18 studies of children, of youth offenders, to their typical peers, um, between those 18 studies. Um, I believe that represents 3,304 individuals. Um, so there's a lot of data in here. Um, so we included, uh, just the children incarcerated in, uh, juvenile justice settings, not community based settings. [00:15:00] Um, and of course that's another rabbit hole. Um, the United States course rates quite a few children in juvenile justice settings. Whereas, um, you know, some of the other countries, uh, represented in our review, um, Australia, for one example, um, they use a lot of community based rehabilitation, um, for their youth offenders. So there were fewer children incarcerated there. I  [00:15:22] Amy Wonkka: literally wrote down a. And texted it to Kate from your article this morning. And I do just wanna read it here, cuz it connects to the point you just made the United States has more youth in incarceration than any other country.  [00:15:39] Reed Senter: Oh, yeah, of course. Um, not just by population, but by, uh, per capita as well. Um, total the United States, I believe there are around 60,000 children, uh, that are currently incarcerated. Um, you know, the rate varies by state. Um, my home state of Pennsylvania, uh, we have 235 children [00:16:00] per 100,000, uh, incarcerated, um, different states range from, I believe Vermont has the lowest, um, 58 children per a hundred thousand are incarcerated. Um, all the way up to the highest, uh, South Dakota incarcerates, almost 500 children per 100,000. Um, now compare that again to Australia because I have their data readily available. Um, Australia incarcerates 27 children per 100,000. Um, so that's less than half of our lowest state. Um,  [00:16:33] Kate Grandbois: I, I have so many things to say, but I'm gonna stay focused. Mm-hmm so. What I really appreciated about reading this article was considering the cultural components that are involved in this problem, not only, and, and how that intersects with, with us as professionals. Um, but it brings me to a question that I was gonna ask later, but I'm gonna ask now because mm-hmm, , it's relevant to what you're saying [00:17:00] out of all of the, out of all of the data analysis that you conducted, did you, since we've already established that this is really important for SLP to be aware of because of the high prevalence of DLD, were there any components of language intervention as part of these settings of incarceration?  [00:17:21] Reed Senter: So we didn't focus necessarily on studies for intervention. Um, I'm sure that could be a whole nother, uh, systematic review. Um, but while we were doing our research and, you know, reading through these articles, we did come across, um, you know, several different models for rehabilitation. Um, within the United States, it seems inconsistent. You know, there will be some facilities where, um, you know, youth offenders have plenty of access to. You know, rehabilitative interventions, um, whether it's, uh, psychologists or social workers, um, speech, language pathologists [00:18:00] working in juvenile justice settings are less common, but they're not completely non-existent. Um, there are some places that contract through their local school, uh, systems. Um, there are some places that contract through, um, I guess, local governmental agencies. I dunno if that would be, uh, department of health or, um, department of corrections. Um, there are opportunities for, uh, SLPs to provide intervention directly to, uh, youth offenders. Um, and of course, you know, that's just within the incarceration framework. Um, you know, we see in some places, uh, you know, more community based rehabilitation, um, where, you know, children might go to, uh, you know, a, uh, residential facility either just during the daytime, um, in sort of, uh, You know, serve out their sentence, um, in that kind of facility or, uh, you know, it might be residential or it might just be, um, you know, almost like a [00:19:00] school for youth offenders. Um, these might include some community based, uh, service projects, um, as part of their sentence that might not, um, there are, there are plenty of different models and it varies by state, by, um, locality by country, for sure. Um, but it's, it's not universal.  [00:19:20] Kate Grandbois: I'm sorry that I derailed you from your original, your original communication of everything in your study. So please it feel, I would love to hear more about the  [00:19:30] Reed Senter: meta analysis. Oh, absolutely. Yes. Um, So, yeah. Uh, we, you know, of the studies we found, um, more than half of them, 11 of the 18 studies were conducted in the USA. Um, there were three each from the United Kingdom, three from Australia, one from New Zealand. Um, and again, we just threw all of those. Uh, we call them effect sizes into, um, you know, a statistical analysis software. That's much more complex than anything I understand. [00:20:00] Um, but that's how we identified, um, you know, first the prevalence of language disorders in youth offenders. Uh, like I mentioned, um, 50, 50 or so percent, uh, with mild to moderate disorders, um, and additional 10% with severe disorders. Um, and then we were able just to compare the population of youth offenders to, um, you know, like the community sample. Um, and we found that on average, the average youth offenders language ability is about one and a quarter standard deviations below the mean. There were, uh, differences between the countries. Um, what we found was, uh, you know, especially compared to the United States, uh, United Kingdom had a significantly larger discrepancy, um, between, uh, the youth offenders, um, and the typical population. Um, and, uh, I mean, I guess I attribute that to it requiring a, uh, it likely requires a [00:21:00] higher threshold of offending, um, to get yourself incarcerated as a youth kingdom. Whereas it, you know, it doesn't take as much to become incarcerated within the United States [00:21:12] Amy Wonkka: was wondering when I was reading through kind of like the background section of the, of the article, you guys talked a lot about. Kind of the language based demands that are placed on a youth offender, who's been incorporated into the judicial setting. Um, and, and these were things like the Miranda warning or the charter cautions in Canada. Um, just some of that justice system related vocabulary. I didn't know if you could just talk to our listeners a little bit about those pieces because people might not be aware of the unique linguistic demands of being involved as a youth in our judicial system and kind of what those pieces are. Cuz it was interesting even for youth who [00:22:00] had typical language development, there were some real challenges there in some of those places. [00:22:06] Reed Senter: Yeah. Really children with, uh, language disorders are at a major disadvantage, um, along every single step of the, the path. And um, you know, like you mentioned, your listeners can, uh, um, You know, read our article for more. Um, Dr. Pam snow also had a, uh, a great review back in 2019, um, called speech language pathology and the youth offender, epidemiological overview and roadmap. Um, and that provides, you know, again, just a really great roadmap of how at every single step of this journey, um, children are at a disadvantage. Um, so if we think of that school to confinement pipeline, um, we know that language influences a lot language, um, influences academic success like reading, um, rioting, math, um, it comes into play for all of those. So children with language disorders are [00:23:00] at an academic disadvantage, um, language also, uh, factors into behavior, um, because children with poor language will have a poor, uh, student to teacher interactions, um, will typically have poor social skills, poor engagement. Um, and when we see, uh, language influencing both academics and behavior in that way, um, when academics and behavior. Kind of, uh, interact. That's what sets the student on their entire lifelong path to success on their achievement, their social success, their life outcomes, um, their propensity for incarceration. So children with language and behavior disorders, um, you know, from the very beginning, they will have poor social interactions, poor academic outcomes, which leads to higher rates of disciplinary referrals, higher rates of suspensions. Um, maybe they don't do as well in their class. Um, and they're more likely to drop out, which is another risk factor for [00:24:00] delinquency. Um, so between all of these, um, you know, referral suspensions, um, dropout risks, um, that leads to a higher risk for delinquency. So language disorders. We can draw that link there. Um, once they're in that whole delinquency pipeline, um, like you said, um, you know, from the moment they interact with a law enforcement officer, um, you know, perhaps the law enforcement officer is reading them their Miranda rights and, uh, um, you know, there, uh, you know, constitutional rights during arrest. Um, there are studies out there that demonstrate that children with language disorders, um, typically cannot understand the Miranda, um, warning. Um, we see, I think there was a study of, uh, you know, high school offenders, um, that determined on average, they had maybe like a, a third grade, um, oral comprehension, um, Ability. And then they [00:25:00] compared that to the, the Miranda warnings. They, they took actual scripts, um, read by law enforcement officers. And those were at like a 12th grade level. Um, so which is wild,  [00:25:11] Amy Wonkka: like that's wild kind of broadly. That's sort of wild that, that, that, that's what a choice that we make in terms of something that's supposed to be informing people of their rights at, at that high of a level, because we all exist on a bell curve in terms of language skills. Like, but yeah, that's  [00:25:30] Reed Senter: wild. Don't even get me started my understanding of the Miranda rights, um, are, you know, There are the specific rights that we are supposed to be read. Um, but there's no legally mandated script. So, uh, that same study that evaluated those Miranda warnings, um, you know, they found that they arranged from like 50 words to, you know, some officers were, uh, spatting off like 500 words worth of warnings. Um, that's what, like two pages, double spaced. Um, [00:26:00] And we think of things like, uh, you know, we all saw the, the Daniel Shafer, uh, video where, uh, you know, he was killed by police officers. Um, the police officers were spouting off contradictory instructions. They were saying, don't move your hands. And they, then they were saying crawl towards me. Um, he didn't understand, he put his hands down to crawl towards the law enforcement officer. Um, and when we think of, I'm not saying, you know, Daniel shaver had a, a language disorder necessarily. Um, but if we think of somebody who does have language disorder and then they're hearing contradictory, uh, inconsistent instructions from law enforcement officers, um, they're gonna have a tough time with that  [00:26:41] Amy Wonkka: and you're in a heightened state of arousal. So like another thing we know about language skills are that for all of us, Ty typical language or not, when we're in that elevated heightened state, our ability to process and respond is, is gonna be decreased  [00:26:59] Reed Senter: [00:27:00] 100%. Absolutely. Even moving on past the, you know, that initial interaction with the law enforcement, the, you know, whether it's the Miranda warning or whether it's just following their instructions. Um, children with language disorders are going to have a more difficulty understanding trial procedures. Um, there was a study of, I think, 20 youth offenders. Um, and most of them couldn't tell the difference between a prosecutor or a defense attorney. Um, they didn't necessarily, uh, all understand the word testimony. Um, so they don't understand how they're supposed to defend themselves. Um, once they're in the testimony, a child with language disorder, um, is going to have a more difficult time articulating their. I'm telling a consistent story and, you know, the defense attorney or the, sorry, you know, the prosecutor is gonna jump all over them for any inconsistencies in their story. Um, I can see that leading to a, uh, more likely chance, uh, for [00:28:00] conviction. Um, I think that's part of how more children with language disorders end up in at a school to confinement pipeline. And then once they're in there, they have fewer, um, opportunities to rehabilitate because literacy is an important of rehabilitation. Restorative justice, uh, conferencing is, um, hopefully trending upwards. And that scenario where, uh, children's language disorders might struggle  [00:28:25] Kate Grandbois: for our listeners who maybe haven't read this article. Can you define or tell us more about restorative justice and what that.  [00:28:34] Reed Senter: So restorative justice conferencing is a, uh, growing movement. I think you see it in, uh, you know, some judicial settings and, uh, increasingly I think you're finding it in some schools as well, um, where, uh, the youth offender is, um, essentially encouraged to, uh, um, you know, just have a conversation with the, the victims, the people that they heard. Um, and of course, you know, [00:29:00] this is likely dependent of the, the victim's willingness to engage in the process as well. Um, but by, you know, having that open conversation and, uh, you know, discussing, you know, Hey, here's an apology. Here's what I did. Um, Here are steps that I'm going to take in the future to fix it. Um, and then just being able to listen to the, you know, the victim, tell their side of the story as well. Um, you know, there are plenty of studies out there that show that this is, um, when done correctly and I'm sure you all have stories of, uh, times and places where it's not done correctly. Um, but when done correctly, this can be a, uh, a healthy and restorative process that reduces the risk of recidivism. Um, but of course, again, it's moderated by language ability. You can't have that great conversation if you're, um, you know, both emotionally charged and, uh, you know, struggle with communication, struggle with language and, uh, you know, [00:30:00] expressing yourself, telling your story. Uh, that's just a door that's not as wide open for you as it might be for, uh, typical peers. [00:30:08] Kate Grandbois: One of the things that struck me. When I read your article was how many barriers there are for youth with language disorders through this entire process. And I, it was very overwhelming to think. I mean, I think globally, we think, okay, there's a higher prevalence. I can see how these, how that's related or how that unfolds. But then when you get into the statistics of vocabulary barriers, I mean, it was, it's just the pipeline as you call it is long and arduous. I mean, just so many steps in the process. Everything from Miranda rights, I mean, starting in the classroom with negative teacher interactions all the way through first officer contact all the way through vocabulary. Um, and self-advocacy [00:31:00] through a trial. I mean, it's a, it's a very, and, and I say this back, I say this as a reflective statement, because for those listeners who are. Here with us. And haven't read this article. It is a very complex, large problem, much when you get into the numbers, it is much bigger than most of us who are even vaguely aware of this issue. It's much larger than we actually think. Do you think that that's a fair statement?  [00:31:27] Reed Senter: I think so. Um, I might be biased by my own personal, you know, investment in this. Um, but to me it just seems really bleak. Um, we can see models from other countries, um, where there are alternatives. We don't have to lock up this many children. Um, it's not like, you know, Australia, which incarcerates far fewer children. It's not, we like we see, um, just waves of, uh, youth violence and, uh, criminality. Um, you know, there, it doesn't have to be this way. Um, but it is, and [00:32:00] not to, you know, remove the personal responsibility component from these youth offenders. But they're children. Um, they're children who, you know, more than half the time they have language disorders. Clearly they have some sort of, uh, behavioral problems if they ended up, uh, incarcerated to begin with. Um, and we, uh, you know, I speak as, uh, you know, an educator, we educators, um, we have evidence based practices for language. We have evidence based practices for behavior management. Um, so it seems to me that, um, somewhere along the line, whether it's, it's not just LPs, I, you know, I'm not gonna pin all of the responsibility on us, but we as educators and we, as a society are failing these children. I  [00:32:47] Kate Grandbois: wanna read. This seems like a, a good place for me to read this quote. This really stood out to me. Um, and it, maybe it's a nice transition into our second and third learning objective, uh, learn second and third learning objectives related [00:33:00] to supports that we can provide. Um, this is on page 1,168 of the article identifying and examining additional risk factors, such as language may allow researchers and practitioners, right? So us may allow researchers and practitioners to determine which specific types of evidence based interventions, maybe most effective at providing youth with the skills necessary to successfully navigate the justice system and re-entry into society. And then this next sentence really hit me. This short term focus can then lead to the more important goal of ultimately changing the life trajectories of these youth via evidence based interventions that promote engagement in pro-social peer and community networks. That is a very powerful sentence. Yeah. When you start saying things about changing life trajectories and I, I would love to hear [00:34:00] more about that.  [00:34:02] Reed Senter: Yeah. These are the stakes they're high stakes. Um, you know, clearly as speech language pathologists, we chose this profession, not for the money we chose this profession because we want to help people. Um, and part of that is we can help people by communicating, um, Swallowing too. I know they're swallowing peeps out there. Um, but you know, at its core, our field is helping people communicate. Um, that is a basic human right. It's essential. Um, and it ties into so much of what we consider, you know, not just short term success, you know, passing a vocabulary quiz or, um, you know, learning syntactic structures. Um, but it's a huge factor in lifelong achievement, social success, life outcomes. Um, and if a child gets, uh, incarcerated along the way that is going to derail they're, um, you know, [00:35:00] lifelong path. Um, so I mean, to me, this is, this is one of the highest callings because it's not just, um, you know, and I don't mean to minimize this, but it's not just helping them pass their vocabulary tests. Um, This, this is their lives. These are lives at stake. Um, you know, of the youth offenders in the, uh, juvenile justice system, uh, I think it's about half of them will go into be repeat offenders. Um, and once you get wrapped up in that, uh, you know, pipeline of repeat offending the game's over for you. So if we, as SLP have the capacity, um, you know, to put, um, you know, put the brakes on this pipeline, I believe that's our obligation. We need to make sure that we're, um, in the right spaces where we can divert this pipeline, um, in a major part, um, you know, one of those major spaces are the schools. There are plenty of SLPs in the [00:36:00] schools. Um, so we just need to make sure that we're well equipped to, uh, provide the supports we. So how  do  [00:36:08] Kate Grandbois: we do that? I know that's a very big question for a very big problem, but can we talk a little bit about, and I I'm specifically thinking about our third learning objective, the targeted linguistic and behavioral supports, um, you know, and in combination with this quote from the article that I just read in terms of identifying and examining additional risk factors related to this pipeline. [00:36:37] Reed Senter: Yeah. That's um, that's a great question. And it's an important question, um, because it really gets to the whole, what can we do about this, um, research doesn't exist in isolation? You know, we're doing this so that we can figure out, um, And I think it ties back to, um, you know, in a sense certain behavioral principles, I think as SLPs, you know, obviously we have language in our [00:37:00] name, um, but we need to take a two-pronged approach to intervention. We need to, um, be mindful of both language and behavior. And before I get started, cuz I can probably hear some of you groaning at home. Um, I'm not suggesting SLPs need to adopt behavior into our scope of practice. Um, nor am I suggesting that we can replace behavior therapists and specialists. Um, rather I think we get the most banging for our buck when we can, uh, um, you know, support behavior by reinforcing their expectations across settings. Um, we get the most bang for our buck in therapy when we can manage. Children's challenging behaviors. Um, and when we can use our knowledge to compliment other disciplines, um, so from a behavioral, uh, perspective, and I know, um, there's a lot of behavior knowledge here, um, on, on this podcast. So, uh, please pipe in, um, I think a lot of it comes down to knowing your ABCs, your antied, your behaviors and your consequences, um, [00:38:00] starting with your antied, um, you, you know, you might take a, a function based thinking approach for that. Um, what is setting this child's behavior off? Are they looking for something, are they seeking something? Are they trying to escape something or avoid something unpleasant? Um, are they just doing it for, you know, the pure stimulation? Like, uh, um, you know, if we think of maybe a, an autistic child rocking, you know, it's a behavior, but it's, you know, Purely stemming. Um, so if we can identify those antied dent behaviors and then the consequences, which aren't, you know, strictly punishment, there's reinforcement, there's punishment, there's positive and negative reinforcement and punishment. Um, and I think it's important that we understand the, the difference between those. Um, but by taking that behaviorist perspective, um, we can figure out where. Most appropriate point to jump [00:39:00] in would be, do we need to, um, set up an anec and intervention where we can, um, you know, cut the behavior off, um, before it happens. Um, do we need to set up, you know, a better system of consequences, you know, beating this child's fingers with a ruler isn't working. So, uh, maybe we set up some sort of a positive reinforcement, um, reward system and, you know, say what you want about reward systems, but positive reinforcement, uh, seems to me like it has strongest evidence behind it. Um, so just knowing where we can jump in with behavior, um, not just language, but definitely taking that two-pronged approach in the therapy that we do. [00:39:38] Kate Grandbois: And I just wanna jump in here of two things. So if you're listening and you're not familiar with these terms, antied behavior consequence. Um, we have an episode called I'm not gonna be able to remember the name off the top of my head, but I think it's behavior management, part one that lays out that exact three term contingency and sort of verbally walks people through what [00:40:00] that is. Um, and I think the second, the second point that I wanna make is. How important and I, and please correct me if you have, or, or, you know, if you have anything to add, but it seems to me that good collaborative relationships with your behaviorally oriented professional, um, is a critical piece here. And I say behaviorally oriented professional, because depending on your workplace setting, it might be a, B, C, B a, it might be the school psychologist. It might be, it could be any various, you know, various titles, um, of people who are responsible for positive behavioral support plans or whatever model your workplace setting embraces. Um, and I know personally, just from carrying both licensures, but also from my clinical. And, and my existence in this prof in both professions, that those collaborative relationships between speech pathologists and behaviorally oriented professionals can be very, very strained, [00:41:00] um, for a variety of reasons related to overlapping scopes of practice related to, you know, feelings of encroachment, the list goes on and on. And that's not what, that's not what we're here to talk about, but my point is, That, when you think of it through the lens of how important this is and to use your words, um, when there are lives on the line, when you have the opportunity, and again, I'm gonna quote your article here to, um, change the life trajectory of youth at risk. Then it is absolutely worth your time and effort to find a way to navigate that collaborative relationship, have an open conversation with them about how important this is, share this article, you know, try and find a way to move through whatever discomfort you're experiencing or whatever, as Amy. And I always say, whatever emotional food poisoning you have, or whatever, grumpy feelings you're bringing to the table about that behaviorally oriented professional, and really try and consider what [00:42:00] interventions could be better implemented with both brains at the table. And that's the end of my soapbox. I just wanted to sort of piggyback onto that a bit. How important I assume that collaborative relationship is.  [00:42:12] Reed Senter: No 100% and I will, uh, I will second that soapbox. I think that's very important. Um, shameless self-promotion here. Um, there are resources out there for SLPs that are looking to develop their, uh, you know, own behavioral management practices. Um, I co-authored and article with my advisor again, um, about, you know, some of those very, uh, low investment, um, you know, evidence based interventions for behavior, um, whether it's, uh, visual activity schedules or behavior specific praise, um, you can find that on my website, I'm sure it'll be linked somewhere. Um, so there are these evidence based interventions that SLTs can implement independently that will help them manage behavior in their settings. Um, but from all of my research, from all of my understanding, the best behavior [00:43:00] management system, Is the one that the student's already receiving. Um, if the, you know, if you're working with a student who has a behavior specialist, um, or a behavior plan, that's implemented by a special education teacher, um, make sure you take the time to learn that plan and, uh, you know, be there for those meetings because, you know, behavior overlaps with our, our scope of practice, you know, especially because of that whole, uh, language to behavior association. Um, but make sure you learn what everybody else is doing to, uh, support behavior. Um, in that way you can, you know, continue yeah. To manage that behavior plan, um, across all settings, not just the classroom, but in your speech therapy setting too. Um, and that will be more successful than anything the SLP tries to implement independently. [00:43:52] Amy Wonkka: And I think, I mean, just to think more about the interdisciplinary collaboration, it does keep [00:44:00] also bringing me back to educating other providers in your institution about this connection between behavior. And language. Um, and so, you know, if you're in a school, just being aware of what that referral process looks like, making some connections with whether it's behavior specialists or special educators or whomever is sort of driving the Boston terms of behavior management and behavioral supports for students in classrooms. Um, you know, maybe, maybe just reach out in a friendly way and, you know, let people know that you're a resource. And I think, you know, Reid, you made the point the last time I brought this up just about the reality that, you know, there aren't enough LPs and we're all like drowning under these scary caseloads. Um, you know, and that's sort of a separate soap box that I get on about advocating to make sure that your employer adequately staffs your position. Um, but yeah, just thinking about, you know, extending it obviously through the therapeutic piece and implementing the [00:45:00] behavior plans consistently, but also making sure that. These kids are even on your radar because mm-hmm, some of the figures we talked about earlier today indicate that there probably aren't awful large. There's probably an awfully large number of those students who, who we don't even  [00:45:16] Kate Grandbois: know about.  [00:45:17] Reed Senter: Yeah. And delinquency aside, um, we need to be mindful of that language and behavior association. Um, I think it's, if you, uh, you know, if you find a kid in kindergarten who has, uh, um, some sort of language delay or disorder, um, they are twice as likely as they're typically developing peers to develop, um, challenging behaviors, um, you know, within the next couple of years. Um, and we see that, uh, not just in, you know, those externalizing behaviors, um, those are the ones that we. You know, based on the name, we can see them externally when a kid's throwing a pencil. Um, you know, that's an externalizing behavior. We can see that when a [00:46:00] kid's, uh, bullying a kid or some, uh, calling somebody names, um, or, um, you know, just hopping out of their seat, those are externalizing behaviors. Um, you know, we see those manifest, um, but also internalizing behaviors. And I don't know, uh, you know, again, I was blissfully unaware of this, um, but I don't know how many SLPs are aware of, you know, the propensity for, uh, internalizing behaviors in children with language disorders. We think of that as anxiety, depression, um, you know, other clinical things like that. Phobias children with language disorders are, um, You know, again, twice as likely to experience, um, both externalizing and internalizing behaviors, uh, over the course of their lifetimes. Um, so these children that we're working with, you know, um, as a school based SLP, you know, language was a huge part of my caseload. These children are very, very likely to present with some sort of challenging behaviors, whether it's something we can see or something that we can [00:47:00] see. So it is vitally important that we, you know, we take advantage of the resources at our, uh, disposal, whether it's evidence based practices or whether it's, um, you know, Collaboration with our colleagues who might be better versed in, uh, um, you know, the practices than we are, or even just the colleagues that are better versed in the students that we are. Um, you know, I see, you know, say Johnny, I see him once, maybe twice a week for 30 minutes and his teachers, um, spend hours a day, maybe, um, with him, um, they know the student well, so they are a resource, um, for, you know, what's going on in their lives and how we might be able to manage it, to get the most out of our limited time with this child. I so  [00:47:45] Kate Grandbois: appreciate the, the point that our students with language disorders are also at risk for internalizing, uh, I think I was aware of that, but when you said it, it [00:48:00] really resonated with me a lot more. Um, and again, just considering the seriousness with which we need to approach our treatment and our evidence based treatments, that we're not just very rarely are we just treating language. There are so often so many more, um, related issues or experiences that go along with a language disorder. And if we just treat the language, we're not really treating the whole child, we're not treating the whole system. We're not really engaging in as much person-centered care as our code of ethics and evidence based practice models call us  [00:48:40] Reed Senter: to do absolutely. It's all about taking a holistic view. Um, you know, when I'm working with a, a student, um, You know, I'm not thinking, you know, oh gosh, I hope 10 years from now. Um, I really hope he's just mastered his prepositions. I'm thinking 10 years from [00:49:00] now. I'm really hoping that the student, you know, has the, the tools necessary for success, um, in language or speech or fluency or, um, what have you, you know, all of those are components of success. Um, but by taking a holistic view, we can just make sure that we keep the bigger picture in mind. And I'm not saying that we need to treat everything. I'm not saying we need to be a counselor and a behavior technician and a psychologist. And, uh, um, teacher, I'm not saying that we need to do everything ourselves, but we owe it to our students to be a part of that, um, collaborative network to make sure that, um, You know, we're providing them with the holistic services that they need, but then also that their providers in other settings, um, are also, um, you know, providing them with the services they need. Because if they're working, say with a, a psychologist or a counselor or somebody, um, who's trying to teach them, um, you know, say self-regulation, but they're using [00:50:00] vocabulary. That's way outside of this student with a language disorder's, um, capacity. Um, you know, they're not gonna have the, um, they're not gonna be set up for success either. So by being part of that collaborative network, um, we just really need to be ingrained in the whole entire, um, whole holistic process of maximizing the student success.  [00:50:22] Kate Grandbois: So we've got, I'm just thinking about our third learning objective related to linguistic and behavioral supports. We've gone over some of the behavioral supports, um, antecedent, behavioral consequence, collaborating with behavioral oriented, professional, maximizing a team approach. Um, I'm not sure if you have other behavioral support suggestions, but I also wanted to know about linguistic supports that you would, that the research shows that you would recommend.  [00:50:50] Reed Senter: Yeah. Um, and again, before we move on, if you want to, you know, hear more about those behavior, um, specific evidence based practices, there are some that are available on my [00:51:00] website. Sounds like, uh, you all have had great conversations on your podcast as well. So those resources are there. And please take a couple minutes to, uh, familiarize yourselves with those resources. Um, but in terms of linguistic supports, um, I think that's, that's where SLPs shine. And I don't know that there's a whole lot that I can, uh, you know, tell your listeners that they won't already, uh, you know, know in some sort of level, um, because I'm sure your listeners are at the very peak of, you know, practicing with evidence based practice. Um, but I do really want to, uh, you know, single out literacy as being a big deal. Um, and again, we haven't yet done a systematic review of, uh, juvenile justice interventions. Um, but some of the articles that, uh, you know, we've come across in our research, um, suggest that literacy is the number one predictor for reducing recidivism. Um, if a child gets a literacy intervention, perhaps [00:52:00] while they're, uh, incarcerated, um, That will be the one biggest factor in whether they become a repeat offender or not. Um, if they can get that literacy intervention before they offend for that very first time, um, that might help divert the pipeline. Um, so I know, you know, literacy is, uh, it's one of those things that I think more and more LPs are talking about it. Um, and there are, you know, an increasing number of resources out there for evidence based practices and literacy. Um, and I, I do want to, uh, you know, embrace the science of reading approach. Um, I'll just go ahead and align myself with that, um, pipeline. Um, But in terms of literacy, you know, some schools might have reading specialists, some schools, um, might say, you know, oh, literacy, you know, that's not necessarily the SLP, we'll just have this other person work on it. Um, but if you're in a school that lets you work on [00:53:00] literacy, um, I know we're already overworked as it is, but if we can work on literacy, that might be one of the biggest factors, um, in diverting the school to confinement pipeline. Um, so keep that in mind, especially when you've got a child who's, uh, you know, um, been placed at risk for behavioral concerns that you think, you know, oh, they're gonna end up as, uh, you know, juvenile delinquent or something like that. Um, make sure those kids are getting the literacy instruction that they need.  [00:53:29] Kate Grandbois: I have one quick que I'm sorry to interrupt you, Amy. I have one quick question about that. So what we've learned just through interviewing, you know, on our podcast interviewing other literacy specialists, is that depending on where you are in the country and depending on, on your workplace setting literacy might not be within the scope of practice or within the role of the S L P on the team. Because it, my impression is that literacy intervention can often be the [00:54:00] role of a reading specialist or a resource specialist, or, uh, you know, various titles, depending on, on where you work. And I'm wonder. If there are LPs listening who don't feel that literacy intervention is within their scope of competence, um, in terms of, you know, intervening within their therapy time, would you recommend having this direct, you know, bringing this issue to light when in a collaborative relationship or having that SLP reach out to the literacy, the person who is in charge of literacy instruction, I also have to assume that early screening and identifying is a huge piece of this. So maybe the SLPs role is more advocating in case they have a, a hunch that someone needs to be screened. Can you tell me a little bit more about what an SLP can do if they're not in charge of litera in charge of literacy, or if they don't have it in their scope of competence?  [00:54:55] Reed Senter: Yeah, I definitely think those are two very real, very major issues. [00:55:00] Um, for an unrelated research project, I was interviewing SLPs across the country. Um, uh, that was about, uh, executive function interventions. Um, and the one thing that I kept hearing, uh, across interviews, um, was that SLPs are getting pushback, um, saying, stay in your lane, um, in different schools. And that was true for executive function interventions. Um, but they also mentioned that, you know, oh, it's kind of like with literacy too, stay in your lane. Um, so yes, I'm sure there are highly qualified SLPs out there. Um, who could do wonders for literacy that are being told, stay in your lane? Um, if that's the issue, I highly encourage those SLPs. Um, you don't necessarily need. Teach literacy in your sessions, but work with the people that are working on literacy with these students, um, and make sure they know what they're doing, make sure they're embracing the signs of reading, make sure they're teaching, um, both decoding, um, comprehension, [00:56:00] um, all of that, um, stay away from that whole like, oh, what's the first letter. Can we guess? Can we look at these pictures and uh, um, you know, make a guess what this word is. We want to teach, you know, real skills, decoding and comprehension. Um, so. There are plenty of ways you can embed literacy in your therapy. Um, you can say, oh, I'm working such and such skill and we just happen to be doing it through a book. Um, and then again, it just comes back to that collaborative relationship. If you have a relationship with the reading specialists where you can, you know, support evidence based literacy practices and, um, you know, bring to their attention, you know, Hey, are you working with Johnny? He has, um, emotional and behavioral disorders. And I know these kids are at a, um, hugely heightened risk for literacy problems too. Um, you know, whatever it takes to make sure that the child is receiving the services they need. Um, so that's, I think the first issue you brought up, but then the second issue, um, SLP, [00:57:00] who don't necessarily feel like it's within their scope of competency. Um, and that's, that's a huge problem because. We are a profession where we're encouraged to be, you know, jacks of all trades, um, and arguably masters of none. But there are just so many trades that we can't even be jacks of all of them, much less masters. Um, so if literacy is without, um, or outside of our area of expertise, um, I mean the easiest solution would be, Hey, go educate yourselves. And I know that's so easy for me to say from the other side of things, like I literally have time in my day devoted to just reading, cutting edge research. Um, that's a luxury that school based SLPs don't have. I know that's, I mean, let's be real. That's a huge reason why I got back in academia. I was, uh, spending my lunch breaks in, uh, the Asha journals. Um,  [00:57:59] Kate Grandbois: You guys are the same. [00:58:00] I'm just saying you've met, you've met a match  [00:58:02] Reed Senter: in each other on top kindred spirits but, uh, um, whatever it is, the easy solution is, you know, well, let's shore up that weakness. Um, that might mean listening to, uh, some of your nerd cast episodes, that address literacy. Um, wouldn't that be cool. Um, but again, it's just, it's all about making sure that the students get the, the services they need. So if you don't know literacy, if you don't feel confident, if your idea of good reading instruction is well, let's take a look at these pictures and guess what's going on here. Um, and maybe that's what the words say. Um, I encourage you to refer to someone else. Um, we should not be practicing something that we do not feel professionally competent in. Um, so until we can address that area of competency, um, Please make sure the students are getting the services that they need. Cause again, these are the highest stakes imaginable. [00:59:00] This is incarceration here  [00:59:01] Amy Wonkka: and it's, and it's such a good point that first of all, we, we can't reasonably know all the things in our scope of practice, which is gigantic. Um, and a referral is not a bad thing. We don't have to know and do everything it's physically impossible for us to know and do everything. Um, but what we can do is identify this need and this knowledge, that literacy is such a pivotal skill. Um, for our students who, who either are, or may become youth offenders and engaged in the justice system, um, we can be aware that literacy is really important and we can make sure that these students are connected with the appropriate resources and make those appropriate referrals. Um, I also did wanna let our listeners know. We had in season three, episode 23, we had Tim DeLuca and Kate Radwell come in and talk to oh, great. Specifically about DLD and dyslexia. And what does it mean for [01:00:00] the SLP? So that might be, that's like a nice intersection, um, of those pieces that for those folks who maybe it's not in your scope of competence, but, or, or you just like to add to your knowledge base on that, that might be, um, was a fun podcast. Give it a listen.  [01:00:16] Kate Grandbois: We also had one on, uh, with Jeanette Washington related to dyslexia, um, evaluation and different state regulations. So that's another resource that we can, um, link in the show notes.  [01:00:29] Amy Wonkka: So one other thing that kind of stuck out to me as I was reading your article, um, was that, you know, the language disability is a huge piece, but it's definitely not the only variable that seems to make a difference in terms of who, what youth find themselves engaged in our criminal justice system. Um, so some of the pieces that really stuck out to me. These very stark differences, um, across racial and ethnic groups, um, as well as some [01:01:00] real differences across socioeconomic status, specifically the correlation with poverty and likelihood of a language disability, and then also likelihood of being involved in the criminal justice system. So I didn't know if you could talk to us just a little bit and inform our listeners who might not be aware of. Significant differences.  [01:01:22] Reed Senter: absolutely. And I'm glad you asked about this because it's just a very vitally important component of this whole puzzle. Um, I want to be clear and make no mistake about it. The school to confinement pipeline is a deeply racist institution. Um, it was conceived in racism. It perpetuates in racism. Um, it unfairly targets minorities. Racial and ethnic minorities. Um, and as such, it is just one of the grave injustices that plates our society. Um, [01:02:00] The, the school to confinement pipeline, uh, a major component of that is zero tolerance policies instituted in schools. Um, and you might think like, oh zero tolerance, you know, that's fair. That treats everybody the same way. Um, but we find is that it's not fair that it doesn't treat everybody the same way. Um, zero tolerance policies are most likely to be implemented in a, um, You know, minority school districts, urban school districts, um, you know, school districts where those kids are, the ones that, you know, get locked up. Um, part of that might be differences between, um, you know, the, the racial and ethnic and cultural backgrounds, um, between the teachers and the students. Um, we know. Black children are more likely to see in school, uh, in school, um, when they have black teachers. Um, I don't know how much of that is, uh, just being able to receive the culturally relevant [01:03:00] instruction that they need. I don't know how much of that is, um, because the teachers can recognize. Um, or better equipped to recognize, you know, actions and behaviors as, um, cultural rather than, uh, um, you know, problem behaviors. Um, I don't know how much of that is the fact that, um, perhaps white teachers, um, don't necessarily understand, um, you know, dialect the difference between dialect and disorder. Um, and really when it comes to our meta-analysis. Um, the whole dialect and disorder thing really is the elephant in the room. Um, because when we first started, that was one of the things that we were interested in. We wanted to see, um, how many of the participants in, you know, each study, um, spoke, say, you know, African American vernacular English, um, a, a V E um, as opposed to. You know, the standard American or general American English. Um, but the, [01:04:00] the studies didn't mention that the studies didn't mention dialect. Um, I'm personally curious because we know. Um, you know, people with different cultural and dialectal, um, differences are overrepresented in speech, language pathology, um, they're overdiagnosed with language disorders. Um, I was wondering, you know, what kinds of culturally relevant assessment practices, um, are these researchers using in their studies to, uh, ensure that, um, you know, they're correctly distinguishing between children in the pipeline who. You know, dialectal differences in disorders. Um, I couldn't really find anything. Um, you know, I, I didn't read every single one of the studies. We split them out, you know, between three different readers. Um, But none of the studies I reviewed made any mention of dialect or culturally relevant assessment practices. Um, so many of them relied strictly on [01:05:00] standardized scores, like, uh, um, you know, the self or, uh, the, you know, the whisk language measures, um, Peabody, picture, vocabulary tests. So many of these, you know, they're staples of our, uh, you know, SLP practice, but. Not necessarily equipped to, uh, discern between dialectical differences, cultural differences, um, and what actually is, um, a real disorder. So that's the elephant in the room. We, we know that black children and other minority children are overrepresented in juvenile justice, confinement settings. Um, we know that many of those children speak in. Um, you know, different dialects. Uh, we know that our profession, speech language pathology, uh, is over 90% white. Um, so we just, that's one of the mysteries. We, we don't know how much of this is accurate and how much of this is just manifestation of a deeply racist school [01:06:00] confinement pipeline. [01:06:03] Amy Wonkka: Thank you for sharing all of that. I think. You know, another really important piece is. Being aware of culturally responsive assessment practices in general, and moving away from this overreliance on norm reference assessments because we know, and we're learning more and more about how to be effective in our assessment process. Um, and hopefully in the future, that will be better represented. The literature to come, it would be great to see, you know, future studies looking at dynamic assessment and maybe incorporating some components of norm reference assessment. If it's appropriate, if it, if the normative sample even just re even reflects the. Population of students we're testing. Um, but I think that that's, that's hopefully a shift that we'll see more and more in our field, because it is a problem. We don't, we as a population, as we sit here through, you know, three white people talking [01:07:00] about this, but we don't as a field, represent the diversity of the clients who we're serving and we need that's, that's something we need to be very aware  [01:07:09] Reed Senter: of. Absolutely. [01:07:12] Kate Grandbois: And if anyone who is listening would like to learn more about the relationship of linguistic diversity, language, ideology, and racist infrastructures and white supremacy. We did interview a researcher at Chelsea PVE on that exact topic it's in our library and the Ashe CEU for that course, our process for free. Um, it was a really wonderful conversation and we encourage anyone who's not familiar with Chelsea Pervet and her work to, um, look it up. We will list it in the show notes as.  So before we wrap up, I'm wondering, are there any other linguistic supports that you would recommend an S L P be aware of in terms of, um, mitigating risk or identifying risk factors?  [01:07:56] Reed Senter: And again, SLPs should hopefully know, [01:08:00] um, you know, their preferred evidence based practices. Um, I don't think any of this specifically speaks necessarily to, um, you know, youth offenders or children place that risk for youth offense. Um, but for that population in particular, it's so vitally important to teach functional transferable skills. Um, so if you're working on say vocabulary, for instance, um, Teaching functional vocabulary. Um, but also teaching it through roots and a fixes, um, that can be transferred to, uh, you know, other contexts and other settings, um, you know, teach things that will matter, teach things that will be important to their lives. Um, I know we're running low on time, so I do want to give, um, a brief shout out. Um, let's see, in, uh, 2019 or no, 2020, um, Dr. Shamika Stanford, uh, published an [01:09:00] article in an Asha journal school based SLPs role in diverting the school to confinement pipeline for youth, um, with communication disorders. Um, and that article talks a lot about, you know, the overlapping risks between, uh, developmental language disorder and juvenile justice, like, uh, low verbal intelligence learning and reading disabilities, impulsivity, low theory of mind and empathy. Um, all of those, you know, Concurrent risks. Um, but then it goes on to talk about what SLPs can do. Um, you know, both through the identification, um, assessment goal setting, and then, uh, most importantly, culturally and linguistically relevant intervention. Um, so if any of your listeners are wanting additional information beyond just, you know, behavior language, it's important and that's, you know, what sets the S for delinquency, um, that might be a good article for them to check out as. [01:09:56] Kate Grandbois: And we will link every, all of the articles that you've mentioned and all [01:10:00] the resources that we've mentioned will be linked in the show notes. Um, they'll also be listed on the web, on our website for anybody, if you are commuting or jogging or folding laundry, and your hands are busy, all of those resources will be there for you to check out later at another time we have so enjoyed this conversation, and I'm so grateful that you were able to, to join us this morning. Do you have any last words, any parting words of wisdom that you would like to leave our audience with?  [01:10:31] Reed Senter: What we do is important. Um, whether the child is a youth offender or on the path or, um, you know, or not what we do is important. So we owe it to ourselves and more importantly, we owe it to the children that we serve, um, to do the best we can. This is important. Um, and it really can make a difference. So, uh, Another important piece of this puzzle is advocacy. And of course I'm a little bit biased because I served as a, [01:11:00] um, you know, the vice P uh, president for governmental affairs, um, for my state association, um, and a large part of that was just trying to drag people into advocacy. And I think there's this misconception in our field. That advocacy means. You know, showing up on advocacy day, carrying a sign, maybe talking and shaking hands with a couple legislators, which is just deeply and profoundly intimidating. Um, and then going home, um, that can be a part of advocacy, but it's so much more than that. Um, part of our role is to advocate for ourselves. If we don't feel like we have the knowledge in culturally. Um, relevant assessment and instruction. Um, we need to advocate for, um, ourselves to be able to, you know, pursue continuing education on that topic or, uh, you know, get an in-service or professional development. If we feel we don't have the resources to do so, we need to, um, advocate for that. If we feel like we need, uh, better instruction or, [01:12:00] um, materials for literacy assessment. Um, we need to advocate for ourselves for that. So advocate for yourselves, um, advocate for your students. Um, and we've talked about this throughout the podcast. Um, make sure you, uh, explain the impact of language, um, to all of the stakeholders. Um, make sure the students understand, you know, Why am I like this? Why am I getting speech therapy? My speech is fine. Oh, it's my language. Um, explain to them, uh, explain to their educators. Um, if your student is involved in a, um, you know, one of the, um, You know, meetings. Oh, shoot. What's it called? Student  [01:12:39] Amy Wonkka: referral, like student referral process, I guess. [01:12:42] Reed Senter: Yeah. If your student is involved in one of those, um, you know, make sure you explain to the other educators the impact. Um, if they're getting in trouble, if they're about to be expelled for a behavior, um, talk about how their language may have, uh, you know, influenced their behavior there. Um, so, you [01:13:00] know, advocate for your students advocate for yourselves, um, advocate for fair policies. Um, Policies that will hear out students rather than say a zero tolerance policy that doesn't give the student the opportunity to explain or defend themselves, um, advocate for, you know, a, uh, a fair process where you can hear them out in a way that even with a language disorder, they can make themselves heard, understand, um, and help them advocate for themselves. And then yes, finally, it's hard. Advocate for legislative policies that support schools and reduce incarceration, research, and vote for candidates that support these policies, um, call your legislators. You can write to them. Um, it's so easy. Um, you know, whenever Asha has one of their, uh, Asha advocacy things, um, you can just type in your name and your email address, and they'll practically auto fill it out themselves, but I really encourage you all to, um, You know, reach out to your legislators personally. [01:14:00] Um, it's intimidating. And if you don't wanna do it directly, maybe get involved with a state association. Um, it's also working with those state officials. Asha handles a lot of things at national levels and Asha supports, um, state associations, advocacy. Um, but a lot of times it is these state associations, um, that have the best chance to have things matter, um, at the level that it can actually be dealt with. So, um, Yeah, I know advocacy is scary, but please try your best to get involved. It's it's important and it matters. I also  [01:14:32] Kate Grandbois: think that based on what you, what I've heard you say, SLPs are in a unique position to be advocates based not only on our roles within school systems, but also because of our unique knowledge. Related to language disorders and how, and now that anybody who's listening has taken this course, . And how language disorders are related to school to, to this school, to confinement pipeline, particularly.[01:15:00]  And I'm going to quote again, your article, um, when it comes to ultimately changing quote, ultimately changing the life trajectory of youth via evidence based practice and intervention. So, um, we are in a really unique positions to support that advocacy.  [01:15:18] Reed Senter: I like what you're saying there, especially about us being in a unique position, um, because yeah, speech, language impairments are what the most common or the second most common, um, eligibility category in the United States. Um, so if you're building a personal connection, if you're talking to, um, You know, you're a state legislator, for instance, there's a decent chance that they may say like, oh yeah, I have a nephew who, uh, sees a speech therapist or something like that. And that's a connection that you can use. You can be like, oh yeah, tell me more about them, you know, learn about their issues. Oh yeah. You know, I work with students like that. I also work with these students who are at risks and that's, that's a segue that you can use to, uh, um, [01:16:00] you know, Build that personal connection, which is super important, um, for advocacy purposes, but then also segue it into, you know, whether it's, uh, you know, the youth to confinement pipeline or whatever you're advocating for. Um, just build that connection and leverage it. [01:16:15] Kate Grandbois: Thank you so much. Thank you so much. This was really, really wonderful, and we really appreciate your time.  [01:16:22] Reed Senter: Thank you for having me. It's been a pleasure.   [01:16:25] 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 [01:17:00]  thank you so much for joining us and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published May 23rd, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). 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 . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:40] Kate Grandbois:  Today's episode we get to welcome back, uh, someone who has been on our podcast before, who we have so much fun with. As a matter of fact, before we even hit the record button today, we've been chatting and laughing for about half an hour. So we're really excited for today's guest. We are really [00:02:00] excited. Um, we're really excited for today's guest. Welcome back, Dr. Lindsay Griffin.  [00:02:05] Lindsay Griffin:  Thank you. Thank you for having me. I too, am excited to be here.  [00:02:10] Amy Wonkka:  It's always nice to see you. Um, and today you are here with us to discuss complex airway management. Before we get started can you please tell us a little bit about yourself? [00:02:20] Lindsay Griffin:  Sure. So I am Lindsay Griffin and I work at Emerson college where I am an assistant professor. My main topic area is dysphagia or swallowing difficulties in adults specifically, but given my clinical background of working in acute care and in rehab, I also have some clinical experience in complex airway management. [00:02:49] Kate Grandbois:  I am very excited to learn about what that is because as our listeners know, this is very far out our scope of competence and knowledge base, and you're going to teach us all the things [00:03:00] as you always do, but with a couple of laughs along the way, I would be willing to bet. This is very exciting. Very exciting. Okay. So before we get going and start bombarding you with likely more elementary questions than you're used to, I am going to read through the learning objectives and disclosures. For those of you listening, who have asked that I have skipped these. I can't ASHA makes me read them so I will get through them as quickly as possible. If you need to put your podcast player on a 1x or a 2x and fast forward, I'm not going to tell anybody. So learning objective number one, describe the difference between tracheostomies and larygectomies. Learning objective number two, explain the SLPs role in management of patients with tracheostomies and laryngectomies and learning objective number three, recognize external resources for acquiring deeper knowledge of complex airway management disclosures, Lindsey Griffin's financial disclosures. Lindsay is an assistant professor at Emerson College, Lindsay Griffin nonfinancial [00:04:00] disclosures, Lindsey as a member of ASHA, SIG 13, and the dysphagia research society. Kate Grandbois's financial disclosures. That's me. I'm the owner and founder of Grandbois therapy and consulting LLC. And co-founder of SLP nerd cast. My nonfinancial disclosure is I'm a member of ASHA SIG 12, and serve on the AEC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy MASS ABA the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis special interest group. [00:04:30] Amy Wonkka: Amy that's me. My financial disclosures are that I am an employee of a public school system and co-founder of SLP nerd cast. And my nonfinancial disclosures are that I am a member of ashes, special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children. We've done it. We've disclosed and given objectives. [00:04:49] Kate Grandbois:  Sometimes when you say disclose, I think you say disclothed, and that makes me giggle. I just wanted to tell you that.  [00:04:57] Amy Wonkka:  Okay. We can research. If that's the word, we can be [00:05:00] smart and funny at the same time. It's fine. It's totally all right, Lindsey, why don't you start us off by telling us, I mean, like Kate said, we really don't don't know much at all here. Difference between tracheostomies and laryngectomies. [00:05:12] Lindsay Griffin:  Okay. So they are actually quite different vastly different, some would say, um, but are frequently confused from people who don't understand what they are. So a laryngectomy is usually, always, um, completed by a surgeon as a treatment for someone who has head and neck cancer and it is permanent. It will, uh, always, it will never be better in the fact that the larynx is surgically removed, the voicebox larynx, and it does not grow back. It does not grow back no. So it is permanent, whereas a tracheostomy can be temporary or permanent. [00:06:00] And, um, it is, uh, surgically placed as a way of usually helping, um, with someone's breathing. Although there are instances in which they're prophylactically placed. So they're placed before somebody has difficulty. If there is suspicion that someone will have difficulty.  [00:06:18] Amy Wonkka:  and silly question number one of many, to come. Tracheostomy, anatomically is below thelevel at the larynx, right? Like if you're picturing it in your head while you're driving along listening.  [00:06:30] Lindsay Griffin:  Yes, that is correct. It is below the level of the vocal folds is below a level of the lyrics. So the, a small incision is made on the outside of the neck and the trach tube is just sort of rested in that. And the trachtubes that's below the vocal folds. Correct.  [00:06:50] Kate Grandbois:  So do people get total laryngectomies for things other than cancer or is it really exclusively as a treatment for, [00:07:00] for cancer as the diagnosis? [00:07:01] Lindsay Griffin:  I would say 99% of the time it is because of, a head and neck cancer diagnosis, but no one ever always or nevers in medicine. So you always, you know, odd cases, but usually it's for head and neck cancer. Okay.  [00:07:20] Amy Wonkka:  So as a clinician, you're probably more likely to encounter somebody who's had a tracheostomy than you are somebody who's had a laryngectomy, unless you're, you know, kind of working in a place that's doing a lot of those types of surgeries. Is that fair to say? [00:07:32] Lindsay Griffin:  Yes, that is fair to say. And in more recent years there's been a big push for organ preservation. So the, um, face of head and neck cancer has changed drastically over the past few years. So it used to be a disease that a lot of people got, who were smokers and drinkers, and really, they just can't tease apart smoking from drinking. So they lumped them together. It's probably mainly smoking that contributes to head and neck cancer.[00:08:00]  Um, and then that cancer was commonly, if it was laryngeal cancer, was commonly treated with a total laryngectomy, but with less people smoking over the years, that type of having that cancer has the incidences have decreased. And now we're seeing a larger rise of head and neck cancers spurring from HPV, which is human papilloma virus. It's a sexually transmitted disease and it's the same HPV has the same fibers that they're looking for when women have pap smears in the cervix, HPV can lead to cervical cancer. And so when you have a pap smear, they know pretty much where, where the, um, HPV likes to hang out. And so that's the area of, of the cervix in which they scrape, but in the, um, head and neck cancer population. Where HPV likes to live is [00:09:00] a little, um, it's a little bit more reclusive in the head and neck. And so it's not necessarily an area that they can just like scrape and find out if you have it. The other part is that HPV in some people clears up by itself and no problems develop, and then other people that can lead to cancer. So in the HPV related cancers that are occurring, the population tends to be younger and they also don't have this history of smoking and drinking. And then the head and neck cancer can also occur in various places. So like the cheek, like the inside of the cheek, the tongue, the base of the tongue still can happen on the vocal folds and around those areas. But usually the vocal fold areas are more aligned with inhalation of tobacco.  Kate Grandbois: That's scary.  Yes. Yes. But with the HPV vaccine that came out a few years ago, hoping that HPV related head and neck cancers will [00:10:00] also go down as more people receive the HPV vaccine, but now there's vaping. So TBD on the outcomes of that. [00:10:10] Kate Grandbois:  So would a patient receive a total laryngectomy, if they had HPV-related cancer in their cheek as in a treatment that is like, sort of like, well, we're going to take it all out just to be safe. Or is this a very specific to it being in the larynx?  Lindsay Griffin:  Yes.  Kate Grandbois: I told you they were going to be very rudimentary questions. [00:10:31] Lindsay Griffin:  The, uh, total laryngectomies are and partial or inductors are in response to cancer of the larynx specifically.  [00:10:41] Kate Grandbois:  Okay.  [00:10:43] Amy Wonkka: So these, these two different procedures are really different. We talked a fair amount about laryngectomies. It sounds like that's really specific to a cancer of the larynx, which that demographic is shifting because it's kind of a different [00:11:00] reason that we're seeing people are coming in with these cancers. Tracheostomies, I feel like even when I was in grad school, you know, I had some patients who had tracheostomies for, for a number of different reasons. I, I wonder if you can talk to us just a little bit about what some of the reasons might be, that you might as a speech pathologist, be working with somebody who has been given a tracheostomy. [00:11:24] Lindsay Griffin:  Sure. So, um, one of the biggest reasons that people get trachs or tracheostomies is because they have prolonged need for mechanical ventilation. So they've had some sort of medical illness, whether it's a stroke or they've had some sort of respiratory disease or something that takes them to the acute care hospital. And potentially, usually, they are intubated first, which means a breathing tube is in their mouth, goes down the back of their mouth and then through their vocal folds and rests there. And so usually it's like taped across their mouth as well. So it doesn't fall out and they're usually [00:12:00] sedated, uh, to some extent and that's so that they don't pull it out cause it's an uncomfortable process. And so then that ET tube is what we call it. The one that's in the mouth is then connected via tubes to a ventilator, which is a machine that's helping them to breathe at varying levels. So when someone is well enough, the team, the medical team will. Try to take the ET tube out or at least change the ventilator settings. And hopefully the person can now breathe on their own. Everything's fine. They, they breathe on their own, but in some instances, um, they aren't able to wean from the ventilator and they've had the ET tube in their mouth so long that it's now we need to figure out a new plan. They're going to need ongoing support. And so then they have the surgical procedure where this incision is cut on the external part of our neck. And the tracheostomy tube is just laid in into their trachea. That is one of the main reasons [00:13:00] that somebody would get a trach and then that tray can be attached still to the ventilator and they can continue to receive that same level of support, but they also can wake them up now. So they're not so sedated or not sedated at all and get them sort of up and moving, which then all of those mobility components then, um, increase their, their readiness for rehab and hopefully it helps with their health.  [00:13:24] Amy Wonkka:  There, there are a number of different pieces. I was wondering if you could refresh my memory a little bit about, you know, there's, there's not just one type of trach, right? There's a lot of different, [00:13:33] Kate Grandbois:  like I remember the word cannula, is that a word that is used as a word, memory? [00:13:39] Lindsay Griffin:  Um, so there are some trachs that have double cannulas using your word. Yeah. And so, uh, they have the part that goes in a person, but then inside of that is another tube and that is really just [00:14:00] for cleaning purposes. So if the person has a lot of secretions, they tend to have, um, a tray with two cannulas, double cannula, so that you can take out that middle one, clean it or replace it. And. Um, what do you don't have to actually replace the whole trach? Um, trachs also have, can have a cuff. And so that if you are looking at the person outside of their body attached to the trach, there will be kind of like this little balloon filled thing that's hanging off of their trach. And that corresponds to sort of a little balloon thing inside their body. That's wrapped around the outside of a tray. And so when there is air in the balloon outside of their body, then the balloon that's inside their body is also full of air. And what that does is that it closes off their upper and lower airways from one another.[00:15:00]  And so they're really just breathing in and out of the trach that is in theur body. Whereas if the cuff is deflated so that there's no air in it, or if it's a cuffless trach, then air can still move around the trach and up through the vocal folds, and then up through the upper airway, whether or not someone can be successful with their cuffed, successful with voicing, um, with their cuff deflated or with a cuffless trach depends on a lot of, um, they're like in like personal factors, like the strength of their respiratory system, for example. So maybe they have a really strong, um, respiratory system. And so they can get enough air up through the vocal folds, despite having this also hole in their, in their neck. That is a tracheostomy. And so their vocals can still vibrate and still reverb up through their resonance's track and then be articulated and [00:16:00] still make speech. But what some folks aren't able to do that. Another variation of the trach is the, um, the size of it. So eight is a pretty large one and it is the diameter of the trach is what the number refers to. And then a four is a pretty small one. So usually like a 6, 7, 8 are the more common ones in adults. And so if somebody has an eight, for example, that whole, that external hole, which is really the trach tube in their neck, is going to allow more air to go out of it. And it's going to take up more room in the trachea versus, um, uh, six for example, which is going to have a smaller diameter. They might be able to push more air up, past it through the vocal folds and use that air for speech. Does that make sense? [00:16:48] Amy Wonkka:  That makes so much sense that that was so informative, what about speaking valves? Is that a thing? [00:16:57] Lindsay Griffin:  Those are a thing before I [00:17:00] talk about speaking balance, I just want to just sort of go back to your other question about why people might get traipse in addition to prolonged need for mechanical ventilation. Um, another reason that somebody might get a trait is prophylactically. So before they actually need it. And we see that sometimes in the head and neck cancer population or the ALS population. And so with head and neck cancer, if their cancer is close enough to the airway, that the medical team suspects, that one, the part, when the person begins to receive chemo or radiation, and things start to swell that it might occlude their airway, then they would get a trake placed prophylactically just while they're undergoing treatment. And then once their treatment is over, then it would be removed. Um, for folks with ALS some choose to, um, go on a ventilator, um, sometimes at home, toward, as the disease progresses. And so even before they need the trach or vent for, um, actual breathing, sometimes they have the trach placed [00:18:00] so that when it comes time to need mechanical ventilation, they will, um, just have the trick as well as actually the G-tube usually placed surgically as well, because both of these, the trach and the G-tube require some anesthesia to be placed. And usually by the time that they get to the point where they need the trach for breathing, then it becomes a little unsafe for them to have the anesthesia so they can sometimes have it placed early as well. And then the finals, and then I'm going to mention is usually for secretion management and you see that you tend to see that, um, you can see it across the lifespan, but in kids sometimes you'll see trachs placed for, um, if they just have a lot of secretions in their aspirating that, and they need a lot of, um, we call it pulmonary toileting. Basically they need like a lot of sectioning and help to get their, um, secretions up. Then a trach can be placed to help with those things. Because the other thing about trachs is that it allows for direct suctioning of secretions, um, with a suction catheter that you, you being SLPs [00:19:00] as well can put in the trach on the outside of the person's body and suction the stuff that's hanging out. [00:19:08] Kate Grandbois:  that was always a lot of vocabulary that I'm just not familiar with. Particularly pulmonary toileting, never heard that term. Is that really what it’s called?  [00:19:18] Lindsay Griffin:  Yeah. Feel free to use that Amy Wonkka:  catchy. [00:19:24] Kate Grandbois:  You've given. I mean, this is, this sounds like a very complicated process. It sounds very intimidating. And I have a question that's related to our next learning objective in terms of safety and training. So when an SLP is involved in the team, I mean, I'm thinking about myself as a new grad. There is no way that I would have been qualified to do any of those things. And I know, you know, we go into our workplaces and we have supervisors and we have CF supervision, but I'm, I'm under the impression that this is a [00:20:00] medically fragile situation that requires a lot more training for safety purposes. Is that an accurate assumption? [00:20:06] Lindsay Griffin:  Um, yes. This is a population that tends to be more fragile and you do need some extra training. Um, when I was interviewing for CFs. I didn't have any experience in complex airway. And I really wanted some, so when I, when I got my CF, I was hounding my CF supervisor repeatedly for experience in complex airway, which she eventually granted, which, I mean, it makes sense that it wasn't like day one, but I wanted it to be, I was so excited. So, um, I always tell students that anytime that they can even just be in the room with somebody who has a complex airway and asking questions about it, that it is good to have in your back pocket.  [00:20:50] Amy Wonkka:  And I mean, there are also, I'm sure a lot of other professionals that you can learn from not just the speech pathologist, but maybe respiratory therapists, [00:21:00] physicians, surgeons, it's such a specialized area of the field. [00:21:04] Lindsay Griffin:  It is, it is. Um, yeah. ENTs, surgeons. Pulmonary pulmonary pulmonologists and definitely respiratory therapist. I would say even, even respiratory therapists are the most accessible of the list that we just, we just went through. And when I worked, I worked at an LTAC, a long-term acute care hospital as, as my CF. And so our respiratory therapists were just like wandering around caring for patients and I'd be like, Hey, can we talk about what PEEP is? Because I just couldn't understand some of these terms that I was reading about. So, and they were obviously, so-so, so-so helpful.  Kate Grandbois:  What's peep.  Lindsay Griffin: Peep is, I don't know why it took me so long to understand what the heck this is, but you know, if you think about your lungs and there's these little air filled sacs that just keep getting smaller and smaller and smaller, the smallest of them are called the alveoli and everyone's alveoli.[00:22:00]  Tiny bits of air in them to keep them inflated, they cannot be completely deflated or we will suffocate. And so that air is called that tiny little bit of air in the alveoli is called peep. And the reason that it was something that kept coming up and notes was that when somebody is on a ventilator, one of the settings is the amount of peep that the vent is providing to the patient. And I, and, and sometimes that can be the higher levels of peep that they're receiving means they’re, they need more vent support than somebody who has a lower amount of peep. And so I, I understood that concept, but I wanted to know like what the heck is peep and one day. Claire, the respiratory therapist finally got through to me and I was like, wow [00:22:46] Kate Grandbois:  Claire, the respiratory therapist has now contributed to educating however many people are listening to this. So thank you, Claire is a trickle down effect of knowledge, right there. There you go. This is why we need to learn from our peers more often. [00:22:57] Lindsay Griffin:  That's right. [00:23:00] There's also really great external resources too, that, um, anyone who's wanting, um, experience with complex airway should definitely think about, Passy-Muir valve, which are the speaking valves that you mentioned that I would love to talk more about. But Passy-Muir is one of the bigger names of the speaking valve companies, and they have a ton of free resources on their website for clinicians about what the heck is a speaking valve and how do I assess for it and what things do I need to know. And they also have really great reps who will come out and do in-services to like the whole rehab community at your hospital or whatever the case may be if you request them.  [00:23:43] Amy Wonkka:  It's funny because one of the things we were talking about before we started talking with the recording feature on was just like these funny analogs between the area of AAC, where Kate and I work and you know, this area of dysphagia. And I think that that's one piece that's another kind [00:24:00] of commonality is, you know, having these relationships with the vendors of the equipment that you may be using with your patients and just knowing that they are a resource where you can learn so much and don't hesitate to, to kind of seek that information out and learn more from the people who are actually making the products that you're using or might be using. [00:24:22] Kate Grandbois:  And I I'm pretty sure Passy Muir has. Um, I'm pretty sure they have free ASHA courses for free Ashesi use on their website, just as another.  [00:24:37] Lindsay Griffin:  I and another brand is called Shiley and Shiley has some resources too, but not as, not as well known as Passy Muir. PMV has also Passy Muir valve, the lingo. I will say that, um, a lot of the research that Passy Muir talks about on their website, they paid for that research. So, you know, be aware of [00:25:00] potential bias, but the product is a good product and very well used and they do offer free CEUs. It can be a wealth of information.  [00:25:09] Kate Grandbois:  Well, that sort of brings us to a more direct question about our second learning objective about the SLPs role. So, you know, as quote unquote experts of the larynx area, you know what, assuming that an SLP who is interested in learning more about this has access to the resources that I know you haven't totally finished telling us about, but you will. So interested in this area, consuming a lot of resources, consuming a lot of CEU's let's even play, pretend that they have a mentor or a supervisor who's going to take them under their wing, which I know is not standard in a lot of work settings, but let's play pretend. Since we have two very different presentations between a tracheostomy and a laryngectomy. How does the SLPs role [00:26:00] differ between those two presentations? I guess would be my first question.  [00:26:05] Lindsay Griffin:  So for tracheostomies or trachs, it tends to be. Having them tends to tends to be more, short-term not for everyone, but a majority of people. And so, um, one of our biggest roles is assessing for speaking valve tolerance and that it can be done in an acute care. It can be done at any levels of care, even outpatient. And, um, speaking valves are typically thought about going on trachs, but there also are speaking valves that are called, um, that are also, that are speaking valves, but they're, they're inline valves. And so somebody who has vented with a trach can also, um, use a speaking valve to be able to communicate. Although that is my experience done less often because. If somebody has vented, they maybe are on the way to not being on the vent anymore. And so [00:27:00] sometimes healthcare facilities will just wait until they're off the vent. But in some instances it has been that in my experience, it's been really effective ways for people to communicate their medical wishes, have conversations with loved ones with healthcare providers, or just be able to communicate that their foot itches and they wish somebody would scratch it. So, um, inline valves certainly are something to consider, but I think that the more traditional thing that we think about is putting a speaking valve on somebody who's trached, but not vented. And, um, a speaking valve is a one-way valve, so it allows air to go in to the person, but then when they exhale or when the air is coming up from the lungs, um, the valve closes off. And then the air is forced up through their vocal folds through the residence track into their articulators so that they have speech similarly to how, how we do.  [00:27:54] Amy Wonkka:  I mean, obviously its speech itself is a super big benefit of a speaking valve. Are [00:28:00] there other benefits to using a speaking valve as well in terms of maybe oral care or, um, swallowing maybe. [00:28:07] Lindsay Griffin:  Yes. So there is research to suggest and Passy Muir is the maker of some of this research that when the, when somebody is wearing a speaking valve and it has, they have more of a restored function of, of pressures and sensation and connection of the upper and lower airways that they're swallowing can be safer as well as a result. And so there is a push for somebody to eat with the speaking valve. Although, depending upon the person, plenty of people can eat without speaking valves as well. But if you think about the primary reason that somebody has a speaking valve, which is the fact that they had this prolonged need for mechanical ventilation, if you think about it from like a rehab, [00:29:00] getting stronger sort of spectrum, okay, now they don't need mechanical ventilation. They have just a trach are they strong enough to be eating orally or do we really need to be working on the breathing aspect first? So I always tell my students in dysphagia that breathing trumps swallowing, somebody needs to be able to breathe before you can swallow. And so maybe somebody is, has an open trach, which means no speaking valve a majority of the time, but they can handle some speaking valve trials. And if their respiratory system was stronger, they could go to the speaking valve all the time. So then you would have to balance. Is the respiratory system strong enough to eat if the respiratory system is not strong enough to tolerate a speaking valve all the time. So sometimes that is the decision for why they're not eating yet because they still need to get stronger from the respiratory perspective. So then assuming they're able to tolerate the speaking valve during all waking hours, then [00:30:00] following that they usually do, um, capping trials. And then, which is basically just like closing off the trach tube and basically restores the, uh, airway to typical functioning. And once they're able to tolerate capping trials, then the trach is just literally removed, very simple. And the incision usually closes up very quickly within like 24 hours. But it will sometimes have gauze over it just to keep it clean. So usually when someone is wearing a speaking valve frequently is when we start to think about swallowing, not in all instances, but certainly in a lot of instances. So a speaking valve can help with that. Um, one of the biggest things I would like to say about speaking valves is that if somebody has a cuffed trach, so that's that balloon that's hanging out the side of them and that balloon has air in it then the balloon that's inside that's also wrapped around their trach also has air in it. [00:31:00] If you put a speaking valve on somebody, while both of those tubes, both of those balloons have air in it, they will suffocate. So it is incredibly important that you only place a speaking valve on somebody when the cuff is deflated. And that is again, because the speaking valve was a one-way valve. So air comes in. The speaking valve, but then basically the person can't exhale because the cuff is inflated. So there's no way for the air to go up through the vocal folds, but also the speaking valve was present. So there's no way for the air to come out of the trach and so they can suffocate. So it is incredibly important to only place the speaking valve on someone who you have tried to pull out all, all, all of the air from a cuff to trach.  [00:31:46] Amy Wonkka: So  just to say that one more time [00:31:48] Kate Grandbois:  I was going to say I'm sitting here at this very serious look on my face. That sounds horrible  [00:31:54] Amy Wonkka:  If we’re putting a speaking valve on an  inflated cuff. [00:31:55] Lindsay Griffin:  Yes. And you don't know what those words mean, then [00:32:00] just don't place those speaking valve.  [00:32:02] Kate Grandbois:  And I feel like if you don't know what those words means, you should maybe seek some additional supports or continuing education or supervision or something before, before you're in a position to be making that decision in a vacuum. If someone's life is on the line, that's, that's a really big deal and a tremendous responsibility. Okay. So we've talked about the, I mean, I I'm, I have so many additional questions too, but before I get to it about the medical team and collaboration with other professionals, because presumably you are not doing any of these things by yourself as the SLP, you're doing these things in conjunction with respiratory and nursing, I would imagine. And all these other kinds of things let's can we shift a little bit for a second and talk about the laryngectomy portion? So what is the SLPs role for a patient who has had a laryngectomy?  [00:32:57] Lindsay Griffin:  So, as we talked about, the larynx is [00:33:00] removed during a laryngectomy, which means the person is no longer able to speak. [00:33:04] Kate Grandbois:  I'm still giggling when, when Amy said, and it can't go back, grow back because that's like the funniest, of course it can’t. I just thought it was  [00:33:12] Amy Wonkka:  Our liver can grow back. There are funny parts of the body that it's  [00:33:16] Kate Grandbois:  just the liver right? Is there another part of our body that can grow back? [00:33:27] Kate Grandbois:  Okay. Can continue. We can table that for another time. [00:33:32] Lindsay Griffin:  So, um, yes, so it is, uh, removed and so they can't speak. And so, um, if you can see someone before they have the total laryngectomy, then certainly part of your role would be trying to figure out if they would be open to doing some voice banking, because then we could potentially build a voice for them after their [00:34:00] laryngectomy, which still sounds like them, which can be huge. There are some companies that specialize in using your own voice to build a huge collection of everything you could want to say. Um, but then there are also just some instances of like recording some well-known phrases on your phone that then you can play to your loved one, like telling your, your partner that you love them or reading a book to your kids or whatever. Maybe you always say that one silly phrase. And so people are gonna miss hearing that. And so you say that, so trying to record some things that are meaningful for the person, if they're open to it, some folks when they're diagnosed and then find out they need a total, total laryngectomy, or just in such shock. And they it's, they're like, yeah, we'll get to it. And then maybe they never do so obviously approaching it with caution. If you can see someone before the surgery, that's a great strategy, as well as talking to them about what, what methods of communication they're [00:35:00] going to use immediately after surgery. And also of course, doing education about like what it's going to be like, um, after surgery, when you, when they can't communicate in the same way. So some people write, some people get AAC devices will be this voice banking. There are, you know, like low tech, AAC boards that are in the hospital that people can point to. Like, I need to go to the bathroom, for example, things like that, but trying to restore communication the best that you can beforehand and giving people an idea of what, what it's going to be like after, because as Amy said, larynx doesn't grow back. And so this is permanent. And then let's say, they have the total laryngectomy. They are able to communicate in the short term and now that, um, things are more stable. The next thing that we think about is restoring speech and there are three main methods that we can do that with depending upon the [00:36:00] person. And so  [00:36:02] Kate Grandbois:  I think I remember two of them and I'm going to, I'm going to throw my I'm going to let myself be vulnerable here and see if I can. So one of them, there is a device that causes vibration that can be shaped by the pharynx, right?  [00:36:16] Lindsay Griffin:  Yes. That's called the electrolarynx.  [00:36:21] Kate Grandbois:  And then I want you to tell us about all of these in more detail before I list them. So this is the other one is a method where you swallow air and shape and use vibration with the top sphincter of your esophagus.. [00:36:34] Lindsay Griffin:  Yes. Wow.  [00:36:38] Kate Grandbois:  I learned something in graduate school. I was paying attention most of the time. Um, I don't remember the other ones  [00:36:45] Lindsay Griffin:  like those. So go ahead, Amy. Do you want to,  [00:36:47] Kate Grandbois:  oh, do you remember the third one dream team? Come on [00:36:49] Amy Wonkka:  No I have nothing to contribute to this. Other than saying I asked Google and the liver is the only organ that grows back. [00:36:55] Kate Grandbois:  So thank you for asking Google for all of our listeners who were on the edge of their [00:37:00] seats about body parts, they grow back. Okay. So those are two what's another one. [00:37:04] Lindsay Griffin:  Third is a puncture, which is frequently just abbreviated to T E P Kate Grandbois: tracheoesophagealpuncture. What is that?  Lindsay Griffin:  Okay, so the TEP, the surgeon creates a hole between the back of the trailer. And the esophagus and then the patient will have a prosthesis placed, um, which is a one-way silicone valve that allows the air to flow from the trachea to the esophagus and then to speak. They have to close off the stoma or the hole that's on their neck now, which is a direct access to their trachea. Um, they have to close it off, usually with a finger to redirect the air through the TEP prosthesis, unless they have [00:38:00] a tracheal stoma valve, then, then the air just naturally goes through and they don't have to place their finger. And this tends to be a source of confusion for anyone who works with patients, but not necessarily in complex airway. When I worked in acute care, we would get many consults for patients who were coming into acute care for something unrelated to their, to their airway. Maybe they fell and broke their hip. Maybe they had a heart attack. And many years ago they had had a total laryngectomy and they had something different about their neck. And so the medical team would consult speech and say, this person has a trach and we don't know how they communicate, but then when you would go and speak to the patient, it's just an old laryngectomy with a TEP. Um, and they have no problems with it and they didn't need to see us at all. So because the, um, stoma is present [00:39:00] on the outside of the neck. And also sometimes there are some things in that stoma that help the person to talk. They can, it can be confusing for people who don't work in complex airway. So when the sort of taking like five steps back when the larynx is removed from a total laryngectomy, the trachea is basically rerouted to end at the neck. So there's a hole, that's a permanent hole in the person's neck. And now they're called neck breathers by some people. And, and that can be important to know, because when you are giving somebody CPR who has a total laryngectomy, you actually have to give the breaths to the stoma, the hole in the neck versus, um, on the mouth and nose, because now the upper and lower airway are no longer connected, which is also why some people in hospitals are confused about the presentation in front of them. [00:39:57] Kate Grandbois:  Wow. Okay. That was, that was a lot. Um, I'm [00:40:00] I, my, my anatomy is really rusty, so I'm, I have the diagram in my head, but keep going.  [00:40:06] Lindsay Griffin:  Okay. So part of the SLP role is to help with placing the TEP and then also doing TEP changes because this little silicone valve is in the person's stoma forever. And so, you know, sometimes it gets dirty and needs change so that it doesn't, um, cause any infections or sometimes the stoma will get bigger, you'll need a different size, things like that. And so some people can do those on their own and then other people, um, depending upon the TEP would need help from an SLP to do that. [00:40:38] Kate Grandbois:   Interesting. So tell us about the other ones that I mentioned the electro larynx and the sphincter one.  [00:40:43] Lindsay Griffin:  Yeah. Okay. So, um, the artificial larynx is the, the main brand is electrolarynx. So they're sort of used interchangeably kind of like saying PMV versus speaking valve again, they're just a brand name versus not. And so the, um, artificial [00:41:00] larynx generates sound. It makes this buzz sound. And when the person holds it up to their neck or, or there are some that you can place it in your oral cavity, in your mouth, then they're able to shape that sound, that buzz that's created from the artificial larynx and shape that using the, um, speech articulators and make and make speech. And so I think like within the past few years, I've seen plenty of commercials about like, don't smoke, or you might have a voice box like this. And so if, if you can remember those commercials, that's what it looks like. Uh, esophageal speech, like you mentioned to the person basically like swallows air and then kind of like burps it out. And as they're doing that, it makes the PES which is the pharyngoesophageal segment. It's the top part of the esophagus. It makes it vibrate. And then they can shape that vibration again, using their articulators to make speech. But this doesn't work for [00:42:00] everyone based on the amount of tissues that were taken during the total laryngectomy. Sometimes there's not enough PES or pharyngoesophageal segment to vibrate to produce sound.  [00:42:11] Kate Grandbois:  I would also imagine that would take some training. I mean, in order to learn how to do that. So. I mean, everybody's heard there, their younger brother burp the alphabet. Right. But you want as a speech pathologist, as a professional, trying to empower someone to be able to communicate with their best self, I would imagine that would take some training to make it sound in such a way that they was aligned with the patient's wish to communicate, I guess. [00:42:41] Lindsay Griffin:  Yes, for sure. Both using the esophageal speech method, as well as using the artificial larynx, both take practice and SLPs can help with both of those things. Um, the artificial larynx especially usually has to be placed in a certain location and that's variable among the patients. So [00:43:00] it's not just, just about moving it around and finding that sweet spot that gives them the best voicing. [00:43:08] Kate Grandbois:  Interesting. Is there any drawback to the esophageal speech in terms of constantly putting air in your, in your esophagus, does it have any, are there any other side effects, like reflux or consistent need to burp because all the air didn't come out or something I don't know. Are there any other like, drawbacks to that method? [00:43:32] Lindsay Griffin:  Not that I'm aware of from like a anatomy physiology perspective, some people can be quite good at it, whereas others just maybe can never get it. So it's more individual variability and also about like which parts are still remaining. What can you, do you have enough tissues to vibrate?  [00:43:53] Kate Grandbois:  Okay. So let's talk about the team. You're part of a team in this environment. I would imagine a hundred percent of the time. [00:43:57] Lindsay Griffin:  Yes. This is true.  [00:43:59] Kate Grandbois:  [00:44:00] Well, who are you working most closely with? Most of the time, which individuals  [00:44:06] Lindsay Griffin:  for laryngectomy, if it's a new laryngectomy you're going to be working with usually like the oncologist, the ENT, which also tends to be the surgeon. But if they're not then a surgeon, respiratory, nursing, if they're inpatient, obviously the patient and family. And if you don't know a ton about laryngectomies another SLP who does, and then another resource that's pretty good for laryngectomies is similar to passy muir makes speaking valves, Blom-Singer makes laryngectomy supplies. And they also have a lot of really great continuing and resources on their website. And then they'll also do in-services and they have really great like patient support systems as well. So they, if you, if a patient contacts [00:45:00] them, they they'll give them samples of things to try to see if they like it and provide a lot of education. I don't think that their educational materials on their website offers ASHA CEUs, but it's still a great learning resource for sure.  [00:45:13] Kate Grandbois:  And are there overlapping scopes with other professionals? I can be difficult to navigate in terms of what our role is on the team as SLPs versus it's just sounds like there are so many moving parts and it's so complicated. I have to imagine that there are some shared responsibilities that could be determined by workplace norms or licensure standards. [00:45:34] Lindsay Griffin:  Yeah, I'm sure. There are like about who, about caring for the laryngectomy and also like who gets to educate the patient on the laryngectomy? I think pretty much probably everyone educates the patient on some level about what those specific instances are. But I think for the most part, it's understood that we're, we're there to help with communication and speech. And that [00:46:00] really is like pushed and understood as part of our role and are under our umbrella. And I, and I think mainly the other members will say, well, talk to speech about that because I mean, who doesn't want to be able to communicate as you fine AAC ladies know. [00:46:18] Amy Wonkka:  Well, and you mentioned earlier voice banking and how, you know, some patients may choose to do some voice banking. If that's something that's an option available to them. And I did just want to put out there, John Costello at Boston children's hospital has done so much with voice banking that not, not that I, I know much about using it in the context of a laryngectomy, but that might be another really nice place to look. If you are an SLP, who's interested in learning more about that.  [00:46:46] Lindsay Griffin:  Yeah. Um, yeah, he also does it for ALS too. So not just for the head and neck cancer population. I was recently like within the past year or two, I was at Boston children's in Waltham where John Castello works because my son has [00:47:00] had tubes in his ears and we were just going for like a regular checkup. And we were waiting in the waiting room and I heard a voice behind me come out and introduce himself to a patient and said, hi, I'm John Costello. And I, whatever the introduction was. And I whipped my head around as if I had just seen a celebrity and I was like said to my three-year-old at the time. That's John Costello. And he was like, okay, no, but like, he's kind of a big deal here. It was a very celebrity sighting for me. He has no idea who I am, but I did see any person once I didn't get his autograph but I should have [00:47:29] Kate Grandbois:  He’s the nicest, he was my professor. And he's the nicest, nicest man. Hi John, if you're listening, I'm sure you're not, but I've shared cases with him. He's just the most collaborative, wonderful clinician. And if anybody is listening is interested in reading any of his work. I know he's published a couple of things through children's hospital with our chain. He's just contributed so much to the field. So thank you, John, for your work and you're the best. And maybe we can convince you to come on as a guest sometime, but that's a, [00:48:00] another topic topic for another time. Okay. So. I'm thinking about SLPs, who are listening, who, you know, we've gone through, you know, not only the difference between these two things, but there are different levels of complexity, the different levels of knowledge that you need to have the roles on the team. Let's talk a little bit more about our last learning objective in terms of other resources and things that SLP has can do to expand their knowledge base in this area. Because as you said, having been the SLP and their CF really is like chomping at the bit to get this experience I'm operating under the assumption that this is something that not a ton of SLPs have an, have a lot of competency. And is that a fair  [00:48:49] Lindsay Griffin:  assumption or. Yeah, I think that it is a fair assumption. And I also think that it's important to differentiate that just because someone has experience with Trex doesn't mean that they would [00:49:00] have equal understanding of, or experience with laryngectomies and vice versa. So even though they're both dealing with the airway, they're both dealing with airway in much different ways. And so, um, just because you have access to materials about one doesn't necessarily mean you would have the same access or knowledge about the other. I have a ton more experience with tricks than I do with laryngectomies. Even though I worked on a head and neck cancer multidisciplinary team when I worked in acute care. So, you know, you never know in terms of like ways that you would seek information, always continuing ed classes, always your colleagues from varying disciplines, as well as the SLPs that you work with. And then these companies that make these devices or. Pieces also have a lot of these really great continuing ed, um, information on our websites and articles are always a great place to gain information. [00:49:59] Amy Wonkka:  I would [00:50:00] imagine too, that it's the, it's the type of placement just having had, had having had a placement like this. When I was in grad school, I worked with part of my placement was acute care subacute care TRACON van. Um, and it definitely seemed like it was sort of hard to get into that area of the field if you wanted to. Um, so I think it seems like the type of job that there would be kind of a long onboarding process relative to SLPs who maybe go work in a public school. You're kind of, here's your, here's your caseload? Go ahead. Run with it. I would imagine it's a different experience if you're working. With people who are having tricky ostomies or laryngectomies. [00:50:44] Lindsay Griffin:  Yeah, for sure. I, and, um, for example, like when I was doing inline inline speaking valves in acute care, I never did that without having a respiratory therapist with me, it wasn't something that I was comfortable doing on my own [00:51:00] part of that is because the vent beeps continuously, because it thinks the person is not getting the oxygen or the air they'll, um, support that they need. And so part of that is that the respiratory therapist will monitor the vent settings, which is something I've never done. Mainly. That is always something that the RTS have done when I'm doing anything that requires modification of vent settings. That is, that is their job. I don't understand the vent nearly to the extent that they. Well, and we talk a  [00:51:28] Amy Wonkka:  lot on this show about scope of practice and scope of competence, right? Because technically, you know, we, we all pass the Praxis for all speech language pathologists here, but very clearly this is not in my scope of competence, nor is it in Kate's scope of competence. And we talk a lot about like that self-awareness as a clinician and how important it is to know what you don't know and know when you need help and know when you need to collaborate with other people. Um, and I would imagine that is to some extent, even more [00:52:00] important in a medically based setting.  [00:52:03] Lindsay Griffin:  Yes, absolutely. Do not have a false sense of, I got this, certainly seek out help. I usually tell three cautionary tales about my false self confidence when I was practicing. Would you like to hear it from? Yes, please. [00:52:22] Amy Wonkka:  I would like to, and then I'll feel afraid. [00:52:28] Lindsay Griffin:  Okay. So, um, the first is that when I was working in acute care, at one point I had a patient who I thought had had his cuff deflated before, and it turns out he had not. And, um, I was fitting in for speaking valve for the first time and ID flee. He was sitting in liquid in the chair, his SATs were hundreds. Perfect. He was starting in the nineties. You want them to be above 90? And so that just means that his oxygenation was good. And so I deflated this cuff and put the speaking [00:53:00] valve on him as one does. And. Uh, he was fine for a few seconds, maybe a few minutes. And then all of a sudden his SATs started dropping and dropping and dropping and they dropped to like the seventies and yeah, it was very bad and he was in the ICU. So we had a lot of nursing support and the nurse came running in because she could see the monitors going crazy. And basically we got him back under control and he was okay. But really that I did that because I didn't suction him before I deflated as cuff and everything that was sitting on top of the cuff just fell into his airway and caused him to dissent. So my cautionary tale number one is to always suction the patient's trake before deflating the cuff. Whether you think they've had it done or  [00:53:49] Kate Grandbois:  not lesson learned, I'm very scared  [00:53:52] Lindsay Griffin:  move on. Yes. The second one was even worse, actually like my license revoked for [00:54:00] telling these stories. The second one was I had this patient who, um, was in the Altec. He had just recently had a trake placed prophylactically because he was going to be having, um, chemo, radiation for head and neck cancer. And he had a very large base of tongue, um, mass. And they were afraid I was going to include his airway as he swelled. And so we had the training, it was an uncuffed trake and he was very sad in the room when I first met him. Um, and I was seeing him for a speaking valve evaluation. And, um, because he had just had the, the trake placed usually around the trake on that outside of person's neck is a piece of goals and that's usually like, just for comfort. And then also attached to the trait is kind of like a foamy thing that is Velcroed on each side. And it holds the tray in place because otherwise the trade could just fall out. So, um, I thought I'm going to do, [00:55:00] do a really nice thing here and change the goals that is under his trait, because it was like really bloody and full of secretions. And like, if you're already sad who wants to then have that? Right. So I removed both Velcro pieces from the parts that's wrapped around his neck, keeping the tray in place. And I took the goals out. But before I go put the gauze back in, he caught. And his trait flew out of his body and on to the floor of a hospital. Oh my God.  [00:55:33] Amy Wonkka:  It's a  [00:55:33] Lindsay Griffin:  bad place for your trick to be. Yes, that is true. I mean, like, thank God he didn't need it for, um, breathing at this point in his life, it was just prophylactically placed. So they had to call code blue and respiratory came running in and they gave him a new trick and, and he was okay, but that is still a horrifying experience that I did. I did do that. And, um, [00:56:00] respiratory, then we, you know, we talked about it. There was an incident. I'm not above saying that. And, um, which is fine. It should have been, they said that in the future, should I want to remove anyone's gauze to just undo the Velcro on one side of the tray tie? Not both. And keep your hand on the, like the outside part of the, which is called the flange, so that should they cough, it would still remain in that. [00:56:29] Kate Grandbois:  Okay. Lesson number two, only undo one side and keep your hands. Yeah, I'm the flange. Yep.  [00:56:34] Lindsay Griffin:  That's right. The third cautionary tale was, as you recall, I said I was desperate for treatment experience during my CF. So on the very first patient that my CF supervisor took me to see who had a trake. I was just like, I was in it. I was standing at the edge of his bed. I was just watching everything that was happening. And the first thing that she did [00:57:00] see, point number one was she suctioned him. And so you put the suction catheter in the person's true. And sometimes that will make them cough. So I'm standing at the edge of the bed ready to go. And when she suctioned him, he coughed so strongly that his secretions shot across his bed, onto my face and onto my scrubs. My favorite story lesson number three is not to stand in front of an open trait. Right. CF supervisor was standing to the side of the patient when she suctioned him as I should have been doing as well. Wow. And then I always carried extra scrubs in my locker. So like that's maybe less a number for wow.  [00:57:45] Kate Grandbois:  So first of all, thank you for sharing because none of us, all of us who are seasoned clinicians or who go on to be researchers make mistakes. And that's how we learned vulnerability is a key component of moving our lives forward. So thank you for [00:58:00] sharing. Yes. And it's also making me think that. Anybody who is listening, who wants to learn more about this? The importance of having peers and colleagues and mentorship. And I encourage everyone to find someone and reach out to someone. I mean, so part of our podcasting adventure is contacting people and. I would say nine and a half out of 10 people, almost everyone in our fields. Uh, at least that we've contacted is excited to share their knowledge, excited, to teach excited, to participate in exchanging, you know, giving knowledge onto people who are, who are looking to learn. So if you're listening and you really want to learn more about this, I would encourage you to start contacting people, find someone at a local hospital. You know, people are often really open to mentorship. We just, it's not a norm in our field to ask, and it's not a norm in our field to have that as a component of [00:59:00] your job. So not that a men, not that making mistakes is still impossible with a mentor, but it's really nice to have someone you trust to say, Hey, I did this wrong. Can you tell me how to do it better and be vulnerable with that person in terms of, you know, learning.  [00:59:16] Amy Wonkka:  Because it's impossible to do everything perfectly. Here's just your, your little, self-help a reminder of the podcast.  [00:59:24] Lindsay Griffin:  I have  [00:59:24] Kate Grandbois:  to remind me of that all the time for  [00:59:26] Amy Wonkka:  anybody who's listening. It's true. Aren't perfect. We all make mistakes. That's part  [00:59:31] Lindsay Griffin:  of what makes us, I just told you three of my largest mistakes like of my life. And I also would just like to clarify that, that those three things happened over the span of several years. I wasn't like nurse ratchet going in there, like murdering every trait patient. It was like, I would do a lot of really, really good things. And then like periodically make these terrible mistakes.  [00:59:55] Kate Grandbois:  But even,  [00:59:55] Amy Wonkka:  even if it's not, you know, something that you look back on it. [01:00:00] Cringe overtly about, I think that, that, that really is something that Kate and I talk about a lot on this show, I think is, is the idea that if you're not constantly sort of reflecting on your practice all the time, even those of us who've been doing this for quite a while, at this point, there are still things that I'm doing now today that I will look back on in five to 10 years and think, oh, I did that. [01:00:23] Lindsay Griffin:  Huh? Wow.  [01:00:25] Amy Wonkka:  So, you know, I think that that's part of just being a reflective clinician also. And then you learn the big things. Like don't stand in front  [01:00:32] Lindsay Griffin:  of an open trade. Yeah, that's  [01:00:34] Kate Grandbois:  true. In our last couple of minutes, is there, are there any additional resources or partying, you know, closing thoughts that you want to share with our listeners? [01:00:45] Lindsay Griffin:  I think something that I would say is if this is something that you're interested in, definitely seek out the resources, do like the book learning component of it, and then seek out a person who will [01:01:00] be with you every step of the way so that you're not standing in front of the trake and you're not letting tricks fall out. And you're learning how to suction people and putting it all together in a way that is the safest for the patient. Um, and this is an area that the patients are fragile and you do want to treat them as such, but also you aren't working alone on this. And so barring any justice. Terrible decision. Like the three I shared with you, the patients are going to be okay. So they're fragile. You should be aware of that, but you also shouldn't be afraid of it either because you are functioning on this team in a way that everyone's trying to do the best for the patient and just leaning on those resources, I think is important.  [01:01:50] Kate Grandbois:  You're the best. Thank you so much for coming and hanging out with us again. You're so knowledgeable and. Just fun with this was really, really [01:02:00] great. Lovely. Well, maybe we can, can we, maybe we can convince you to come back for a third installment, but we'll see, we'll see. I re we just really appreciate all your wisdom and storytelling, and you've just got so much to share. So thank you again for being here. Thank you. I appreciate that. And to everybody who's listening, if you are driving, running, biking, folding laundry, whatever you're doing, there will be a list of, um, resources in the show notes. That is. So in case you couldn't take notes in your, what was that book or what was that website? Everything is listed in the show notes in your phone and your podcast player. Um, it's also listed on our website if you want to reference it again in the future. And I think that's it. Thanks again, Lindsay so much for joining. Thank you so much for joining us in today's episode, as always, you can use this episode for Ashesi use. You can also potentially use this episode for other credits, [01:03:00] depending on the regulations of your governing body. To determine if this episode will count for professional development in your area of study, please check in with your governing bodies or you can go to our website, www dot dot com. All 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 at dot com. Thank you so much for joining us and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published May 2nd, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). 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 . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:41] Kate Grandbois:  We are so excited for today's episode. We are going to cover a topic that we have covered before. But today we get to welcome a guest who has this in their area of expertise and is going to teach us so much. Welcome Krista Covell-Pierson.  [00:01:56] Krista Covell-Pierson:  Thank you. It's great to be here. Thanks for inviting me.  [00:02:00] Amy Wonkka:  Thank you for [00:02:00] joining us, and Krista, you're here to discuss private practice, which is an area I know just smidge over, nothing about, um, before we get started, can you please tell us a little bit about yourself?  [00:02:13] Krista Covell-Pierson:  Yeah. Um, I, my name is Krista. You already said that I live in Colorado, born and raised, and I've been an occupational therapist for 20 years, which I always remember meeting people that would say that. And I'd be like, that's never going to be me, but it's me now. And I've had a private practice for about 14 years and we service all of Colorado and Wyoming and we do mostly older adults. And, but we do do some pediatrics too. And I live in Northern Colorado with my husband and two three-year-old twins and a six month old baby. So it's very busy if you hear them. I apologize. Um, hopefully everybody's following directions and they're not going to bother us.  [00:02:56] Kate Grandbois:  That's okay. Our young ones and pets and things [00:03:00] bother us on the podcast all the time. So don't worry about that.  Krista Covell-Pierson:  In good company.  Kate Grandbois: Yes, exactly. You also do some business coaching in your, in your work. Isn't that right? I know we've talked about this leading up to the podcast. I wanted to make sure I mentioned that.  [00:03:12] Krista Covell-Pierson:  Yeah, I, that I have just come by, honestly, just out of my own personal experience. And when I became somebody in business, I mean, I was a therapist through and through, so I didn't know what I was doing at all, but there was really nobody for me to reach out to at the time. There's definitely a lot more resources now for therapists than when I started, which is great. But I do do business coaching where people can hire me from across the country. And we can talk about things from, if you're just thinking about starting a business or you're maybe in the first couple of years, or maybe you have an established business and you want to talk about making changes or all different kinds of things can come up as a business owner. We also offer some business coaching opportunities for specific things like marketing, um, recruitment. And that is one of my colleagues that works with [00:04:00] me at the practice. And then we have somebody there too that specializes in billing. Cause there's always a ton of questions. Billing and insurance credentialing and how do I do it? And what does this mean? So that's available as well, but we do do that. And it's a very customized thing that people can just hire us for exactly. Maybe they just want to do two hours with me to ask questions. Other people want my support, you know, every two weeks, it just depends on what the person is looking for. [00:04:24] Kate Grandbois:  Well, as a fellow business owner, I'm very selfishly excited to absorb this knowledge because you're right as clinicians, we don't get training in this area. And when you go into private practice and you go into business for yourself, you're left with Google, and maybe some bad advice from other colleagues or people in other industries who don't quite understand the nuance of billing and funding and marketing. And some of all, all of these things in the healthcare space, which is such a, uh, such a niche, but we're like a niche within a niche. You know, it's not just healthcare. It's, you know, it's it's interventions [00:05:00] and supports it's, it's rehab, all those kinds of things. So I'm really excited selfishly to have this conversation. And before we get into the learning objectives, I also wanted to mention that you've been incredibly generous and offered to do a Q and a as part of this podcast for our subscribers. For those of you who are listening, we offer, um, a monthly Q&A to our subscribers. It's the first Tuesday of every month at 4:30 PM Eastern standard time. And we record it for our members who aren't able to attend. Um, so people can come and ask questions live. So if you're a subscriber and you're interested, stay tuned for an announcement on a specific date coming up, you can find that date out through our email and our social media channels. And Krista, thank you so much for being so generous with your time for that. And I can't wait to pepper you with all the questions more after we're done with this conversation.  [00:05:50] Krista Covell-Pierson:  No, absolutely. And one of the things I love to do is help other therapists become successful in business because the more of us that are successful, the easier it's going to be for [00:06:00] everybody. And the more people we can reach and make an impact with. So if I have a nugget of information that I can give to somebody else, I'm more than happy to do that because I've had people do the same thing for me. So I'm excited that you've included me in this and the Q&A. It’ll be fun. [00:06:16] Kate Grandbois:  Well, like I said, selfishly motivated. So I'm excited. I'm excited to learn from you. It's going to be exactly right. Okay. So, um, first before we get into it, I have to read learning objectives and disclosures. For those of you who write in and ask me to skip this part, I can't ASHA makes me read it so we will try to get through it as quickly as possible. Uh, learning objectives, learning objective number one, participants will be able to identify three marketing strategies used in private practice. Learning objective number two. Participants will be able to identify two strategies for maintaining HIPAA compliance and private practice. Learning objective number three, describe benefits and limitations of both private pay and insurance funding and learning objective number four participants will be able to [00:07:00] describe the importance of personal development in private practice. Disclosure. Krista Covell-Pierson's financial disclosures. Krista is the owner of Covell care and rehabilitation that offers rehabilitative services and business coaching for private practices, billing and business development. Krista Covell-Pierson's nonfinancial disclosures. Krista has no nonfinancial relationships to disclose  Kate that's me, my financial disclosures. I'm the owner and founder of Grandbois therapy and consulting LLC. And co-founder of SLP nerd cast my nonfinancial 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 mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis specialist. [00:07:48] Amy Wonkka:  Amy's financial disclosures. I am an employee of a public school system and I receive compensation as co-founder of SLP nerd cast. And my nonfinancial disclosures are that I'm a member of ASHA, SIG 12, and I also [00:08:00] serve on the AAC advisory group from Massachusets advocates for children. All right. We've made it, the dull bits are done. Krista, why don't you start us off by talking to us a bit about the basics? What is marketing and why is marketing so important when you're opening or running a private practice?  [00:08:14] Krista Covell-Pierson:  Sure. Marketing is hugely important. And when I first started in private practice, I had actually, I had worked as an OT in skilled nursing and home care and a couple of different settings, hospital settings and stuff. And I actually had also worked as a director of marketing for a skilled nursing facility. And that was sort of a weird thing that came about. I wanted to be in rehab, but there were no jobs available. And so I took the social work position. And then, I mean, I was really young and this older gentlemen that worked high up in corporate with his big suit on who kind of intimidated me was like, you should be the marketer. And I think he just saw somebody that was eager to learn, not afraid, but pretty [00:09:00] naive about going out and like just talking to people. I didn't think it was a big deal, you know? And so I think when we talk about marketing, we have different perceptions of what we think that is. And I said to that gentleman, well, that sounds great. I'll do the job, director of marketing, what's marketing. And he looked at me and was like, Uh, maybe I made a mistake, but then he ended up training me on marketing of all different types. So you can look at things from online marketing, you can do magazine articles, you can do radio shows, you can do networking events, whatever it is that you're going to be marketing your services, your name, your company, or product, you have to get it out there. And we spend a lot of times doing the things that we know how to do and as therapists, or maybe, maybe product development, depending on where the therapist focuses. We're really good at those things. We're not always great about getting that information out to the general public or to other professionals in a way that [00:10:00] they can understand. So it's growing that arm of your business. It can feel really uncomfortable. Like you're wearing somebody else's clothes, you know, it's like this doesn't feel like me, but it's really important in order to get your business to actually become a business and pay you otherwise, it's really just a hobby and that's where marketing can make the difference between a successful business and a non-successful business. So that's really where somebody has to start.  [00:10:27] Kate Grandbois:  So this was one of my first lessons in private practice. And I, I learned this from my husband who works in business and this sort of always, you know, hi Gill, I love you. You're a wonderful human being, but he's always sort of yelling at me and giving me the critical feedback that I need and reminding me that you don't have a business without a customer. And I get so distracted by what he calls the shiny penny. So business cards, a website, all of these bells and whistles, but you don't have a, a business without a customer. And I have learned that you don't have a customer [00:11:00] unless you have put it to market, unless you have basically told people that you exist. [00:11:05] Krista Covell-Pierson:  Yeah. And it can be, that's sometimes the scariest piece. Cause it's like, we have this big idea of, well, this is my company and it's going to be so awesome. And it's so important. And look at these, you know, people I've helped at my regular job and now I'm going to go out into the world. I'm going to do this, but we don't really want to go out in the world because it's scary. We don't want to have our dreams and things crushed because it's, you know, we have to tell people what we're all about. And somebody might say, well, we don't need that. We don't like that when you don't know what you're doing, I've been there. And even in the beginning, because we're a mobile, outpatient practice. That really didn't exist when I was first starting out, except for maybe a few sprinklings across the country. And I, for years had people ask me like, oh, well, what you're doing really isn't legal. And I was like, really? Okay, well maybe you're not my people, but it's like, I'm not going to market to you, or I'm going to market to you a lot and change your mind. But it's just, it it's exactly that you can't get [00:12:00] any forward momentum if you're not doing marketing. And it's really easy to get caught by that shiny penny. I went to a mastermind group and Kate, I think I shared this with you, but we were all different industries. And one of the ladies that was in the group with me had started an event planning business, and she's awesome. I've known her for years. She had left the nonprofit industry and she started this company. She had reprinted her business cards because the pineapple wasn't quite in the center, she had this lovely website that she had spent thousands of dollars on and all this stuff. And then I said, well, that's awesome. You know, how many clients are you seeing a month? And she's like, well, none. And she said, I really, you know, I haven't really started marketing yet. And I'm like, oh my gosh, you're already like five grand in the hole. And so she eventually, actually never got her business off the ground. And she went back to her regular job and a big piece of that was because she just did not feel comfortable doing the marketing piece and didn't, and I see a lot of therapists get bogged down on what their practice is going to look like someday. And it's a [00:13:00] dream, but you have to get out there and do the hustle.  [00:13:03] Kate Grandbois:  And I also want to say that for a lot of us, doing the marketing. We think of it as like a gross salesy kind of experience, right. And we're clinicians were not necessarily trained to be putting ourselves out there in that capacity. And it does have a bit of a public feel to it. So I have learned that it doesn't have to be that way. It can be still uncomfortable and very much outside your comfort zone, but can still be done and be effective without feeling so uncomfortable that you never want to do it again. And I'm wondering if you could walk us through some strategies that, you know, just thinking about our first learning objective, what strategies have you used or would you recommend that you find are successful for people who are starting a practice? [00:13:46] Krista Covell-Pierson:  Yeah, I'm happy to go through some of those. And before I do that, I do want to say this, this sort of changed my perspective about marketing a little bit, because I felt that way too, that I was too salesy or pushy, or they, you [00:14:00] know, people were too busy for me, but this is what changed for me as when I had a paradigm shift that people need this information, because if they don't have it, they can't make the best decision for their loved one. And that changed things. So then I was just, I literally walked by somebody at pumpkin patch yesterday and I overheard her say to her friend, I wish our occupational therapist didn't do just exercise stuff, but I don't think we need OT. Cause I can exercise all the time. And I looked at my husband and he was like, oh great. You know, and I was like, I’m gonna talk to that girl, she doesn't know what we can really do. You know? So there's just that time that we're doing like a public surface and there's lots of different ways to do that and get good information out there about how to help. So some of the things that I recommend and there's people have to weigh out the pros and cons of each one based on what their [00:15:00] market is. And if you need to figure out who your market is, then who are your clients, but also who's your referral source. So for me in the beginning, especially were older adults. A lot of my older adult clients had dementia. So they were my client, but not really the best person to market to because they're not going to remember me in five minutes. And so their spouses, their adult children, their physicians, their neurologist, those that was more where I needed to spend some of my marketing time. So figuring out that client versus, um, referral sources is also important, um, if you're online a lot, then you do want to develop that online platform. If you are in your community, like I am, you gotta get off the computer and people get really stuck in the computer and, you know, sending emails, we do it all the time, but you gotta get up and you got to go out into the world. And one of the best ways to do that to start out is to just volunteer. You can find a bazillion different organizations that are looking for [00:16:00] volunteers, find something you're interested in, find something that might connect you to people that you want to meet, whether it's physicians, or maybe you want to go see what's happening with rotary, because a lot of older adults are there and maybe they have friends and neighbors and family members that need to talk to you, but get involved and volunteering is really fun. It's a way to give back. And then you're going to learn a little bit more about your community and your organizations that you work with when you go behind the scenes as a volunteer too. So there's a little bit of strategy there, but it's a great way for people to get to know who you are and what your heart is, and just get out there and volunteer. So I've done, I don't even know thousands of hours of volunteership. And then eventually you can take on more leadership roles in those volunteer organizations too, and then grow your skillset in that way, which definitely benefits your business. I definitely recommend joining your state board. Um, I was the OT association of Colorado's president for a couple of years, learned more than I ever thought I could ever learn by being [00:17:00] serving on the board. And I never, in a million years thought I would do that, but I learned a lot, you know, with the lobbying piece, getting involved in that way, which is definitely helpful for my company, because I want to know if our types of services are on the chopping block and I can advocate for that. And then maybe coming a little bit more of a leader, then draws other therapists to the company to also want to work with us, which is helpful. And then they also can help us with networking and marketing. Giving presentations. This is a big one. To other companies like therapy teams, home health agencies. That's huge. So figure out what you do and what you do well. So for example, I am board certified in pelvic muscle dysfunction. And if you're whatever told me that I'm like going into people's, you know, groups that are total strangers to me, and I'm like, let me talk about pee and poop and you know, your rectum and all this other stuff. I mean, people are like, I was  [00:17:52] Kate Grandbois: I’m five years  old. You can't say rectum and not expect some sort of a giggle. I'm just saying, [00:17:56] Krista Covell-Pierson:  I know, I know. And that's how I felt for the longest time. [00:18:00] But then I got really passionate about it and people started raising their hand and the group saying, well, I've got this going on. And sometimes even then I was like, Ooh, it's a little much for me, but it works, you know? And then you also stand out as a leader. And even if you're not board certified in something, even if you're a speech therapist, a general practitioner, guess what you were extremely skilled, you might compare yourself to somebody that, oh, they've been in the business a bazillion years. This, that the other thing, you have a skillset in your back pocket, very highly educated people. So go out there and do some marketing in that way. Do you want me to keep going? I have some more to talk about too.  [00:18:38] Kate Grandbois:  And I had one question, I wondered about the power of screening. So I've seen some practices in our area offer free screenings for preschools, which is a great referral source, but also doing a service to your community as well. When you talked about volunteering, it's sort of, you know, it's a free service that you're giving, but you're also establishing yourself as a resource in the community [00:19:00] for people who may need your services.  [00:19:02] Krista Covell-Pierson:  Yeah. And I can testify to that for sure. So we did, um, let's see, it was last week we did two screenings, one for the hospital. We did some balance screenings and then we did another one at an independent living facility and did balance and fall screenings. And we walked away from, with eight referrals from one group and six from the other, I mean, that's awesome.  [00:19:27] Amy Wonkka:  And when you're trying to coordinate these relationships with the community where you're setting up these screenings, what are some techniques that you have used, or some strategies that you've used to form that relationship initially with the setting and maintain it over time? [00:19:42] Krista Covell-Pierson:  Yeah. So that's a great question. And I don't think there's like a big science to it, but there's this: be genuine, be consistent, be kind and continue to educate. People are very busy. We all are. And we forget about things. So if somebody said [00:20:00] that sounds like a great idea, let's set it up next month and then they don't call you and you think, oh, what a flake, no, go back. You know, and just make that call say, Hey, it's me again. Don't mean to bug you. But you know, we talked about this next month. Can we set it up for this and just to keep coming back to it. And I don't give up on people. I mean, if they're, obviously you have to go with your gut. I mean, if you, you know, when you're getting the cold shoulder, you don't just, don't, don't be irritating. Kate Grandbois: Right, right, right.  Amy Wonkka:  Don't be, don't be that one.  Krista Covell-Pierson: Yeah. But to be honest, and you can even tell people say, Hey, you know, we're looking to grow our business. And we think that we could offer some screenings to your organization. Maybe one time or maybe monthly. And a lot of times people are also looking to kind of beef up what they can do or what they can offer. And that independent living facility that we were at, they're always looking for ways to tell families, you know, that we're here, we're independent living, but we're also here trying to look out for your older adult, loved one. And you know, Covell care is here doing, [00:21:00] um, fall prevention screenings every month. And we can sign up your mom before she even moves in, you know, blah, blah, blah. So they're jazzed about it too, because it makes them look good. And really, if you can get to the point where when you're marketing with people. If you know them by their first name and you feel like you could not even that you will, but that you feel like you could ask them to go get a cup of coffee with you. And it wouldn't be weird. That's when you know, you're kind of on the in and maybe you don't even like that person at all, but that doesn't matter. You just want to have a good, solid relationship with people.  Amy Wonkka: That’s such a good barometer.  [00:21:37] Kate Grandbois:  I was just to have to say that exact sentence, that's a good barometer for so many things. I love that. [00:21:44] Krista Covell-Pierson:  Yeah. Cause you don't want to, I mean, you wouldn't just be like, Hey stranger, you want to go to coffee? They'd be like, no, I don't, I don't know you. But if you're like, you know, able to joke around, you know, about their family or, you know, look for things to, if they have, you know, a new. You know, [00:22:00] cast on their arm, ask them what happened, you know, or talk to them, get to know them. It's just like your patients. You want to get to know them on a personal level because you want to work together. And same thing if you work in a team in a skilled nursing facility or a hospital, you're going to get to know your colleagues. Don't let those barriers of the fact that they work for other organizations get in your way of growing great friendships, truly friendships with people in your communities.  [00:22:23] Kate Grandbois:  I think that's a great suggestion. And I'm wondering, did you have other ones that you wanted to say? [00:22:28] Krista Covell-Pierson:  Yeah, I have a handful. Um, so one place to that is out and about a lot in the world are home care agencies and you can do that for peds. You can do that for adults and there's all different types of home care. So you've got your skilled home care and your non-medical home care. They're going to want different things from you, depending on what you provide, but if you can give them tools that they can use in the field and do an in-service in that way too, and then always tell people how they can interface with [00:23:00] you or ask them. What is the best way that we can interface with your organization? How do we make referrals to you? Because you're also building your toolbox. So you're the best practitioner in your community to make recommendations. Like I know there's a skilled nursing facility in Fort Collins. I'm not going to steer people towards that one. I'm going to steer people towards ones that I know with confidence that are doing a good job, but I don't know that unless i’m in it. So go out and meet those home care agencies and find out who's doing what, and then you'll find people that have specialties in those organizations that can benefit the patients that you have as well. You brought up a great thing about screenings. So your local hospitals you can look at anything like that, that they can offer. Sometimes that like ours has something called the Aspen club. You can get involved with them. That's all older adults membership-based but they have tens of thousands of people and you can ask them, Hey, could we come in and present to you? Could we do some clinics? [00:24:00] And again, they may say no. And there's a lot of red tape about around those big organizations, but just get to know those organizations more and more. And I can tell you, we just kind of stuck with it. Met some people at the hospital here and there. We still maintain those same relationships, 14 years later. And now we're actually in their computer system at the hospital in the emergency room. So if somebody has a fall and comes to the ER, we're buried in there somewhere that the ER doctor can make a recommendation to us, but we wouldn't have gotten there if we didn't just kind of follow those breadcrumbs. And even though it wasn't like the first time we went to them and they were like, come in and do a clinic, we'll give you 15 referrals. They just, you know, we just kind of were like, well, what do you do is what we do? And we kept that relationship going. So reach out to your hospitals. I like to say, make a chicken list and make a list of, the chicken list is make a list of a hundred people. And then look at that and think who's the most intimidating [00:25:00] call those people first.  Kate Grandbois: Oh no. Don't call them at all. That's scary, right?  Krista Covell-Pierson:  Yeah. I was, we have a big hospital up here. They have like, like they're like the rehab team. That's like, we are the best rehab professionals and I'm like, I can't call them. Once I called them, I'm like, they're just like me, you know? And we became friends and stuff, but, oh man. I mean, I was like, Sweating to call them.  Kate Grandbois: I was nervous and now I don't want to how the people on my chicken list.  Krista Covell-Pierson:  Great. But make a chicken list. And even if you just chip away at it. But interestingly now the rehab director that was there for years and years now, she works for me. So there you go. There you go. There you go organizing events in your community. Again, this goes along with, um, volunteering, but maybe make it a little more skilled depending on what you can do. Maybe it's, you know, you can just say, we're going to set up our own group of that. We did a big Tai-Chi class in the park and started inviting people to come, you know, after [00:26:00] COVID started opening back up, uh, sending report cards to physicians. That's a good one, too. They get a lot of paperwork. So get permission from your patients and their families. Take some pictures, get you in there. Show the before and after say, you know, even if you can't see it, take a picture before, and then, you know, you guys all smiling together at the end saying these are the successes we've had because stories paint a beautiful picture, and everybody wants to see their patients doing well. And that gets through to the physicians a little bit better than sometimes just another report. I can't even imagine how much paperwork they have to sign off on.  [00:26:38] Kate Grandbois:  I love that idea. Yeah, because you're right. A picture. Well, I mean a story paints, what's the, what's the, what's the expression picture, right? The storytelling component I mean, we are working in therapy and rehab. These are human experiences. So being able to share the human experiences that you've had with your patients or clients I think is, is a great thing to highlight.  [00:26:59] Krista Covell-Pierson:  Yeah. [00:27:00] And when you're presenting share those stories, because there'll be people out there in the world that are going to say, that sounds like me, you know, or that sounds like something I'd want to be part of, instead of just saying there's 74,000 people in the country that have this disorder, that's just less relatable at the other thing I was going to say too, is reach out to specialists too, like neurologists and psychologists, because we tend to think of PCPs as where we're going to go. You know, if you've been in healthcare for a nanosecond, you know that everybody's got this special doctor and that special doctor doesn't talk to this doctor. So make sure you're reaching out to those folks. I noticed that they don't get quite as inundated as the PCPs. So I think that's important. And then reaching out to support groups. That's another big one and talking to them and, um, coming in, maybe once, once a month you can offer things. You can drop stuff off for them, or you can take it one step further and be a support group facilitator. I did [00:28:00] that for three years, I think at the Alzheimer's association. And it was once a month and it was at night, it was humbling to say the least. And it made it challenged me as a therapist in so many ways because the people that were coming were telling me things that I was like, this is, this is like the really hard stuff, but it kept me in check with what people were really going through at home instead of just coming in as an OT sometimes, and seeing a snapshot of things, but just the grief that went with it and the problem solving. And sometimes literally as a therapist being like, I got nothing, I don't know what to tell you to do. And so that was really helpful too. And, you know, made great contacts there. And then again, you know, families get to trust you. So they want you to come out and see your loved ones. Those are some of the strategies that I have for marketing that don't have anything to do with like going out and putting up a billboard, you know, you can still do that stuff, but this is [00:29:00] a little more boots on the ground. [00:29:02] Amy Wonkka:  I feel like a lot of the things that you've talked about related to marketing also have a lot of benefit as a clinician and probably also as a business owner, like they sit like, they sound like a lot of these things are personal challenge and, and growth areas, right? Like call the scary people, get a better appreciation of, you know, what your clients are or their caregivers are experiencing. Like all of these pieces are not only. Challenging in one way, you know, they're, they're stretching you in a couple of different ways that can have payoff across like multiple domains.  [00:29:35] Kate Grandbois:  Not only that, but what resonated with me about a lot of what you were saying is how relationship-focused this is. Um, and I think that benefits you in, in a variety of ways as well. So not only like Amy’s saying, does it inform you as a human and as a clinician, but also what I've learned is people buy things from companies and other people that they know like and trust. So if [00:30:00] you don't have a relationship with someone where they know you, they like you and they trust you, or they you've established yourself as a, as a content expert, or maybe, you know, at least a specialist, even if you're general practice, I'm using that term. As, as you know, you obviously have a master's degree in something, then, you know, they may not send you those referrals. I think the cornerstone of what you're saying, being relationships is it's so important and something that we don't think of, we think of like paid ads on Facebook or the website, you know,  [00:30:34] Krista Covell-Pierson:  and the interesting thing about therapists, that's what we're good at. We are relational. We know how to ask the questions. We know how to talk to the crabby people. You know, we know all that stuff. It's what we do. So if you look at it, as it really is going out and assessing your community who needs speech therapy, who needs this, who needs me, it's much different. Where as, when it, even when I [00:31:00] talk to the people that market Covell Care, when they're nonclinical, they have a different approach. It's, you know, we'd like to donate and have our, our plaque put up with a Christmas tree and I'm like, yeah, that's great. Where's the people. And so I'm like, is that really, that it's important. You want people to recognize your logo and your name, but as therapists, we really are marketing by doing what we do and that's connecting with other people. So if you think about it that way too, I mean, it's, you have more marketing skills than you probably think you do in the beginning.  [00:31:39] Amy Wonkka:  It's just like ripping off that uncomfortable chicken list band-aid  [00:31:44] Kate Grandbois:  Chicken list bandaid  [00:31:45] Amy Wonkka:  self promotion or what have you, but there's a, but there's a whole other side to this private practice bit too. Right? Because in addition to being a business, we're talking about being an allied health care business. And when we talk about health care, we need [00:32:00] to talk about HIPAA and all of those rules that go along with it. So I wonder if we could move into our second learning objective and just talk a little bit about that and the HIPAA compliance piece. [00:32:10] Krista Covell-Pierson:  Yeah. So this is where some therapists then are like, you lost me there. Like I'm not interested. It's just too much.  Amy Wonkka: Yeah, pointing right at myself right now. Krista Covell-Pierson:  It honestly it's me too, but it is a necessity, like you said, and you do have to look at all these different pieces of having a business and learn it. I think we tend to think we know about things because we've been told about it from other employers or even our own experience. We've all been, we've all signed a HIPAA thing when we go to the doctor and we don't read it, you know, we don't, but you don't know. So this is what I recommend for all practitioners that have to comply with HIPAA. And if you are billing insurance, then you have to comply with HIPAA. [00:33:00] My personal recommendation is even if you're not doing anything with insurance, I would just go on the safe side and follow the HIPAA guidelines. They're there to protect people. And there's really nothing wrong with that, is it a little bit of a pain? Sure. But it is just kind of the way it is now. So it's better to just get over the fact that you may not want to do it, just do it anyway. So it's just, you know, you're protecting your patients' identities and that's an important piece of that. And we have to remember too that with HIPAA, it's not just that, you know, Krista Covell Pierson is what you're protecting and maybe my birthday is. You can't be sitting at a coffee shop together like Amy and Kate sitting around saying, you know, oh, I just saw that patient earlier. And she's just, she's really struggling because her mom passed away from Lou Gehrig's disease. And then she had to put her poodle down. You've just given, identifying information out at a coffee shop and we can't do that. And I think people forget like, oh yeah, that does identify people. Cause if her daughter was sitting at the next [00:34:00] table. She would probably be like, are you talking about my family member? So we have to just remember that that's what we need to do. So in order to be HIPAA compliant for all practitioners, I recommend start at HIPAA 101. Even if you feel like, you know what it is, take a class, there's great webinars about it, but go to a reputable source, don't go to your Facebook groups and ask, you need to find out what the laws are and you need to learn them. And that goes for lots of things. But, um, I would recommend taking a HIPAA class even annually if you can. And definitely every other year. Because laws change, rules change. And if you don't know about it, you're not going to be compliant and you could really get yourself in some hot water. So that's where I would start with the education piece. And then as you're building your business or combing over your business, you just have to remember that everything about your business has to be HIPAA compliant. So for example, like who are some professionals that you might work with in your businesses, [00:35:00] that aren't speech therapists?  [00:35:02] Kate Grandbois:  You mean they are employed within the business? [00:35:04] Krista Covell-Pierson:  Yeah. Or maybe contractors you use for different things, like maybe billing person, a billing person, your CPA, somebody that does payroll, maybe your website designer. And what we know is they may see some HIPAA information. And then all of a sudden they need to be HIPAA compliant as well. So there's something called a business associate agreement and they have to sign that. So you have to make sure that you have that. So if you have a fax machine that's virtual, your Google or whatever you use, everything has to be HIPAA compliant. If you don't have that BAA you can't really get their buy-in to say, yes, we are HIPAA compliant with your stuff as well. So those BAA's are important if you've never heard about that, don't worry. I think that's the other thing. Private practice therapist. So I was like, oh my God, like, I've been in bad practice five years. I don't have any of that. It's like, it's okay. Just start. And so plug it [00:36:00] into Google. It will come up. They'll, there's lots of forums out there that you could get where you can sign it. The other person signs it. Um, it's a pretty simple thing to do, but that's important to have those on file and get those updated every once in a while because the requirements for the BAAs do change. So some things that you have to think about, like I mentioned, the fax email, if you're using EMR, any billing software that you use, um, your landlord, potentially your CPA, any contractors, anything like that? Everybody has to be HIPAA compliant if they're tethered to you in any way.  [00:36:32] Kate Grandbois:  I think that's great advice. I think this is one of the areas of private practice that's very intimidating. Because like you said you could get in hot water. And when I say hot water, I mean like, you know, you could get sued, you could lose your business, you could lose an asset, the personal asset. I mean, there's a lot of, there's a heavy risk there. And another thing that we don't necessarily get educated on in graduate school, you know, we leave graduate school, knowing that patient privacy is important. We leave graduate school knowing that HIPAA is a [00:37:00] thing. But when it, you know, when you're working in most work settings, you get to pass the buck to your supervisor. You're covered under the entity of your employer. But when you are the employer or you become an entity on your own. The bucks stops there. I mean, you, you have to, you have to know these things. It's so important. [00:37:17] Krista Covell-Pierson:  And then in addition to doing your education every year, it's also important that a business owner does an audit on their business every year. So you look at things and you're going to maybe mark it as like a tiered system. So for example, I'll look at things at Covell Care and I'll say, okay, email, are we HIPAA compliant here? And then as we got bigger, even though we had the HIPAA compliance agreement and everything like that with Google, I thought, you know what, we're going to take this a little step further. And we added something called pobox, which, um, further encrypts our, our emails going in or out and, you know, Because we, our risk became bigger as we got bigger. [00:38:00] So it's important to look at those things and then like text messages. We had to convert over to a HIPAA compliant app or make sure when tele-health came out, especially got so big with COVID. We had to make sure everybody was using a compliant tele-health program. So those are the things that you just go through. You know, maybe it is a moderate risk. So you have minimal risks, like no risk, minimal risk, really nothing's no risklet's be honest, but minimal, moderate, and high risk, anything that's in high risk, get that down to at least moderate. Then when it gets into moderate way out, what those risks look like. And then if you say we scored this as a moderate risk, and this is why it also shows somebody that is maybe auditing you later. If you got in trouble for something with HIPAA, or you need to present something that it shows that you weren't just lackadaisical with the whole thing, but that there was a rationale behind it. So keep track of those things and do it every year. I do it and it usually takes me a couple of [00:39:00] days. [00:39:00] Kate Grandbois:  I love that suggestion. I know that there are, you know, everybody's personal threshold of risk is very different. So some people are really comfortable. With high levels of risk, ahh it’s fine, it’s never going to happen to me, .I'm not going to get sued. You know, other people, myself and Amy are very risk averse and don't like any of them. And then there's everything in between. But I love your suggestion of at least documenting the fact that you've acknowledged the risk and that, and what steps you've gone through to mediate those risks and how important just that one step is. So even if you feel like you have a high risk tolerance and you're comfortable with X, Y, or Z decisions that you've made, I still think it's a critical step to, to evaluate those things on paper, create permanent products that are related to them and a paper trail for your thought process, so that you can show that you acknowledge the risk and that you're not, as you said, what did you say? Lackadaisical, Willy nilly. You're just not, you know, you know, you're not just like [00:40:00] not caring and just going about your business flaunting it everywhere. [00:40:02] Krista Covell-Pierson:  Yeah. And taking that class also shows too that you, you know, that you care that you're entering.  [00:40:12] Amy Wonkka:  I think there must be a piece that sort of spins off of this, depending on the size of your business, to that, that addresses your, how, how you manage your employees and how you make sure that you're not the only person who's aware of these rules. You know, you're not the only one who knows not to have that conversation in the coffee shop, but everybody knows it and you have a plan to make sure that everybody knows it. But yeah, there are, there are a lot of different moving parts and I'd imagine it depends on the type of business that you're doing as well. Are you doing, are you in a facility and you've rented a space and you're doing a lot of direct service. Are you doing mostly remote service? Are you leasing a space somewhere? So all of those variables in terms of like how you're storing your files and what that looks like,  [00:40:54] Krista Covell-Pierson:  and you have to talk about what happens in an emergency situation. So if you're mobile like me [00:41:00] and you leave your computer in your car and your car gets stolen well, oh, now, you know, it's bad news, but if you have a policy in place that you hope people will follow, that you never leave your computer in your car, ever, you take it in with you or you carry it in your bag. If he's got to stop at target, you know, that's what we tell people. I did have an employee once that literally at the facility that we work at, she just left her computer. In the, like the family room, she went to go talk to a patient and left it there and then somebody moved it. So it shouldn't have been left there and she freaked out. Luckily it was just placed like next to the couch and everything needs to be password protected. So that's another thing, but it could have been a really bad deal. And luckily for us, it wasn't, but it was literally a mistake and those things happen. So then you'd have to know that mistakes do happen. What's your plan if you have a privacy breach? So if somebody would have taken her computer, what do we do? Who do we notify and how do we notify [00:42:00] them and who needs to be, when, how do we call the clients? How do we tell them that it is protected or it is at risk or things like that. So, and it's really easy to go in the rabbit hole and it makes people get really afraid, but just can't  [00:42:13] Kate Grandbois:  I have no tolerance. [00:42:16] Krista Covell-Pierson:  It is, it all is. And then we talk about insurance and every, I mean, it's just the thing, all the horrible things can happen, but if you put those pieces in place and then every year you're going to be going over that again, it's going to get better and better and better. So, you know, I mean, we hear about, you know, some of the most secure agencies in the world having breaches, it does happen. So you have to be smart.  [00:42:40] Amy Wonkka:  Yeah. If it can happen to the credit agency.  [00:42:43] Krista Covell-Pierson:  Yeah. Right. So you just want to do your best and then have a plan in place. Like what would you do if, and sometimes it's a nice, it's just sort of like a conversation, like who could freak each other out more. So, you know, like, well, what would you do if this happened to you? And it's like, you know, it'd be like, oh my God, I [00:43:00] never thought about that. But it just gets the wheels turning a little bit. So you can put some safety measures in place.  [00:43:06] Kate Grandbois:  So now that we've talked, I'm just thinking about people who are listening. Presumably they're interested in, you know, they're learning more about this. They know how to talk to people, create relationships for marketing. They have a list, a to-do list in front of them to make sure that they're compliant. But again, you don't have a business without a customer and you don't have a business without, because we're in healthcare funding for that customer. So what can I want to spend the next couple of minutes unpacking the cost and benefit of private pay and insurance funding in my practice, I've done both. And I know that there are a lot of, this is a, a very commonly asked question because a lot of people feel like they have to have insurance. And that comes with this whole additional burden of paperwork and billing and knowing the codes. And it's like a whole, a whole other world. And I, I’d love to talk a little bit more about that because [00:44:00] this is another burden that clinicians feel that they have to carry. When they're thinking about opening a practice that can be really intimidating and sort of a non-starter.  [00:44:09] Krista Covell-Pierson:  Yeah. And it is, it is a really tough question. I think everybody leans towards, oh, I'll just, I'll do private pay because it's just like, then that whole crazy box of insurance I don't have to deal with. And then you kind of have to weigh those things out. So with private pay, yes, you get to set your own fees, but they do need to be, you know, reasonable and. The thing that drawback though with private pay is there are some clients that you won't be able to take either because they don't have the funding themselves to pay for private pay, or you're just not going to have access to them at all, because they're only going to go to people that are their providers. So you might be dealing with maybe a smaller amount of people in the beginning. You can certainly grow that, but you're not going to be able to kind of go around and say, okay, well you're blue cross blue shield [00:45:00] and your Anthem and this and that. Like, you're going to just start with those private pay people. So it's a smaller amount of people, but maybe that's fine. And that's, you don't want to deal with all the other stuff. So there's that piece of things, the part where it gets a little sticky, depending on where you work and what you do. So for example, I'm a Medicare provider. I take Medicaid too. So for Medicare. Let's say I never became a Medicare contractor, so I'm on my own. And I meet somebody they're 70 years old. They say, I want to pay you privately for my services. Okay. There are some legal issues that come around that, that they actually have to be presented with the opportunity to go to a Medicare provider. So there's just a lot of you. Can't just be like, why don't I don't do anything like that. So you're still gonna have to keep notes as if you're a Medicare provider. You're still going to have to give them the opportunity to bill. So guess what? Now you're generating a bill for them. You're not submitting it. They [00:46:00] are, but it just, it can create kind of a headache. So there are things that you need to investigate about the insurances and different states have different stipulations around their Medicaid programs to that at least educate yourself on those things first so that you can give patients the correct information. Cause you can't say, oh, sorry, I can't, I'm not going to give you a bill. You have to. So there's some things around that that can be kind of tough when it comes to insurance. Of course, then if somebody just looks on their list of providers and it says Covell care rehab, maybe they'll just call because we're an in network with their. But I think just for folks that might be on the call that may not really even understand like the Medicare Medicaid difference. Do you want me to just cover that and share  [00:46:44] Kate Grandbois: that would be really helpful. ' [00:46:46] Krista Covell-Pierson:  cause I'm amazed at how many people don't really know, but why would they, because when you work for somebody else, you don't care, you don't think about it. So Medicare is your big federal program. So everybody in the United States can have access to that. You have to be of a [00:47:00] certain age, usually over 65, you have, or have a disability. There's different things that you can tap into Medicare. So it's federal dollars. Then you have Medicaid and Medicaid is your state funding. So each state gets money from the feds and then they have money from their state. And then that state can decide how they want to spend that money. So in the state of Colorado, for example, we can do home modifications. So. People that have Medicaid and are in a certain program. They get $14,000 a year to modify their house. But if I drive up to Wyoming, they don't have that benefit. So your Medicaid benefits are going to be different state to state. So people have to know that too, because I meet people all the time. They're like, oh, I came from Kentucky. We can do this. I'm like, no, that's in Kentucky, not here. So you've got Medicare is kind of the big dog and then Medicaid. You've got 50 Medicaid, little puppies running around, spending money. I picture it that way. And then within Medicare. So I like to tell people it's like a big umbrella and then underneath are a [00:48:00] series of other little umbrellas and those little umbrellas cover jurisdictions within the United States. So you have all your Medicare rules and regulations. Then for example, there's Novitas or Noridian, they're big insurance companies. They oversee the states and they decide they kind of interpret the Medicare rules and regulations for themselves. They put out the billing manual and the, their own manual about that. You have to follow within your state. And then we answer to that fiscal intermediary. So for example, we just got audited by Medicare, but that actually means that Novitas is auditing us. So that's who we deal with. So if you want to become a medical provider, you have to find out who your insurance contract is for your state and that's who you're going to get credentialed with. And that's the information that you want to read as far as being compliant. That being said, still read the big umbrellas information, then read your [00:49:00] fiscal intermediaries information, follow whichever one is more strict. So some rules will be more lenient one way. And the other always go towards what's more strict. And then you know that you'll satisfy both areas and then Medicaid will have their own set of billing recommendations and compliance measures. You have to follow as well. If you're any sort of geek like me, Kind of like reading it because you're like, oh, interesting. So we can do, you know, for wheelchair things, but we could do, you know, it's just, it's silly, but once you start reading it, it becomes a lot less jargon-y, it's pretty simple. You just have to read it and it's like a playbook. So,  [00:49:42] Kate Grandbois:  and if you don't want to read it, you can hire Krista to read it for you and explain it to you. So completely confusing and dry. [00:49:49] Krista Covell-Pierson:  Yeah. It's totally dry, but it really is like the playbook, you know, it's like, this is a game it's, it's not a game, so I don't want to downplay it, but these are the rules we [00:50:00] play by and that's how we get paid. So, you know, with your private pay pieces, it's actually still a good idea to be reading those manuals, to see what's being covered, or what's not, there's also things. So for example, dry needling with physical therapy, Medicare's not paying for that. It used to. And so then you have to gather private funding from your patients for those pieces. So those are the things it's important to get to know. A lot of times when I talk to therapists about this kind of stuff, I can feel it. I can feel it right now, even to people that aren't even listening yet, that it's like, they're going, ah, like I maybe private practice isn’t for me [00:50:39] Kate Grandbois:  it's the dread, the, the dreaded paperwork and billing  [00:50:42] Krista Covell-Pierson:  and it's, and there's a lot of fear in it. It's very fear-based and we're always afraid we're going to end up in the orange jumpsuit. And so, you know, like that, there's like these fraudulent things  [00:50:55] Kate Grandbois:  Nobody wants to go to therapy jail. Nobody, nobody wants to go to therapy jail.  [00:50:56] Krista Covell-Pierson:  Jail. Yeah. And it's very, it's a very  Amy Wonkka: Or real [00:51:00] jail.  Krista Covell-Pierson:  We just don't want to be locked up at all. Yeah. And it's just, it's. It's a very fear inducing thing for a lot of people. And I, and I can go there too. The more knowledge you have about it, the less scary it becomes because you know it so well. And again, you're going to take your HIPPA class every year. I strongly recommend, even if you're not in private practice, if you are a practitioner, you should be taking a billing and documentation class every single year of your career. Because a lot of times the documentation you wrote it. I am an expert witness for a case right now for a hospital representing a therapist. It comes down to her documentation. So it's either going to hang the hospital and her or not. And so that it's really important that you know, to have defensible documentation. [00:51:54] Kate Grandbois:  And for anyone listening, who is having some uncomfortable, nervous feelings, I'm also having those uncomfortable feelings, that's, you're talking, I'm like, I've never taken a class. [00:52:00]  [00:52:00] Krista Covell-Pierson:  Yeah. [00:52:04] Kate Grandbois:  It's terrible. This is a really big deal. And you're absolutely right now I'm going to be Googling documentation.  [00:52:10] Krista Covell-Pierson:  Yeah.  Kate Grandbois:  Do you have one that you recommend. Krista Covell-Pierson: I do actually, um, there, if you do part B, I always recommend taking anything through Rick Guwenda. Um, he's a physical therapist, but he covers OTPT and speech. There's a lot of them on, like, I know summit does a good job. They have good reputable people on there. Um, those are two off the top of my head.  [00:52:34] Amy Wonkka:  I think it's a really interesting perspective because I'm all about professional development. I love learning things. I'm going to conferences, I'm reading stuff, but it's [00:52:42] Kate Grandbois:  you started a continuing education platform, right? Friends  [00:52:47] Amy Wonkka:  here I am on the podcast because it really into this, but it's, it's mostly focused on clinical strategies, right? So this is an interesting perspective that in, in [00:53:00] doing that, I'm, I'm leaving out this important piece. And I don't know how many other people are maybe having those same fields right now, but it's an interesting, you know, to kind of add it into the professional development plan that we all have.  [00:53:14] Krista Covell-Pierson:  Yeah. Because like, even with the expert witness case, like the hospital hired me, but the therapist is on the stand. And so, and talk about scary feels like I get scared for her. Um, and it makes me nervous too. But the more, again, the more you know about the documentation, because it really is, I mean, the insurance companies are who's paying you so should probably know what they want to know, therapists that were really good about documenting what our patients are doing, because we're all into the patients. We're not really good about documenting what we do and that's what we're getting paid for. So it's documenting that skilled level of service and. Not necessarily like creative writing as far as like falsifying things, but to be [00:54:00] a good writer so that it's understood about what you're doing and clear that's what you need is great language. [00:54:09] Kate Grandbois:  I mean, you clearly know I could pick your brain for another million years. I, I feel like I could talk about the need for what am I need to do really driven by my own anxiety that I'm now doing something wrong, but I'm looking at our learning objectives and our time. And I'm really excited for the last learning objective, because I know you and I had a conversation about this in preparing for this episode and it's very near and dear to my heart and soul. Um, but I think one thing I, before we move into that, I wanted to ask a question that I get asked a lot and. If you, what your perspective was, I get often asked how much do you charge? I mean, not so much by families, but by other clinicians who are interested in getting into private practice. So how you price yourself, how you price your services for your customer. So, and that can be different. You could be working with families, you could be [00:55:00] providing trainings to staff. You could be providing mentorship or coaching. You could be being contracted by larger businesses, hospitals, or schools. What advice do you have about how to price your own services? Good question. Asking for a friend. Yeah.  [00:55:15] Krista Covell-Pierson:  You want to do a market analysis, find out what everybody else is charging, you know, see what the industry standard is. And if it is something that you're providing that normally insurance would cover, there are some ethical things around that too. So if it's normally a hundred dollars and insurance will pay for that, you really shouldn't be charging more than about 10 to 15% over that. It's kind of the rule of thumb. Do your market analysis, figure out what's what's fair and reasonable. And then. Don't undersell yourself either. So also think about the amount of time that's going to go into your service on the front end and the backend and quantify that. So put numbers to that. So you may be thinking like, oh, I could charge a hundred dollars to go to somebody's house. That's no big deal, but are you doing a lot of prep work on the [00:56:00] front end? Are you writing up a big report? That's going to take you three hours. You need to quantify that and put down an hourly rate that you feel is reasonable and fair. I find that therapists tend to undercharge, but then there's some people out there that I'm like, whoa, like that's crazy. That's a really high rate, but you know, you're only going to get it if somebody is going to pay it. So if you want to put your shingle out there and say I'm $500 an hour and nobody comes knocking, you might need to lower that price. I don't know if that's helpful.  Kate Grandbois: No, very.  [00:56:32] Amy Wonkka:  Andjust before we move on to the next one, We talked a bit about, the next one, the next learning objective, we talked a bit about Medicare Medicaid. Is there a clear contrast between benefits of just being a private pay? Because I heard you mentioned that even if you're doing strictly private pay, you should still be aware of all of these other components you should know about billing. You should know about, um, the fee structure. [00:57:00] So do you favor one over the other [00:57:02] Krista Covell-Pierson:  of being private payer insurance? Yeah. I say take insurance, but I'm super biased. I always have. I, well, I shouldn't say always, I took private pay in the beginning and then people who were paying me were actually other professionals that needed my expertise. So lawyers, psychologists, and then started getting into some stuff with families. And then as I was like, gosh, you have Medicare that Medicare could pay me for the service and you've paid into Medicare your whole life. I should be a Medicare contractor. So that's why I did it. And I feel like the insurance it's opened up a lot of doors for me and my practice that we take all these different insurances. I will say this, that the insurance says, if you're out of network, this is something to investigate. If you're deciding to go in or out of network, especially with some of the big private insurances, not just Medicare. If you're out of [00:58:00] network, sometimes then people will have out of network benefits where they'll still pay for some of your services. Somebody might have a higher copay, but you can get all that stuff by calling the insurance company and asking about that individual specific plan, which we do. We do that for all of our patients. We find out what their insurance will cover first, before we come out, because we don't like surprises. So you can figure that out. Then if you go in network with those people, sometimes your fees that they will pay, you will actually go down. So sometimes it makes more sense to stay out of network, then go in. So those are good things to ask. And you also want to ask, I think this is a little overwhelming for people, but also ask when people have an insurance plan. So let's just say Anthem, what happens if they also have Medicaid? Because that can change some things too for reimbursement.  [00:58:55] Kate Grandbois:  Insurance it's so it's, it's so overwhelming. It is. And it [00:59:00] loops back to something we haven't really talked about, but also I think a driving question that helps you make decisions is what is your business goal? So if you're employed full-time and you want to go into private practice for some supplemental income and you want to see no more than three or four patients on the side or clients on the side, then perhaps the volume that insurance would bring you is not necessary. And you don't have the time to invest in the paperwork. On the other hand, if you have a business goal of developing a clinic or a brick and mortar or hiring people or doing this full time, I think based on my experience, getting a volume of a full case load of private pay is going to be very hard and take you a really, really long time. So I think whether or not to make the decision about private payer insurance can sometimes be really looped back to other variables going on in your life. [00:59:51] Krista Covell-Pierson:  Yeah. That's great advice. Thanks. Okay.  [00:59:58] Kate Grandbois:  So maybe that's the perfect, [01:00:00] awkward segue segue we needed to get into our last learning objective, which I'm going to read it out loud again for the sake of reminding everyone. Cause it's been awhile. This is related to the importance of personal development in private practice and it's personal development, not necessarily professional development. And I can't wait for you to talk to us about this because we had such a great conversation leading up to, um, this episode. [01:00:25] Krista Covell-Pierson:  Yeah. This is a big thing for me. And especially with people I coach, I always like to find out really their level of comfort with this too, because we're always looking towards, okay, we need to figure out HIPAA and we need to figure out marketing we need to figure out this, this, this, because this is what you do for business. And then I'll talk to people and they'll say, well, I'll read one of those. Sometime, or I'm going to read that book and then they don't, but what I've come to learn, and this is just personal experience as the better I became at life, which is like, and I'm not saying I'm like, as [01:01:00] A-plus at life, versus I'm just saying the better I got at certain things, certain skill sets, better my business became. And so, you know, communication, patients, active listening, um, finding out what my own insecurities were, any weird things that you have going on, we all have them. We all have this other side of ourselves that needs to be sort of uncovered and worked on. And when you do that one, you become more empathetic and capable with your people that you're going to be working with and to you grow. And when you're growing, you're stronger and you're more capable of managing a business. If you are going into private practice or you have a private practice, you will learn, it will push you in ways that you didn't think that you would ever be pushed nor that you wanted to be pushed or that you ever thought you would ever have to do. It is not always fun. I mean, let me tell you, when we got that letter that we were being audited, I was like, okay, this [01:02:00] is kicking in some anxiety for me, but, you know, had I gotten that letter 10 years ago, I would have flipped out. So, you know, just to be able to manage your own self is really important. And it will help you with your personal finances, with your families, your relationships that are outside of work, it's all a really positive thing, but it benefits your business. So I can't say enough about that. So conferences, books, webinars, and some people are really into that anyways. And that's great, but there's, you know, go to your Barnes and noble and walk through that. Section and pick something out that speaks to you. It may have nothing to do with business, but read it. It'll help you. There's lots of really awesome stuff out there. I mean, I could give you lots and lots of resources she's for those types of things,  [01:02:47] Kate Grandbois:  we would love those resources and we can list everything in the show notes so that if anyone is listening and biking or driving or running or folding laundry or whatever, all of the resources will be there, they'll also be on our webpage. I also [01:03:00] just want to unpack that for a minute because I, I find it so important from personal experience. And because I think that these, again, components, they have a trickle effect in terms of benefiting your business, benefiting your therapy, benefiting your private personal relationships, benefiting your personal finances. These are things that you're doing to invest in yourself that then have an ripple effect across so many things. And the reason my, I personally, when we talked about this before leading up to this episode and it resonated with me so much, and I thought, you know, spend some time thinking about it. It's related to the relationships that you're making in your community. If you have employees, it's an incredibly important if you have employees. And I feel that it combats something that unfortunately I see a lot, which is this concept of ego. And that's a really big piece. When you have a business is, you know, recruiting people for your business, recruiting [01:04:00] staff for your business. I have a great business. Look at all these things I do well, but what am I not doing? Well? How is when, uh, when should I make a referral to another business? You're not going to be able to answer any of these questions or model really professional humility for your staff if you have ego. And we all have an ego. I mean, there's nothing wrong with it, but knowing how to sit in the discomfort of knowing when you need to grow or when you need to stay silent or when you need to have a difficult conversation. And let me tell you, and you're right, when you're in private practice owner, you are having difficult conversations all the time with patients and families, with staff who maybe might be underperforming or need a little bit more support, um, with billing agencies, with people who are auditing you. I mean, there is just discomfort everywhere. And if you can't sit in it to grow, then it's not gonna, you're not gonna succeed.  [01:04:59] Krista Covell-Pierson:  Yeah. And I [01:05:00] think when you model good behavior, it feels, say that. And I mean, I'm not saying like, you know, right or wrong, like manners, I'm just saying like, when you're really self-managing yourself, well,  Kate Grandbois: maturity it's professional maturity. Krista Covell-Pierson: It is, then people recognize that they see that and they trust you. And then that helps people to feel safe with you because they are. And even with my own staff, you know, sometimes I'll have a staff member that maybe will just be very, very overwhelmed and. You know, as a boss, that's the last thing I want somebody to feel. And so then it's also being able to come in and, but instead of like just saying, okay, well, this is how we're going to fix it. It's also learning how to challenge that staff member to, you know, kind of like a guided discovery. Like how can she manage it better? Like here's some skills here was what we can try, but also help her engage with it too. If I'm not figuring out how to do that as a leader, I'm not going to be able to really support her. And it's just going to keep perpetuating. [01:06:00] There's just a lot of stuff. When it comes to, you know, conflict resolution or advocacy and planning things or mastering, you know, the time that you're working that is really important to organization and then reef, it's a constant refining. It never ends. And you know, even the anxiety about, you know, HIPAA or billing and stuff that doesn't really ever go away. I had the same girl that asked that I was talking about earlier about the business cards and didn't get her business off the ground in the beginning. She asked me, well, when do you stop being so scared? And I was like, I don't know, but you know, it's also, you do get stronger. So things that scared you a year ago or two weeks ago, they're not as scary anymore and you become stronger. So I just think that is a really important piece of it that people don't really see as benefiting the business when actually that above everything else is probably your ace in the hole. [01:06:56] Kate Grandbois:  And I want to unpack one last concept before we wrap [01:07:00] up, which is something you mentioned about leadership and how this relates to personal development. When you are running a practice, even if you don't have employees, you are. You're the boss. You are, you're either in charge of yourself or you're in charge of people who work under you or with you in a collaborative manner. And you can't develop leadership skills with knowledge you can't, you know, and with clinical knowledge, you could be a great clinician. And have great clinical decision-making skills, but those do not automatically translate to leadership skills. And so much of that comes from having space in your, I want to say if something, you know, really cheesy, like space in your heart, but it's a personal journey. It's a personal, it's a, it comes from a personal place to be able to make space for others. And I think a lot of us who maybe graduated and went into jobs, maybe didn't have the best managers or didn't have the best supervisors. [01:08:00] I think for some people tends to be this assumption that, oh my manager's always right. And they're the boss and they're making decisions and that's not what it's about. It's about making space for other people. And you can't do that if you have bees in your bonnet.  [01:08:11] Krista Covell-Pierson:  Yeah. That's true. Those bees. I know that the sting. Yeah. Kate Grandbois: Does that make sense?  Yeah, it does. And I think that's the thing. And I think people don't realize too that when they become a business owner, they are it's, you've already you've that's when the shift has been made, like you're a leader, even if you don't feel like a leader, I was asked to teach a leadership course and I said, I don't really identify with the word leader. And I thought, that’s kind of dumb, cause I am a leader. It just seems weird. Like we don't say like I'm a leader, like who says that, but you are, and people are watching you, people are learning from you, watching from you and they're either learning what they don't want to do or what they do want to do. And you gotta be [01:09:00] able to be comfortable in your own skin too, because like you said, with ego, with business, you can get really, you know, egotistical about the whole thing. We all know people like that and to humble yourself and just know that, you know, every day is a challenge, but being a business owner is no joke. It's tough. It's really tough. And it's not tough in the way that you think it's gonna be just like marriage. You think it's going to be tough. It's tougher in a different way. [01:09:26] Kate Grandbois: So in our last minute or two, as a closing to sort of close this out, do you have any words of wisdom or words of advice for someone who is listening and maybe thinking about this as their next adventure?  [01:09:38] Krista Covell-Pierson:  My advice. If somebody thinks this might be their next adventure is to listen to that w that low it's like a voice or whisper or a feeling and to follow it. And sometimes it's fun to lay in bed and just think about what could be, and that's fine, but just follow it to the next right thing. Pick up that next breadcrumb. You know, if you're interested and you want to find out more, [01:10:00] learn more. If you're like, maybe I'll be a Medicare contractor, do that. If you're like, yep, I'm ready to do it. Just do it. Just keep going, keep moving forward. Because if you get that and if you have so much fear and anxiety in the way, work on that, go see a counselor about it, go see a life coach, hire somebody, you know, call me, um, read a book about it because it's a really powerful thing, but you have every single person listening to this. Whether they go into private practice or not has a talent and we need it in the world and maybe it's in private practice. And if that's for you, just keep listening to that calling and then you'll get stronger in it. Well, it feels so scary. You won't always feel like you're wearing somebody else's clothes. [01:10:41] Kate Grandbois:  That's such great advice. And you brought it full circle with the clothes analogy that [01:10:44] Krista Covell-Pierson:   totally did.  [01:10:49] Kate Grandbois:   It was so lovely.Thank you so much for being here and joining us. You are just a wealth of knowledge and I learned so much. I know Amy did too so much, so much. And for anybody listening, who [01:11:00] wants to learn more again, Krista has generously agreed to participate in a Q&A with us. Stay tuned for a date, check our social media channels, subscribe to our newsletter. If you're interested in attending, it's a Q&A for our subscribers. Uh, it's the first Tuesday of every month at 4:30 PM Eastern standard time. And we hope everybody learned something today. Krista, thank you again so much for joining us. [01:11:25] Krista Covell-Pierson:  Well, thank you for having me. It's really fun. And it's fun for me to talk to people that aren't OTs too. So I'm excited to meet more speech therapists. You guys are doing a great service by this podcast, so it's really fun to be part of it. So thank you for inviting me. Thanks.  [01:11:40] 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 for professional development in your area of study, please check in with your governing bodies or you can go to our website, [01:12:00] www.SLPNerdcast.com . All of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@SLPnerdcast.com . Thank you so much for joining us, and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published December 13th, 2021. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). 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 . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:02:06] Kate Grandbois:  We're so excited for today's episode today. I'm here by myself. My counterpart and copilot Amy is on vacation. Hi Amy. We miss you, but I do have an incredible guest that I'm so excited to welcome. So I'm not going to be lonely. We're really excited to have Tera Sumpter on the podcast today to discuss all things executive functioning. Welcome Tera.  [00:02:28] Tera Sumpter:  Thank you. Thank you. I'm so happy to be here.  [00:02:31] Kate Grandbois:  I'm also so happy that you're here because we've had so many conversations leading up to this. So this is sort of like the pinnacle. This is a very exciting moment.  [00:02:41] Tera Sumpter:  If only, we've been hitting, we’d hit record and hours ago. [00:02:49] Kate Grandbois: Okay. So you're going to talk to us about executive functioning. And before we get started, I have to admit something which I've already admitted to you in private, but I'm going to now admit it in public because I don't know anything [00:03:00] about executive functioning. Um, and I think that's sort of related to the reason why we wanted to do this podcast and we'll get into the details of that later. But essentially executive functioning is often sort of put on the shelf as this thing. And what we're going to talk about today is, is, or what you're going to teach me about today is how executive functioning is so closely related to so many things we do as speech and language pathologists, um, and how important it is for us to embrace it and understand it with a little bit of deeper meaning. Um, but before we get into the fun stuff, I wonder if you could tell us a little bit about yourself. [00:03:37] Tera Sumpter:  I'm Tera Sumpter. I'm a speech language pathologist. Um, my background when I first got out of graduate school, um, my experience was in the medical field. So I did inpatient, outpatient. I did pediatric and adult care. So I really saw the whole gamut. Um, I decided pretty early [00:04:00] on that when machines started beeping in the ICU that I was killing people. So I decided I should probably leave acute care because I freaked out and went to like a full,  [00:04:10] Kate Grandbois: I mean, that's  reasonable. I think that sounds like a very scary and stressful environment [00:04:13] Tera Sumpter:  but I was not built for it. Yeah. One of my coworkers would like dive in and start doing chest compressions CPR when someone coded. And I was like, Kate Grandbois: we all have our strengths.  You do and you right away what mine was and what mine were not. So, um, we, as we kind of talked about earlier, before we hit record, you know, a love of mine has always been cognition and it was something that I was studying really in-depth even in graduate school on my own. And so when I say studying, I was finding that I had to go to other fields like neuroscience, like cognitive psychology liked, um, you know, developmental psychology so that there were other fields that were really studying [00:05:00] cognition, um, and how the brain functions really from a functional level. Um, and that was what fascinated me. First time I heard the concept of neuro plasticity neuro-plasticity I was like, I'm in! Like game on and I just dove down the rabbit hole from there. Um, so I spent, well, gosh, the really the last 14 plus years. Really studying and learning from some of the best in these fields of neuroscience and neuropsychology. And that's sort of, most of my continuing education has come from. So I'm a little bit different in that vein because I'm sort of this hybrid between what's happening in these other fields of psychology and neuroscience and, um, also the speech and language world. So I'm kind of trying to bridge this gap. And as you can see with my work, it's, it's really sort of a hybrid  [00:05:57] Kate Grandbois:  and I love that fresh perspective. I think that's so unique [00:06:00] because there's so much of what we do, um, that is siloed. And we're going to talk about that a little bit later in terms of, you know, we live on speech island, we work on speech island, we play on speech island, but there are other islands nearby that contributes so much to what we do. Bridging that gap is so important. [00:06:13] Tera Sumpter:  Yeah, the analogy. That's a great analogy. I never thought of it that way. I always talk about it like a lens, right? If we're only seeing things through one lens and that lens being the speech and language lens, it's a really, really narrow perspective on a lot of these topics because so many other fields are studying language just to, just to talk about one aspect, right? Like really psychology studied it way before we did and how it develops and you know, what it comes from and where it comes from. All that, all that kind of stuff. There's so many different theories on it, but so many fields are studying these aspects of development that we are the ones treating. Right. So if there's all of this [00:07:00] foundational research being done elsewhere, but we're the ones who have to pick up the ball and actually address it in therapy. Wow. Well, there's a whole lot of foundation that we can be learning from other places, not just, you know, through our one lens.  [00:07:15] Kate Grandbois:  I can feel myself wanting to ask you a thousand more questions and I haven't even read the learning, learning objectives. [00:07:21] Kate Grandbois:  I have to be very careful. Um, but before we get into the learning objectives, you wrote a book on this. [00:07:26] Tera Sumpter:  I did, yes, I did. Well, I said, okay. So I forgot to tell you. So I was in the hospital for a couple of years, and then I started my private practice seeds of learning 10 years ago. Right. So that's, that's really where I took off and started doing very much my own thing. I was able to branch out and be really independent. So with that came, um, I was attending lots of IEP meetings and things for children. And then I had somebody in a meeting, um, that kind of discovered this cognitive processing model that I had developed years ago, um, that I used for assessment and [00:08:00] treatment. It's a very holistic approach. We're going to talk about it today. Um, and she said, I'm one of, I'm like on the board of this big organization here in Ohio, and I want you to come present this. This is brilliant. And I went, oh, okay. Because remember I've been living in a hole for most of my career studying from other fields. So she's like, no, you really need to present to SLPs. So we started presenting conferences, organizations, um, kind of all over. And I would have SLP after SLP, after SLP saying, you need to write a book. This needs to be in a book. And I was like, when am I supposed to find the time to write a flipping book? Like I have three children, I run a private practice. Like, so, um, anyways, I forced myself to get it done. It took away longer than I wanted, but I put the cognitive processing model got down on papers, everybody can access it. And it's been, it's like sold in almost 20 countries. It's [00:09:00] literally blown my mind.  [00:09:01] Kate Grandbois:  That's amazing. And I read it and it's very good. And we're going to talk a lot about the clinical content that you've put in this book. Um, and for anybody who is listening once we're finished and you want to dive a little bit deeper, there will be a link to the book in the show notes. Um, the title of the book is the seeds of learning. Isn't that right? So the title of the book is the seeds of learning. Um, and you also have an online community where people can go to learn more. Isn't that right?  [00:09:27] Tera Sumpter:  I do. I created a community called the Seeds of Learning. Um, it's on the mighty networks platform. Um, it's, it's a private community, it's an educational community. And the reason why I started that again, it was because people kept asking for professional development. And what I was finding from years of presenting is that we get done with the presentation, we get done with the seminar and everybody says, I need more. I need to put this into practice and then I need to come back and I need to help. I need to problem solve this with you. And so that was why I created the community so that every week we get together on zoom, [00:10:00] um, everyone brings their questions. We talk about the things that we did over the week. Problem solving errors that we had issues that we had in therapy. It's on going education and you have access to me all week long. You have me face to face on zoom. Um, and there's self study material that I put out. We go through individual topics of executive functioning, um, and there's lots of self study material. People can get CMHs for it. So, but I went in the community and to everyone learns from each other. So we see, like we see things through one lens. Right. Like, I I've been sitting executive functioning for so long, but I still see it through my eyes. I still see it through my lens. And there's so much value to me presenting what I might experience and the studying that I've done in the therapy that I've created, um, to other people, but then other therapists going, oh, wait, now I see it through this lens. And they teach all of us. So it's really this community, um, has, it's just [00:11:00] been wonderful. Literally the zooms are the highlight of my day [00:11:03] Kate Grandbois:  awesome. So for everybody listening, as we sort of get into the meat of this material, if you are finding yourself wanting to learn more, there will be additional resources listed, and this will be one of them. Okay. So let's get through the boring stuff so that we can get to the fun stuff. Sometimes people write in and ask me to skip this part. I can't ASHA makes me. So please bear with us. I'm going to read our learning objectives and our financial and nonfinancial disclosures, and then we'll get into it. Learning objective number one, define executive functioning and describe its relationship to learning. Learning objective number two, define the cognitive processes model and how it relates to speech and language pathology. And learning objective number three, identify at least two strategies for supporting executive functioning and speech and language. Disclosures Trra Sumpter's financial disclosures. Tera receives royalties from ELH publishing for her book, the seeds of learning, a cognitive processing model for speech, language literacy, and executive functioning. Tera Sumpter's nonfinancial disclosures. Tera does not [00:12:00] have any non-financial relationships to disclose Kate that's me. I'm the owner and founder of grandbois therapy and consulting and co-founder of SLP nerd cast my nonfinancial disclosures. I'm a member of 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 Mass ABA the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. Tera Sumpter's financial disclosures. Tera receives royalties from ELH publishing for her book, the Seeds of Learning, a cognitive processing model for speech, language literacy, and executive functioning. She's also the owner of a private practice seeds of learning, LLC. Tera Sumpter's nonfinancial disclosure. Tera does not have any non-financial relationships to disclose. Okay, we got that done. It was super boring. Let's get into the fun stuff. So I want to start off by sort of looking at some larger concept questions and I have to thank a friend, [00:13:00] an educator friend who brought this to my attention. Shout out to you, Liz. Thank you so much for being my friend and teaching me things. If you read your book and, um, she works in a general education setting with individuals who are, um, struggling with literacy and it blew her mind and she came to me as the speech pathologist, and said, she had all these questions and I could answer none of her questions. And the reality is that as speech and language pathologists, our scopes of practice are very, very large. Yes. A very, very wide, I guess I should say. And when I was in graduate school, which granted was a long time ago, I was sort of taught or given the impression that executive functioning is something that you do with someone who has a TBI or someone who has a neurological deficit. And then when you're done working on those skills, you sort of put it up on the shelf. You don't, you know, you only address it when you need it. Um, but one of the things that my friend helped [00:14:00] that Liz again, thank you Liz, helped me reflect on and something that I learned when I did read your book is that executive functioning is more of a cornerstone that really needs to be considered and addressed throughout all of communication. And I wonder if you could tell us a little bit, a little bit more about that as a deeper concept.  [00:14:17] Tera Sumpter:  Absolutely. So executive functioning is really the foundation, the cognitive foundation for all learning. And so speech and language is just, those are a couple in literacy and right, all of these other types of, um, skills, this large scope of practice that we have, these become types of learning that we undergo from the time that we're born, but found, but the foundation, what has to be in place before we can learn cognitively is the executive functioning. In short, we can say that executive functioning is self-regulation. So that's the shortest, shortest example or shortest definition of executive functioning would be self-regulation. Um, [00:15:00] we can think of, uh, executive functioning, that system is being like the boss of the brain, um, where, you know, it's sort of the, the one that's in charge. We'll talk about this, maybe a little bit more in detail, um, but in charge of. Workers. So we have the workers, the some systems of technician doing the work, but then you have to have the manager, you have to have the boss who has to tell them when to do the work and how to do the work and at what pace to do the work. Right? So all of these types of skills. So the, the executive functioning system is really that boss, the manager. And I also like to think of the executive functioning system kind of like a conductor of an orchestra. So it's also, the system has to, has to make sure that all of the workers work together in this sort of harmonious fashion so that we have this beautiful harmonious output. Right. And so when we talking about output, you know, when we see executive [00:16:00] dysfunction and there's a problem within the executive functioning system, the deficits that we see are performance deficit, That's how they're defined. They're defined as it is a performance based deficit, because it's what we see is a difficulty producing, whatever it is that we're being asked to do, because the system isn't queuing the workers. So getting back to your original question of like, what, um, you know, how, what exactly is the executive functioning system? Why is this something that's so foundational to learning? Why is this something that we should be involved in what we do as SLPs with children, not just TBI patients? Well executive functioning, the system is responsible for making sure that we are aware of our environment. We are cognitively connected to those around us. That's how we implicitly learn and speech and language development for that early, you know, birth to three. [00:17:00] We know that that's such a critical period of development. It's all implicit. We don't directly instruct children. The quote unquote normal development don't know who that kid is yet. I haven't met them. There were a lot of air quotes happening there, but you guys couldn't see my air quotes, but I'm always like whoever that is, don't know who that is. But in the literature we talk about the quote unquote, typical, you know, um, control group, whatever. So, um, but, but yes, so we have to, you know, this quote unquote typical child develops implicitly by soaking up like osmosis, right? Just being a part of this language rich environment. But the language rich environment is not enough because the child has to be connected and has to have awareness of that language rich environment. That makes sense? [00:17:53] Kate Grandbois:  It makes a lot of, and I love the imagery that you're using, especially the conductor. I think that, you know, just the concept of [00:18:00] all of these parts. Working together. And I think, at least for me hearing you talk about this and reflecting on my own caseload or my own clinical experience, it it's one of those things that, well, yeah, it makes a lot of sense, but because we're not necessarily as speech pathologists trained to specifically address the executive functioning, we're sort of only, we're sort of working on, it feels like we're working sort of on the surface without considering, you know, some of these deeper concepts or the roots, if you will. Um, I wonder if you could just to start off with some basics, outline some, some specific components of executive functioning. So off the top of my head, I'm just thinking about what you've said. I would say attention is likely one of them. Yeah, so I could be wrong. Cause again, I don't, a disclaim her. I don't know what I'm saying, but you're teaching me. It's fine. I'm fine. I'm fine. It's comfortable. I'm comfortable with it.  [00:18:57] Kate Grandbois:  Aside from attention. What are some of the other components of [00:19:00] executive functioning that are, are relevant to, um, what we need to know as SLPs?  [00:19:04] Tera Sumpter:  Well, there are a bunch right? There are a ton based on the research that you read, everybody defines it slightly differently. Some people, researchers tend to have like a smaller view, others like a really broader view with a lot more skills. I personally, with my experience, I've found that the broader view where I can really, I guess it's more of a detailed view where there are more skills that I can analyze the better I feel like I can target my treatment. So what are some of those skills? Attention and perception of the environment awareness right, of environment and self are absolutely the foundation. Right? Then we have another big one: inhibition. Opposite of impulsivity, right? Can we inhibit ourselves so that we can allow our partner to take a turn  [00:19:51] Kate Grandbois:  That gets me in trouble sometimes. That can be a human condition across, across everyone, right.  [00:19:56] Tera Sumpter:  A hundred percent. Right. [00:20:00] Um, that is something that we all have to develop and struggle to develop at times. Right. Um, things like energy. Do we have the right amount of energy for a task? Do we have too much energy or are we too lethargic? How about initiation? Just getting started, right? How about those procrastinators? [00:20:20] Kate Grandbois:  I sit down a basket of laundry and just get my phone out. I'm not folding that laundry, cause I don't want to initiate the task because I hate it. [00:20:25] Tera Sumpter:  Right. And so that's, I mean, that gets starts getting into therapy, but that's absolutely right. You've set yourself too large of a goal that seems really undesirable. And so we have to somehow shorten that up. I'm going to fold two towels. Then I get to choose you.  Kate Grandbois: Write me a task analysis.  Tera Sumpter: Well, we'll create a treatment plan later. There you go. There you go. I need one. How about stopping? You know, we say it's time to turn off the TV and go to bed or it's time to do this and go to bed. How's the stopping, right? Anybody has. A five-year-old or  Kate Grandbois: I was just about to [00:21:00] say, that's my son, just yes,  Tera Sumpter: Flexibility. And so when we think about flexibility and usually we're talking about mental flexibility and that can be seen in ways of stopping and doing something else, right. When we have to transition from classes, it could be that way, but another way, um, you know, in terms of assessment and when I see mental flexibility are in those types of language questions where a child has to give me two correct answers, they have to mentally be flexible enough to not just think rigidly about one, you know, or concretely about just one answer. Well, now you have to provide me with another way to say it. That is mental flexibility. So often we think of these as strictly language type tasks, when really there's a lot of executive functioning involved. Okay. How about self monitoring? Can you take inventory of your own actions and your responses and with self-monitoring, if we can self-monitor then we can self-correct, [00:22:00] self-correct then. Just because the child can catch their errors doesn't mean they're going to fix them. And a lot of times we lump these together. They might see that they made a mistake, but they don't take the extra step of self-correcting. All of those are, um, executive functioning. Self-modulation is a big one being able to, again, um, use the right intensity or frequency. How about those kiddos who are really loud and can't modulate their loudness level? Kate Grandbois: Also me, It's fine.  Tera Sumpter: Yes. I have a child who's very, very loud. Yes. And, um, I kept hoping she'll grow out of it and I'm like, Nope, she's not growing out of it. But also like how about physically, when, when we're interacting with our peers, do we push too hard? Right? Do we get too close? All of those things, do we know our own strength in a sense? And can we, can we modulate that. um, balancing multiple demands. Right. That's something I, when I work with my college students, we work with balancing a lot that becomes something hard. Sense of time and pacing [00:23:00] yourself. Right. Time has a feeling to it, knowing that you're going to have to listen to my presentation for 30 minutes versus having to sit in a presentation for five hours feels different. You're like, yes, I can do 30 minutes. And when I say, oh, you're going to have to give Tera something for five hours. You're like, oh gosh,  [00:23:19] Kate Grandbois:  you bring snacks, maybe a secret Sudoku puzzle. Not when we're listening to you.  [00:23:26] Tera Sumpter:  That's been the hardest part with COVID and the zoom presentations, because I'm so interactive. Like I sit on your lap and I'm like all over the place. Like I literally sit on people's laps. I'm all over the place. So like the time is, and it's so much fun. It was so taxing. That, one day we’ll make it happen, done done and done. Sequencing, um, executing a task, uh, working memory. We have to talk about that today. Working memory is massive. Working memory [00:24:00] is holding and manipulating information and being able to recall and pull up information from long-term memory and use it within this, uh, inner immediate type of operation working memory is an executive functioning skill. Anticipating, engaging, analyzing, comparing and contrasting, generating of ideas, associating, prioritizing planning, organizing. decision-making just you executive functioning.  [00:24:30] Kate Grandbois:  That's a lot more than I was expecting. I was expecting like 5. Not a joke. [00:24:34] Tera Sumpter:  And Tera is still talking [00:24:38] Kate Grandbois:  I haven't gotten my Sudoku puzzles out yet. Don't worry. And I'm fully present, fully present. No, but that's a, that's a lot. That's a lot. And I think when you, when you reflect back on that long list and how many of those components are direct influences on language, language use, word choice, attending to your [00:25:00] communication partner, using working memory to, you know, I can't even list all the things you said because there were so many, but every single one of them is related. Um, making me feel like the spokes on a wheel with the center being language, or it's somewhere on the wheel and all of those things, they're all connected.  [00:25:16] Tera Sumpter:  They're all connected and they're all necessary for any kind of learning. And it's not just, not just speech and language  [00:25:27] Kate Grandbois:  before we talk about the cognitive processes model and how it relates to speech and language pathology. I have a couple of smaller related questions that, um, about things that you mentioned in your book that I think will give us a nice backdrop. You mentioned in the book about the pluses and minuses of getting a diagnosis and, and how we as SLPs, okay. So I'm just trying to pull this all together here. We have that long list of executive functioning of things that we're not really necessarily addressing in our speech therapy sessions, where we have the skills and the content [00:26:00] knowledge to maybe address some things on the surface. And we have a person in front of us. Your book is mainly focused in pediatrics. So we're going to use pediatric examples through the process of, or through the course of this talk, this conversation, you have a small person in front of you this child in front of you, who may or may not have a diagnosis, but has been flagged or referred. And I'm thinking about my friend, who's in the general education environment right now, trying to support learners, um, because this doesn't necessarily affect just SLPs. And I wonder if you can talk to us a little bit about this concept of diagnosis and how it fits into this larger puzzle.  [00:26:41] Tera Sumpter:  Yeah. So this, this gets controversial and it's interesting because I'll have people on social media really, really argue with me about this. Um, I, I believe that we're very label happy in our society. We want, we think that once we've found a diagnosis, [00:27:00] I'm using air quotes, again, a quote unquote diagnosis that then we've found the answer. Right. Like, oh yes, the child has DLD or, oh yes. The child has, you know, whatever it, whatever it is, it's like the whole alphabet soup of, of what we give to children,  Kate Grandbois: what acronym.Right.  Tera Sumpter:  Yeah, exactly. So, um, and I would argue that a diagnosis can do one of two things. It can point us in the right direction, or it can point us in the wrong direction and in terms of how to create treatment and how to help the child. And so I think we have to be really careful about putting all of our eggs in the diagnosis basket, because if we're so focused on the diagnosis and what we think are the, what that diagnosis is supposed to mean, we might not see all of these other,[00:28:00] um, you know, symptoms or issues that might be presenting itself that might be able to provide us with the knowledge for better treatment plan for that child. So I think, and this is, you know, what I'm finding is that the really good therapists are already doing this, right. We're looking at the symptoms, we're looking at how the child presents functionally within their environment. And I always say, to me, the diagnosis doesn't matter. It really doesn't matter unless the child needs services other than, and I'm in private practice. Right. So I know it's a totally different ballgame in other settings. Um, but for me, when I have a child in front of me, all I need to do is I need to look through how they're processing information and that's going to give me the best picture of this kiddo, whether or not I give it the label of, you know, DLD or autism or, you know, whatever the diagnostic [00:29:00] code is to me as the practitioner. And that child’s therapist, it doesn't matter because I'm meeting the child where they are based on how they're presenting, you know, across settings.  [00:29:11] Kate Grandbois:  The reason why I think it's so important to, to talk about this is because before we talk about the treatment model is because I think as clinicians, we get the tiny person or the child in front of us and we read their intake forms and we look for a diagnosis. And that gives us an idea of what it is we're going to do that day or what assessment materials we might need. It's like you said, it points us in the right direction or the wrong direction points us in some direction. But what I think is important to highlight is that as clinicians we're there to, for person centered care, we're there to treat a child or a human or a person, however old they are. And in order to engage in person centered care, we really need to support the person [00:30:00] and the quote symptoms. And I'm using air quotes, of the diagnosis and not just the diagnosis itself. So before we started talking, and I also want to say that there are funding components related to this too. So a lot of people get a diagnosis. Because we have to based on our healthcare system to get funding. So I think it's important to keep that as a backdrop in our minds, as we start talking about treatment approaches, and I know we're going to talk a lot more about the cognitive processes model, um, but there are other variables and other factors that we really have to consider in our treatment room besides the diagnosis. And I love the point that you made in your book. And I just wanted to highlight that for a second.  [00:30:39] Tera Sumpter:  Oh no. Can we get something to that? Um, you know, I think I I've spent my whole career really intimately with families being in private practice. That's a beautiful part of private practice is that we really become part of that family. Um, and so I've really watched a lot of them go on this journey of trying to help find [00:31:00] help for their children. And one of the things that I've heard time and time again, is that we lost so many years of good help because it's therapy for the child because they were everyone, they were chasing a diagnosis, right. They were like, well then there was this diagnosis and there was this diagnosis and there was this diagnosis, but nobody was putting it together and trying to piece it together and just looking at how is the symptoms presenting. And so that's, that's one thing where I feel like if we're focusing on that diagnosis, we can end up barking up the wrong trees for too long, as opposed to just looking at the child in front of us. And the other thing too, is I think it's so important to remember is that no two diagnoses present the same, right. We can have two kiddos with dyslexia in front of us. And they're going to look very different, right?  Kate Grandbois:  Because they're two different people, and no two people are the same! Tera Sumpter: but I feel like we get stuck on the diagnosis and we're like, [00:32:00] well, they have dyslexia. And because they have dyslexia, this is what we do. Boom, boom, boom, boom, boom. Instead of really looking at how does the child present? What are their mistakes? When I talk about, when I work with therapists on assessment, right? I always say, forget the numbers, forget the percentiles, forget the standardized scores. Those tell you nothing other than that the child is having trouble. That's the only thing they're going to tell you where you're going to get the most information about that child, how they process information and what you as the therapist need to do about it is in the errors that the child makes. We spend hours at my private practice combing through the data that we get in an assessment at every single, um, stimulus, right. Here's the word was pat and they said, pitt, what was the error? And then once we have all of those, you know, the errors mapped out, then we're looking for the patterns. What are the patterns within this processing? That's where the information is, [00:33:00] on how a child is struggling and how they're processing information. And I feel like we lose that when we focus on the diagnosis.  [00:33:07] Kate Grandbois:  This is a great segue into our second learning objective,  [00:33:10] Tera Sumpter:  stop talking Tera...  [00:33:14] Kate Grandbois:  no, because you're starting to talk about some of these fundamental components of analysis. And I think that there are components of that in the cognitive processes model. And I, and I want to, I want to give you a chance to tell us about the cognitive processes model. First of all, what is it and how is it related to speech and language pathology? I know that's a loaded two parter question. [00:33:34] Tera Sumpter:  Yeah. Yeah. Remind me about the second part. Once I am part way through my  Kate Grandbois: that's what I'm here for. I can do that.  Tera Sumpter: That's reminders. So the cognitive processing model, it is, um, it's, uh, a model of looking at the components necessary for learning, particularly academic learning. And I spent years developing this based on [00:34:00] studying right loads and loads and loads of reading of research what's involved with what, what correlates with what, um, and you can see in the book, the actual diagram and how I use the diagram to plop in information. But it's really looking at these different components, everything from speech processing to language processing, to pulling out phonological processing, um, visual word form area, which the visual word form area for literacy is the part of the brain that visualizes symbols, numbers, letters, um, and then how that correlates to math. And then we see in the model, how executive functioning has to reguluate all of it. So, um, it's just a broader, more holistic approach of looking at assessment, right? That's, that's primarily how I use it. Um, but the assessment drives treatment, right? So if you have a good assessment, it's going to drive, gonna drive treatment. So, um, we do a really detailed assessment based on this model of looking at each individual component. [00:35:00] And how does that relate to speech and language was the second that  [00:35:04] Kate Grandbois:  See you remembered that was such good executive functioning  [00:35:05] Tera Sumpter:  and working really good working memory. That was really good working on the question.  [00:35:12] Kate Grandbois:  Well, and the reason that I want to unpack it and make this connection is because, you know, we are SLPs and often we work in a siloed environment, right? We work on, um, I think we talked about this maybe before we started recording, we work on SLP island right here by ourselves. We don't work. We work here, we play here and there's other islands nearby that may contribute to our work. But for the most part, we stay on SLP island. And what you're getting into with the cognitive processes model is a little bit of an edge or going into some of these other areas. And I, I think because we've, you've already outlined how critical executive functioning is for so much of what we do. I think it's really important to point out specifically what the cognitive processes model has to do with speech and language pathology in the first place.  [00:35:59] Tera Sumpter:  [00:36:00] Yeah, absolutely. And I think to you with. This is what I'm. What I tried to do with this cognitive processing model is offer us a really tangible way of showing how speech and language development is the foundation for so much of our other learning. Right? And we know that as SLPs, we know without speech and language, we're really going to struggle with literacy, right? If we have holes there, well, I'm going to show you how it's also related to math. And I'm also going to show you how all of these components of the processing are needed for learning another language, or doing well in social studies or science, right? What is it that we're accessing for all of this other language and speech and language from a subset, um, processing component, you know, a factor. It is a foundation, but seeing also that the executive functioning is the bigger picture of what has to regulate. [00:37:00] Sort of all of these, sub systems. So it's a lot of what we, we already know. And I've had so many SLPs who read the book, reach out to me and say, you know, like, oh my gosh, this is, this is what I've been feeling for so long, but I didn't know how to organize it. I didn't know how to put this into words, like, because we know that these components, speech, language, right, phonology, some of these things are foundational for the learning that takes place in the classroom. You know, we know that a child's going to have trouble with reading comprehension if they have deficits in language comprehension. Right? Why is that? Because oral language becomes the foundation for these other aspects of a child, can't understand struggling with oral language comprehension, they're going to have a hard time sitting through a lecture and understand what's happening in social studies or science, right? So it does become these components necessary for all learning. And that's what I'm trying to show with this model. Um, but the bigger picture being that yes, speech and language a hundred percent are a massive [00:38:00] foundation, but there's even more that has to happen before that. And that's the executive functioning component that it is, it is truly the root here. [00:38:10] Kate Grandbois:  And everybody who is listening, who has listened to our podcast before knows that we're massive, massive proponents of collaboration and a lot of what you're saying, and this imagery we've sort of touched on about these neighboring islands in our field. A lot of what you're saying. There is overlap here with other professionals. Um, and I wondered, I wondered if you could tell us a little bit about that overlap, particularly with our school psychology counterparts or our neuro-psych counterparts or our psychology counterparts, um, or even our general education counterparts when they're in the classroom and don't have access to an executive functioning specialist, but are turning to the speech pathologist, trying to facilitate more growth in a general education classroom. What, what, what does that look like for you? [00:38:56] Tera Sumpter:  Well, I just want to start by saying, you know, [00:39:00] with that question, if we, if we think that there's no overlap to all of these fields, we're as dumb as they come listen, the brain is,  [00:39:14] Kate Grandbois:  can you tell me what you really think? Just real quick? [00:39:15] Tera Sumpter:  Am I allowed to swear? How many expletives are you allowed to bleep out in when a guest ASHA's not going to like that? [00:39:26] Kate Grandbois:  I don't think they would have it's okay. If this wasn't public, I'd say I wouldn't tell, but it's fine.   [00:39:29] Tera Sumpter:  So, so if all of learning whether or not we're talking about the field of education or psychology or SLP world, or OT or PT, whatever it is. All of this stuff is mediated by the brain and the brain is interconnected. It is all connected. There is no way to differentiate between this processing and that processing. I mean, it's fascinating to see how [00:40:00] quickly the brain will shift, you know, based on that's a whole, that we can’t talk about that. Okay. That's going to get into a whole other topic that was not on an objective, but it's really fascinating research by David Eagleman. If anybody's interested with his book, Livewired, it's amazing.  [00:40:13] Kate Grandbois:  The link in the show notes, just in case,  [00:40:15] Tera Sumpter:  oh my God. He's, he's a neuroscientist. He's, he's brilliant. Um, but, but everything is interconnected and everything is working together. So there is no way for us to say as SLPs that we don't need OT. There's no way that we can say we don't need the psychologist or that we don't need the educators or that we don't need the vision specialists because it takes all of it for a brain to learn. Right. So, um, I feel like it's, I feel like it's sort of a no brainer.  Kate Grandbois: Pun intended.   Tera Sumpter: Yeah, that was good. That was real though, for a Friday to Katie, Katie, that was impressive. So no brainer. I mean, we, we have to see [00:41:00] all of this as interconnected. We have to see the, that all of us need to be working together and why it all blends so much together. And one of the things that I hear a lot from professionals, particularly SLPs when I present is that they hear from other fields, particularly a lot of times the school psychologist will tell them, stay in your lane. Yeah. I I've heard that a lot over the years that they will hear from school psychologist, executive functioning is their domain. Executive functioning is not your domain. Stay in your lane.  [00:41:30] Kate Grandbois:  I recently heard a term for this: disciplinary centrism. So when you think that your field knows better or does better than other fields, disciplinary centrism is a rampant problem across all of medicine, across all of allied health. Every, every discipline has a flavor of disciplinary centrism. And when you start talking about and looking at disciplinary centrism, you start to see a lot of individual variables like ego. [00:42:00] And I think that there are a lot of barriers there. Um, that we, as people, can't control other people, but we can control ourselves. And there's a lot of work you can do to build, to bridge these gaps related to reflecting implicit bias, thinking about your own ego, defining your scope of competence. What do you know and what do you not know? Because you're going to have a much better chance of making a good relationship or smooth, smoothing things over with the grouchy pants down the hall who told you to stay in your lane. If you acknowledge that you can learn from them and ask them and ask them questions and create a relationship. And as we, we literally make a mug with this on it, be a person, not a jerk. So there's a lot of things that you can do to improve some of that inter collaborative relationship. Um, and that's a, not to steal mic from you, but disciplinary centrism is a, is a real thing. I mean, that's why they have a fancy word for it.  [00:42:53] Tera Sumpter:  Yeah, that's brilliant. And it's so important. I mean, we can go into the whole, like philosophy of why that exists [00:43:00] straight from an evolutionary standpoint, we're all trying to survive. Right. It's either eat or get eaten. And so I think that's maybe where a lot of that comes from. Yeah. But I think that when we realize that in our field, in the field of medicine and when we're trying to help other people that this sort of sense of ego and self has to be set aside because it's not about us. It's about the patient in front of us, the client in front of us, the student in front of us. Um, and realizing that we are better together as a team because we're all going to support that system. And that is so critical. Um, I mean, we refer, we are so collaborative, um, within our private practice where we need all of these other people on the team, but that's essentially where I was, what I was trying to offer with this cognitive processing model is that, this isn't just speech and language. And if we are only looking through that micro lens, we're missing a whole lot of other pieces to [00:44:00] this puzzle.  [00:44:01] Kate Grandbois:  Not only that, but let's think about the things from the client's perspective and looking at it through the lens of person centered care. An individual; presumably if you're listening to this, you're interested in learning more about executive functioning. So you may or may not have someone on your caseload who has some who need some supports for executive functioning that individual may have other people on their team. They have other stakeholders, they have friends, they have parents, they have, they have other people in their environment. So if you make it just about speech and language, you're not going to create a long-term supportive environment, or you're not going to facilitate that long term supportive environment because we're transient. We have our clients for an hour, a week, two times 30. I don't know whatever your workplace workplace setting is or whatever your service delivery model is, but it's never just about speech and language. It touches so many other things, and there are a million reasons for that outside of um, math and social studies [00:45:00] and the academic pieces, there are social emotional components to this too. [00:45:03] Tera Sumpter:  100%. Yeah, that was something I actually didn't talk about. That's very interesting is that, you know, executive functioning is a really, really broad umbrella that regulates many what we call arenas of involvement. So it's going to regulate the emotional arena. And so it's, you know, emotional, really our perceptions, our thoughts, our actions. And it's really fascinating because we get kiddos and they come to us again, going back to the diagnosis, um, conversation with a million diagnoses, right. They have oppositional defiance and they have, you know, sensory processing disorder and they have, um, you know, all of these different diagnoses, but that's really because ultimately with these kiddos, the deficit is in the root. The root of that is executive functioning and the executive functioning isn't regulating all of these pieces and parts, they're not, they're struggling to regulate their emotions. They're struggling to regulate their actions. They're struggling, [00:46:00] struggling to regulate their perceptions and their thoughts. So it is a really broad, broad arena. And that's why, you know, working with allied professionals is so, so, so key. Um, having somebody who specifically targets the emotional, if we need that and the sensory, I mean, you can't do executive functioning work without a sensory OT. Just can't do it. It's, I always say executive functioning and sensory processing go together like peanut butter and jelly. And you can't separate the two. They have to, you've got to address the sensory system as well.  [00:46:34] Kate Grandbois:  I love that. Do you have any, for those people who are listening, who maybe have been told to stay in their lane or experiencing a prickly pear, a prickly professional, or some other, you know, unfortunate interaction or where they're not really sure where to get information for how to get, how to make those relationships better. Do you have any practical suggestions for improving those relationships?  [00:46:56] Tera Sumpter:  Absolutely. You just have to educate yourself. [00:47:00] You have to arm yourself with information. When people realize that you know what you're talking about and you can cite sources, then you know, people start to listen. Um, I was asked about a year ago to present to a local group of school psychologists. There were like 70 or 80 school psychologists. It was all on Zoom. Yeah, I know. Well, usually it's, it was a lot of people, but, um, I mean, I was, I was shocked in a way. I mean, it was honored obviously, but, but in my head I think of like, oh wow, the school psychologists are asking me to educate them on executive functioning. Why did that happen? Because they know that I know a lot about it, right? You just have to present yourself. I know a lot about it. You have to learn about it. My favorite places to go to there's a book that everybody needs to buy. You have to put this in your show notes. It's by George McCloskey. If you follow me on Instagram, you know, I reference him a lot. George McCloskey. Lisa Perkins, Bob Diviner is [00:48:00] the book is by, um, called assessment and intervention for executive function difficulties. It is a fantastic book loaded with so much information. I will warn you. It is not an easy read, but it is worth every moment of energy that you put into it. Um, another really good one by Russell Barkley, he's better known. He's kind of like the godfather or the executive functioning. Um, he has a book called just executive functions, executive functions, what they are, how they work and how they evolve. That's a really, really awesome, um, book as well, Dawson and Guare have some good things out there. There's a lot of people and this is where it gets tricky. Right? There are a lot of people out there writing about this topic now, but there's some heavy hitters who've been in this field for a long time. Um, you can't go wrong with Barkley. You can't go wrong with McCloskey. Um, and, uh, I do like, I like Dawson and Guare too. I [00:49:00] don't like their working memory stuff, but other than that,  [00:49:03] Kate Grandbois:  I will link all of those in the show notes so that everybody listening can have those, uh, as a, as a quick and easy access. Um, in our last 10, 15 minutes, I wanted to transition over to our third learning objective, um, and talk about implementation. So in other words, now that you've told us a little bit about the importance of executive functioning, how it's related to speech and language pathology, what the cognitive process model is. And some of the barriers such as interprofessional collaboration and those kinds of things, what are some things that we can do about it? What are some things that people that are listening can do in their therapy rooms or, um, even additional resources to improve our ability as SLPs to do more than just the surface work of addressing speech and language. [00:49:54] Tera Sumpter:  Okay. I'm going to talk about two key components that I think should be a part of everybody's [00:50:00] therapy that's going to target executive functioning. Okay. The first thing that we have to do is we have to increase a child or adult, but in my, you know, in a child's awareness around their deficits, we can't change what we're not aware of. And the, an incredible technique for doing this. It's called reflexive questioning. This is something I talk about a ton. Reflexive questioning is responding to a child's response when there's an error. So for example, um, if a child says, I'm gonna use the literacy example, cause we do this across the board, you can apply it to anything. So, um, if the word is “bat” and the child says “bit”, I'm going to respond to bit. And I'm going to say, when you say bit, what would be the [00:51:00] second letter that you would see? B-i- I it would be I you're right. Does it match? And I'm going to point them back to the original stimulus. And they can say, no, it doesn't match. And I can say you're right again. You've been twice Right. Good job. Let's see. What's the second letter that you use. It's an a, oh my goodness. You're right. Again. You're so smart. What does A say? Oh my gosh, smart again. I went to word say that nice job. What I've done is I've increased that child's awareness around the mistake that they make when we just give the child an answer. So if I would've just said, no, it's not bit it's bat. There is absolutely no processing that takes place for that child. It's completely passive. I'm giving them a response, but the child's brain isn't actively have to get engaged in fixing their own mistake.  [00:51:56] Kate Grandbois:  Not only that, but it's punishing and it doesn’t feel good [00:51:57] Tera Sumpter:  and it doesn't feel good, [00:52:00]  [00:52:00] Kate Grandbois: creating a positive learning environment. You're not associating yourself with anything that is empowering. All of those good feels that we all feel when we do something hard, but feel like, okay, I can do this, that inner loop, that inner self-talk, you're not going to get any of that momentum. If you're just sitting there going, Nope, it's bit not bat or bat, whatever. If you're just sitting there correcting them, you're not going to get any positive momentum in terms of rapport any of that stuff. [00:52:25] Tera Sumpter:  Exactly. It's a very positive environment when you bring in the reflective questioning. Um, the other thing too, you know, a lot of times we'll just have them like, oh no, that wasn't right. Do it again. But that'll be the way that we would address the kind of an error, just, okay, we'll try it again. Well, they might get it right the next time, but there's been no reflection. No self-evaluation no awareness on the child's part of how they erred the first time. And it's the increase in awareness that is gold. It's the secret sauce to changing how that child is going to process their [00:53:00] environment. What would this look like for a straight up, you know, executive functioning example? Let's say we have a kiddo. Um, let's say that we have a kiddo who is looking out the window, right. And they're distracted by something going on outside the window, instead of paying attention to the teacher. How might I handle that with reflexive questioning? I may say, Hey Johnny, where are our thoughts right now? Is that important? Is what's outside important right now. Oh, no, it's not. You're right. I'd be like, I hear it too. I always tell the kids like, trust me, I hear it too. I could probably get an ADHD diagnosis myself, but like, I hear it too. Is that important right now? You're like, no, what's important right now? The teacher talking. That's right. What should we be focusing on? What should we have our thoughts on? Where should our thoughts be? They should be on the teacher. You're right. Good job. Can you show me? Yes. Awesome. Great. So using it that way, instead of like stop paying attention outside, Johnny, you're not listening, right. There's a way to do this that increases [00:54:00] the child's awareness. And with repetition, reflexive questioning ends up wiring the child's self-talk. So they start asking themselves the same questions. Am I doing what I'm supposed to be doing? Are my thoughts where they're supposed to be. Um, those that match,  [00:54:20] Kate Grandbois:  which is an executive functioning skill. That's self-reflection. [00:54:22] Tera Sumpter:  A hundred percent. That's why we do reflective questioning. It's full circle. We're getting the child to self evaluate and to be able to self monitor and to self correct. I mean, let me, let me ask you this. So if you have, um, if you have somebody coming over to your house, right, who is coming over for dinner and they call you on the phone and they're like, oh my God, Kate, I'm lost. What's the first thing you ask them? Kate Grandbois: where [00:55:00] are you?  Tera Sumpter: Great. Right.  Kate Grandbois : Is that the right answer?  Tera Sumpter: You say, where are you? That's what we need to be doing with our children. We need to be saying, where are you? Let me meet you, where you are at your response. And let me help guide you to the.  [00:55:20] Kate Grandbois:  I love that analogy with all my human self, because the analogy is where, cause you you're lost. Oh, well you're lost. And then hanging stuff, just telling them that they're lost telling them what they already know.  [00:55:35] Tera Sumpter:  Yeah. Or try again. Sorry. I know you're lost, but try it again. Try it again. Right. Geez. It's so beneficial. We would, we have to meet them where they are and we in the, where they are is at their mistake. I do this with speech too. I mean, you know, if the child is using the wrong sound, right, I'm going to meet them at the wrong sound and we're going to analyze [00:56:00] the air and sound and I'm going to raise awareness around their aired sound and then ask them if it matches. Right? So I'm increasing awareness around the ears that they're producing so that then they can see the distinguished does this, the distinction between theirs and min. [00:56:16] Kate Grandbois:  I have to assume that this also requires some nuance and finesse and rapport and counseling skills, because I'm imagining myself as a, as a more green clinician. I'm old and crusty now I've been doing this for too long, but you know, I, once upon a time as a new grad, I think back on the things I did and I just absolutely cringe. But you know, I think that I could see my younger self, maybe trying to apply some of these techniques too harshly or without the right dose of support. Do you feel that that's true, that there needs to be some nuance around counseling and positive report to do this reflective questioning well?  [00:56:58] Tera Sumpter:  Well, for sure, like, don't be a [00:57:00] jerk look I'm telling you it'd be a person that. Yeah. I mean, you're not gonna be like, Johnny, are you paying attention? You know? And, and I think always bringing it back to, um, we all experience these kinds of errors and meeting them at that human level of, I get distracted too. Or, you know, sometimes I make mistakes when I read too, or sometimes I'm, disfluent when I talk too, right. Like whatever, whatever it is, we can all meet them there. And that's the beauty of reflective questioning is that you're meeting them there. You're meeting them where they are instead of standing in your spot firmly and saying, get here and get here now. Right where we're walking over to them. And we're saying, we're holding hands with them. And we're saying, I see you and I see where you are and I see your struggle. And we're going to walk together and  [00:57:53] Kate Grandbois:  It’s so validating. Everybody wants to be validated and heard.  [00:57:55] Tera Sumpter:  Yeah, it's so validating. So like my I've worked with all [00:58:00] ages throughout my entire career, but now. I'm old and crotchety, like you were saying. Um, you know, I don't quite have the energy for the littles that I used to have now that I'm in my forties. So I really loved the high school and college aged kids. And I can't tell you like these high school boys, like, I can't get them out of my office. Like they come for therapy and then they won't leave and they're like, give him material. We just like being here. They love being there because they know there's really never a wrong answer. It's supportive. They feel successful. And I'm telling you, it is all because of the reflexive questioning and how we can take a mistake and turn it into a positive and walk them to the right answer. But they can see it themselves. I always tell when I do full like big day trainings and all, everything, I always tell people if there's anything you take away from today, please take reflective questioning. It is an absolute game changer. Oh, I know. I have a quick example too. [00:59:00] So in my mighty networks community, one of the members, Jean, who's amazing. She's, she's more seasoned than we are Kate. She said, I didn't, it wasn't quite sure but I bought into this reflexive questioning. She goes, oh my god, it worked so well. I couldn't believe it. She was like, I asked these little five-year-olds who were squirrely all over the place. Is that what we're supposed to be doing? Where are our body's supposed to be right now? And they're all like, oh, oh no, it's not what we're supposed to be doing. And they got to where they're supposed to be doing just like good job. She was like, I couldn’t believe it worked! And I said, it works.  [00:59:32] Kate Grandbois:  It was one of the most, one of the most important things that I'm hearing about this is that it's done again, just to sort of reflect this back to you. It's done in a positive, supportive, comfortable, and safe therapeutic environment. And yet nobody can learn and grow when they’re being criticized when they need to be validated when they're feeling anxious, no learning is going to happen as a human experience. You are not going to learn [01:00:00] something if you're in fight or flight, or if you're nervous or if you don't have a good relationship. And I love that you're describing this in such a way where you're meeting someone where they are full of support. Okay.  [01:00:10] Tera Sumpter:  So second, second, one second strategy. That is so key is the implementation of visualization into our therapy sessions. So, um, and this is key for both executive functioning and language, because this is really the foundation for what we call nonverbal working memory, which is really this imagination part of our executive functioning system that's necessary for language. So, um, what is visualization? It's this ability to create mental representations within the brain, right? It's if I say, think about the best vacation that you ever went on, what happens in your brain.  [01:00:49] Kate Grandbois:  I actually, I think, I think I might have an executive function disorder. [01:00:51] Tera Sumpter:  Oh no you don’t see anything? [01:00:56] Kate Grandbois:  I have concepts, but I am my visual. [01:01:00] My visual spatial abilities are lacking. It's okay. I'm cool with it. [01:01:04] Tera Sumpter:  We can work on that. Non-verbal working memory becomes a foundation for our ability to have foresight and hindsight. So the only place that the future and the past exists is in our mind, it only exists in our ability to create a representation. So I can't plan for the future. If I can't project myself mentally into the future, I can't self evaluate the past and the mistakes that I made. If I can't see what happened and role play it again in my head, in the past.  [01:01:59] Kate Grandbois:  That's powerful just as like a [01:02:00] person. I mean, if you're thinking, you know, that you that's applicable to everybody all the time. [01:02:04] Tera Sumpter:  Correct. And that's why so many people have executive functioning issues and they can't do this. You have to be, so when it comes to working memory, we have working memory for images, non-durable working memory. We have working memory for sound, phonological working memory, right. We have these two components. And so we can't our concepts and our language are going to be, um, really, you know, conceptually are going to be, uh, what's the word I'm looking for? You know, the non-verbal working memory is what houses these concepts. Right? And so if we can't see ourself moving through the world in our mind, or if we can't see a potential interaction happen with a peer before it happens that if I say this or do this, they might be upset with me. So therefore I need to check [01:03:00] myself and self monitor. Right? All of that requires this ability to visualize and have mental representations either into the future for planning purposes and for self-monitoring and for self-correcting, but also for the really important skills of self-evaluation, which takes place in the past and learning from mistakes so that we don't repeat them again. Right. We took it when I hear parents say all the time, like they keep making, doing the same thing over and over and over again. Why aren't they learning that if they do this, it's not going to work for them. Well, because they're not, self-evaluating, they're not replaying the error over and over again in their mind, trying to self monitor it and fix things, and self-evaluate it. Right. That all requires visualization. So, um, in short, I mean, gosh, I could, I could talk for days about visualization and how we address it and all of that. That's going to be my third book, third book,[01:04:00] second book, which is in the process of being written right now is, um, my executive functioning therapy. And then I think my plan that I have sort of outlined in my head is a third book, which will be language through an executive functioning lens. Yeah. So, but I'll be dead by the time I can get all this it's all in my brain. I just have to get it out.  [01:04:25] Kate Grandbois:  I, this was especially that last one. I feel like so much of what you've said is, and shared is not only applicable, but critical to the work we do in speech and language pathology across so many different components of our scope and so many different apps of that, aspects of, of what we do. Um,  [01:04:44] Tera Sumpter:  and I want something, oh, sorry. That's something that's so fascinating within my mighty networks community is because these therapists are always bringing different, you know, they'll say I had a question last week, Tera, what about, how does executive functioning relate to disfluencies? How does it relate to this population and [01:05:00] this population? Right. And so there, we get to really problem solve with all of these different types of populations that we work with. That's awesome.  [01:05:09] Kate Grandbois:  That's awesome. Well, to anyone who is listening, who, if this is their, you know, either first pass at learning more about executive functioning or if they're, you know, knee deep in it, but when I continue their journey, do you have any words of inspiration or wisdom for those, for those folks who are listening? [01:05:28] Tera Sumpter:  Oh my gosh, you should have prepped me for this question. Any words, [01:05:33] Kate Grandbois:  Amy always does, and I forgot because Amy’s not here.  [01:05:38] Tera Sumpter:  Sorry. Do I have any words of wisdom? Um, I would say just keep reading, keep reading, keep challenging. Um, progress is not made without resistance. And so just because it's always been [01:06:00] done one way doesn't mean that that's the right way. And so if we really want to move our field forward, if we really want to not feel like we're lost in therapy and that we're really reaching these kiddos and helping them, we have to keep asking the questions. We have to keep reading. We have to keep challenging. Why, why, why are we doing what we're doing? Why are we seeing what we're seeing? If you can't answer the why keep digging.  [01:06:29] Kate Grandbois:  Well, I can't say anything to follow that up, so that's just, I have nothing to contribute.  [01:06:36] Tera Sumpter:  Oh, I'm glad that it was good. Oh, thanks. Okay.  [01:06:43] Kate Grandbois:  I am so grateful for your time and I'm so glad that we got to share this with everybody listening. Thank you so much for coming on here and teaching me everything ,  [01:06:52] Tera Sumpter:  Thank you for having me [01:06:54] Kate Grandbois:  and to anybody's who's listening. All of the resources that we mentioned will be in the show notes [01:07:00] and, you know, contact us any time. If you have questions, I don't want to speak for you, but you've been so generous with answering questions through your different channels, social media, people can find you through your mighty networks. Um, there's lots more, lots more.  [01:07:13] Tera Sumpter:  Yeah. Instagram I'm on Instagram every day I post and then get off. Cause I don't want social media drama, so, but I do post and get off. Um, but I do answer DMs. I try to get to a lot of the comments. Um, so you can, a lot of people do reach me through Instagram too, but my email is in the book. You can find me. I mean, you can find me on my website, so I'm not hard to find. That's awesome. Feel free to reach out.  [01:07:37] Kate Grandbois:  Wonderful. Thank you so much again for being here and we hope everybody learned something today.  [01:07:42] Tera Sumpter:  I hope everybody learns something too. And I really appreciate you having me. This was so much fun.  [01:07:47] Kate Grandbois:  Open-door policy for you. Anytime. Anytime.  [01:07:50] Tera Sumpter:  Thank you. You guys are the best.

This is a transcript from our podcast episode published December 20th, 2021. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). 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 . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:02:03] Kate Grandbois:  Hello everybody. Uh, we're so excited for today's episode. I am here solo today while my counterpart Amy is on vacation, but I'm not lonely. I'm not alone. I have the pleasure of welcoming Sarah Penrod onto today's podcast onto the podcast today. Welcome Sara.  [00:02:21] Sara Penrod:  Hi, thanks for having me. I'm so excited.  [00:02:23] Kate Grandbois:  We're so excited because you're going to talk about something that I know nothing about. And I think I say that every episode, but I really know nothing about this. You are going to talk to us about the role of the medical SLP in an ICU, and I, not only have I, I worked in a hospital, it was outpatient, but I am not a medical SLP. I have never worked in the adult population, much less in an inpatient setting, much less in an ICU. I know very, very little about this. Um, so I'm really excited for you to teach me all the things. And I wonder if before we get started, you can tell everyone a little bit about yourself. [00:03:00]  [00:03:00] Sara Penrod:  Yeah, absolutely. So my name is Sarah Penrod. I work currently full-time at an acute care hospital in Maine, uh, 637 to 650 bed hospital, depending on the emergency department, we have six critical care units at this time that I'll go into a little bit. We have a medical ICU, surgical ICU, neuro ICU, cardiothoracic, cardiac, and currently a COVID ICU. Unfortunately. I've been in the field about 15 years. I've always worked with adults. I've been everywhere in the continuum of care. I've been in skilled nursing. I've done a little bit of outpatient. Um, I did inpatient rehab at Spalding in Boston for 10 years, which was a huge learning experience. Um, I worked at a long-term acute care hospital in Boston with a lot of vent weaning and, um, trach involvement, which was really great experience, especially for transitioning to the ICU. Um, I am a, my current interests [00:04:00] are critical thinking in SLP. Um, and really the importance of the SLP on the interprofessional team, this, this concept right now of interprofessionalism that we'll get into where we're not operating in silos, but that we, we fully understand each other's roles and, and what each other can offer, um, is my big thing right now, you know, in acute care, we're seeing a lot of, you know, it's necessary to do a lot of advocacy and education for team members. So it's a, it's an interesting role it's um, as team focused as it is patient focused, which is, is really interesting. So that's what I do, and I love it. It's just been probably the job of my dreams being here. Um, fast paced, acute care, um, unique patients, situations. I mean, I've seen stuff here I've never even thought of. So, um, it's been wonderful and I'm so happy to talk about, um, the role of the SLP in critical care. Cause it's something I feel really passionately about.  [00:04:59] Kate Grandbois:  Well, you've [00:05:00] already said two things that really get me going, which are interprofessional collaboration and critical thinking skills for a clinician, which are two things that I don't know... It doesn't matter to me what setting you work in, what population you work with. These are skills that empower us as clinicians that are critical to our jobs that, my very humble opinion is that we don’t talk about enough, we don't prioritize enough. So I honestly, I was surprised to hear you say those things as they relate to the ICU, but I shouldn't be surprised because they're so important. So I'm really excited to talk a little bit more about that just selfishly, because I also find that very interesting and as a critical piece of our clinical lives, but before we get into all of the really fun stuff, um, I have to read the learning objectives and our disclosures. Um, sometimes people write in and ask me to skip this part. I can't ASHA makes me read it. So please bear with me. I will try to get through it as quickly as possible. Learning objective, number one, identify ways the SLP can address speech, language, communication, and swallowing disorders in the [00:06:00] ICU. Learning objective number two, list the reasons for obtaining and synthesizing the most up-to-date medical information before seeing a patient in the ICU and learning objective number three, list factors that can contribute to success in therapy or confound SLP specific diagnosis. Disclosures Sarah Penrod, financial relationships. Sarah is employed full-time in an ICU set, in an ICU setting. Sarah Penn rides, nonfinancial disclosures. Sarah does not have any non-financial relationships to disclose. Kate that's me. I'm the owner and founder of Grandbois therapy and consulting LLC, and co-founder of SLP and our cast, my nonfinancial disclosures. I'm a member of ashes to 12 as they're on the eighth. I'm also a member of the Berkshire association for ABA and there'll be behavior analysis international and the correspondence, but that'll be in the five-year old system senators group. Okay. Boring stuff is over. Is there anything that would be nice for you to start us off with, um, with some background information, um, before we got into. Before we hit the record button, you and I had a quick conversation about your skillset and it not being very [00:07:00] well-represented across the speech language pathology field as a whole. So out of the, all of SLPs and existence, we're willing to bet based on the demographic data that we have, it's a relatively small percentage of SLPs working in the ICU. And I wonder if you could start us off by telling us a little bit about what qualifications you need to work in this environment, how did you get into working in the ICU?  [00:07:22] Sara Penrod:  And it's a really good question. I think sort of like other jobs and you apply for a position in an acute care hospital and you sort of learn as you go. Um, if you don't have ICU experience, you know, you're the train on the job. Um, find a mentor. I think one of the things that's interesting about critical care, I mean, there's a lot of things that are unique to critical care, but these are also the same patients that you're seeing at acute care rehab. It's just a month before or two weeks before. Um, so these patients have similar diagnoses, similar presentations. Just worse and sicker. So, um, you know, right now there's no, there's no requirement as far as training or years of experience for working in an ICU. I [00:08:00] mean, that's just dependent on hiring you. Right. Um,  [00:08:05] Kate Grandbois:   so my first question then, I guess, in terms of transitioning from that into our first learning objective, are you ready for the most general non question that anyone has ever asked you [00:08:12] Sara Penrod:  I'm ready, bring it.  [00:08:13] Kate Grandbois:  What does an SLP in critical care do? What can we do for a patient in critical condition? So what are we, what can we work on? [00:08:19] Sara Penrod:  So, I mean, you're working on all the same things that we're working on. Um, prior, I mean, like that you're seeing in like skilled nursing and acute rehab. A lot of these patients in the ICU require, um, ventilation, right? It's a lot of them are either intubated. They have tracheostomy tubes and there's a whole lot of management that SLPs can do surrounding, um, the presence of a trach. So when patients are intubated it, they thought breathing tube in their mouth. They're hooked up to a ventilator on city that because patients don't really tolerate, nor would I, you know, breathing tube in the, in the mouth and NG tube to going through the throat. Um, and a lot of times, you know, we're working on ensuring medical stability. So these patients are sedated. At times the, he is asking us as communication in those [00:09:00] patients. Um, but a lot of times, for the most part, if patients are intubated and we're not really seeing those patients are just not quite ready. Um, once patients have transitioned to other forms of breathing. So, um, high flow oxygen or a tracheostomy tube, that's directly into the trachea stoma, then we can start to really get involved. More consistently because these patients already use their mouths, you know, are awake. So the assessment of arousal and conditions like this, where you feeding readiness, right. So patients who have a tracheostomy tube, may have a variety of reasons why they'd have dysphagia. Um, and we're in there to say, how did this dysphagia what's the timeline for, for eating? You know, patient has an NG tube, a feeding through, through the nose. Are they going to need a peg tube, a more permanent solution? So we're getting in there early to try to get an idea based on, you know, medical nosies, um, how quickly they're sort of recovering, medically their physical endurance, their overall strength, ability to follow directions. Are they bombing our secretions? Does it look like their swallowing function is actually preserved? There's just this overlay of medical complications. To try and give the [00:10:00] team an idea of, oh yeah. You're probably going to need to consider a PEG or not actually give this person a little bit more time. Um, it actually come in practice now to us only, even in patients are on the vent depending on the situation. So patients who are otherwise strong, so you might see like a spinal cord injury patient, or even, you know, some of the stronger COVID patient for the primary dysfunction, it's really the lungs and the breathing, but everything else. It's looking pretty good. You know, motorically they’re doing well, maybe they're walking, um, oral facial musculature is intact and strong. Um, able to coordinate breathing and swallowing even on beds that are swelling, their secretions. Those are some of those patients that you might be more aggressively offered, especially if it's working with number 20 and these, or want to eat. And a lot of these numbers, can you do a swallow study on that? We don't have FEEs here, but, um, uh, videofluoroscopic swallowing study or FEESs would certainly be appropriate looking at intermittently looking at this fellow that's, uh, the bottom line for all the stages, right? You have to look at it to know. So a lot of these patients are more appropriate than they might seem on the chart review. So. No, go again, seeing the patient, talking to the nurse, figuring out that, figuring out that mentally, you're going to send that patient and spending [00:11:00] on the other able to gauge activities of taking PO [00:11:02] Kate Grandbois:  Can you just for a quick second define delirium because it's not like a word very casually thrown around where it is part of our vocabulary, but it is a medical presentation. And I wonder if you could just highlight that for us for a second. [00:11:13] Sara Penrod:  Yeah. So delirium is a set of symptoms, basically, um, that is, has an underlying medical cause. Um, it can be related to the ICU day. It can be related to medication changes, um, fluid levels in the body with hydrogen and whatnot. Um, variety of symptoms you might see, um, Hallucinations and fusion confusional output. Uh, confusional verbalizations, disorientation, configurations, um, you know, sleep disturbances. Patients are sleeping at all times of day. Their sleep wake cycle is off, um, agitation, Medis, restlessness, um, where otherwise there's not a neurological reason for this. Patients are architecting sets of symptoms and they can wax to be throughout the day. They can maximum. I mean, it's, it's pretty tricky and it's, um, really a set of symptoms rather than a diagnosis, but you can see in the patient's chart, the medical, you know, of course [00:12:00] exacerbated by delerium, tends to get better, but it's so the older patients can learn for awhile, some of the side-effects of ICU related delirium. So, you know, things that can be delayed and worse. Rooms that don't have windows, right? The patients are pulled out of the time-space continuum more so because I have no idea what time of day it is. Um, inability to communicate the inability to understand what's going around us. People are not awake off. We're not consistently remembering not to get in the ICU that there's a breathing tube in their mouth. Um, you know, baseline psychiatric or personality disorders. People don't wanna be touched or held down. They don't like feeling constrained by lines and tethers. Um, uh, delirium can be made worse by those things as well. So all of these things that you're seeing in the ICU patients, you know, So delirium is a common side effect. And oftentimes that creates a snowball effect where patients require more sedation, because maybe they're pulling out lines or they're there. So I get staff and people are unsafe. Um, so it can create the kind of snow for more sedation is that onboarded. And then there's risk of developing secondary pneumonia now because this person is not alert enough to manage their secretions or to cough and clear their secretions. So unfortunately, the initial ideology for [00:13:00] being in the ICU is not always the end picture for patients. You know, sometimes you do get the nice clean, okay. You know, right. MCA, CVA. And that's it, you know, how easy, um, medical course and more predictable recovery. But for most of the patients, there's a lot of. Complications and for the listeners, um, I did add some complications for some of the ICU patients where it's like, okay, you're in for this one thing, but these are the 10 subsequent things that happened that made your stay longer. It doesn't make it clear.  [00:13:22] Kate Grandbois:  You made our listeners the most beautiful, thorough handout. I have ever seen to a point where I was joking, that it kicked off a series of like slack chats amongst everybody. And on the LP next Yoda, I would really throw a beautiful, so a lot of what we're going to talk about today is listed on this hand out. it's available for download on our website for free. There will be a link to it in the show notes. If you're driving, walking, running, folding, laundry, whatever you're doing, there is a place where all of this is written down and go check it out if you want to learn more. Okay. I'm sorry. I derailed us with my question about delirium. I just wanted to make sure that everybody was aware that this is an actual medical presentation. I personally had never heard of it until I knew I knew someone who had experienced delirium in an ICU and was like, oh, that's the thing. So, anyway,  [00:13:59] Sara Penrod:  [00:14:00] Derail away. Um, so as far as, so trachs vents, that they shouldn't, I think we do speech pathologists, do a lot of advocacy promoting. we could do a whole other podcast on trachs. I don't want to get too in the weeds on that, but complication, right? When patients come off the vent, they, they still can't talk because their cough is a place, a tight seal between tracheal walls and the tree too. So promoting our travel cuff deflated and SPIs, um, and clearly critically thinking to yourself, okay, why isn't the person tolerating cuff deflation, or why aren't they tolerating the speaking valve? This is. The SLPs play, SLPs also can go in and be with a patient for 30, 45 minutes, depending on your hospital and your productivity requirements. But a lot of times the respiratory therapists are not able to do that so quickly as the patient can say, oh, there's pressure or, oh, they cough and have to take it off and go versus a speech pathology can go in  and take an extra check and put it back on. Thank you. Some debriefing. I can do some coaching exercises. So we sometimes have been more time with the patient, which allows us to critically think differently. Um, We're at the big holders of the PMBC and also that you can talk as well. And a lot of times for respiratory, their priorities are a little, you know, more medical. I want this patient to be [00:15:00] able to breathe a lot better than they are right now. It's like, okay, well, can we compromise? Can the patient wear it while I'm in here? Can they wear it when the nurses is in here, you know, so. Those interprofessional conversations. Um, and then if you have a theory that there's some sort of obstruction or that the patient needs a smaller trach, you're having these conversations with the team for maybe an ENT consult or a pulmonary consult to see what can we do to get this person who's otherwise improving is being held up by the trach scenario. So playing a key role there.  [00:15:29] Kate Grandbois:  And I, I was just about to say this all sounds like it's a key component is successfu interdisciplinary collaboration, communication, documentation for when you're passing, if you can't pass each other in the hall. Because it sounds like a lot of these decisions, there's a ripple effect. It's influencing a lot of what else? A lot of other variables that are happening in the ICU is that an accurate reflection? [00:15:51] Sara Penrod:  Oh, a hundred percent. And a lot of, I think you probably spend as much time in critical care, looking at the chart and communicating with the team as you do [00:16:00] with the patients. I mean, these patients. They are critically ill. They're significantly weak. They're very deconditioned. Um, there's not always a whole lot they can do, but you were spending a significant amount of time advocating for them and problem solving. I mean, some of the patients that we're seeing with COVID, you know, um, You know, resp, quick, respiratory failure, you know, we're, we're, the team is doing so much to keep these people alive and keep them breathing. So whose job is it to think about what the swallowing might look like when this is over? Um, you know, a lot of times they're not thinking about that in the moment. So families are having conversations about, will they be able to eat? When will they be able to talk, you know, Looking at patients, even when they're on the vet of the vent to sort of predict, um, some of that swallowing physiology and the longer term care, I mean, this can lead to avoiding peg tubes. Long-term feeding tubes for some of these patients. So  [00:16:55] Kate Grandbois: this is, this brings me to a question about something that you mentioned before. Again, before we hit the record button, before we [00:17:00] get into our second learning objective, you mentioned how important it is for the SLP to get involved early. In the ICU stay. Can you tell us a little bit more about that.  [00:17:09] Sara Penrod:  Yeah. I mean, you know, it's really, it's really important that the, that the team and the families understand, um, you know, the plan for eating and the plan for communication, um, how the speaking valve works, for example, Ways that the family can communicate with the patient. You know, we didn't even, we didn't even get into really any of the language assessments or the AAC assessments.  [00:17:37] Kate Grandbois:  You still can, we'll make time. It's good. I derail with questions all the time. It's cool. We'll get back to it. [00:17:40] Sara Penrod:  No, I love it. But yeah. So the, the importance of getting in there early, um, you know, a lot of times patients are trying to communicate or asking for ice chips and, you know, based on chart review, you might say this person is not appropriate to eat, but you say, okay, can I clear this person for ice chips and reduce their [00:18:00] frustration, reduce their anxiety, improve their oral care, improve their, you know, the oral bacteria in the mouth, just from the natural process of swallowing.  It’s so key, um, not to mention how crazy would you go if you couldn't have any moisture in your mouth, aside from like a green sponge, don't want to think of  [00:18:15] Kate Grandbois:  every, oh, I  [00:18:16] Sara Penrod:  know. I have the most sympathy for patients when they're like, I just want a big drink of water. It's like, heck yeah, you do you and me both. You know, so, um, and it goes back to that reducing of delirium potentially. I mean, there's research showing that early SLP intervention can help shorten hospital stays shortened time to decannulation shortened time spend NPO potentially, you know, um, shortening time spent with dysphasia, potentially avoiding long-term, um, nutrition placement, um, With being able to modify a diet texture or such things. So. You know, and it's really helpful, even if you're not seeing the patient consistently, it's really helpful to be able to be reviewing the chart and being [00:19:00] communicating with the team like, Hey, you know, I don't feel safe seeing this person right now, but here are my parameters. So that the team is not just wondering and not just, you know, arbitrarily placing a peg. It's like, oh no speech said, you know, once they were doing pressure support on the ventilator or once they could sit upright for 20 minutes that they would, um, more aggressively assess the swallowing or assess the communications. Um, super beneficial, just so that the team knows kind of what's the trajectory here. A lot of times I'm saying this is not safe because you know, patients on a hundred percent oxygen, they can barely catch their breath with one episode of swallow happening. But if you can get them down to, you know, a certain amount 50 liters, let's say, and they can tolerate, um, you know, PT and OT mobilization a little bit more, that's my parameters for this patient or whatever it is. Um, so everybody's on the same page  [00:19:52] Kate Grandbois:  again, that collaboration piece. I mean, that's gotta be so important.  [00:19:56] Sara Penrod:  Totally necessary. Yeah. You can't operate in a silo. [00:20:00] And we have a really good communication system with our physicians that we're able to just chat them really quickly and say, Hey, these are my thoughts. Um, which has really, I think, changed the practice just to be able to, to summarize concisely. This is what I'm thinking and say it in a, in a more direct way it's been, it's been really wonderful. [00:20:16] Kate Grandbois:  That's awesome. Well, I wonder if you could tell us a little bit more now about the language assessment and AAC assessment. [00:20:24] Sara Penrod:  Yeah, absolutely. So there's sort of two camps, right? There's there's this camp of patients who have like a true language disorder, you know, like, uh, uh, left MCA CVA, or, um, you know, some, sometimes you're seeing that with those right-sided strokes, you know, significant dysarthria you're seeing apraxia. So you're sort of conducting it just as you would in rehab or in a skilled nursing facility. Um, keeping in mind, those, those medical aspects, you know, what, what lines are in place in the patient's room, um, you know, those kind of safety parameters, but then you're, you're really looking at language sort of the same way, you know, is this [00:21:00] person awake long enough to communicate or is arousal the issue? You know, can they follow directions, can they answer yes, no questions. Are they able to make their wants and needs known? And then there's sort of this other side of communication, that's really, is this a medically induced communication disorder? You know, sometimes you're seeing, it's not really dysarthria, but it's certainly a motor speech, um, communicative efficiency issue because of significant deconditioning or, um, significant lethargy or overall, you know, significant physical weakness or, or low effort on the part of the patient where it's like, I don't even, I don't even have the energy to communicate at the sentence level at this point. Um, you know, a lot of the ventilator patients, no communication deficits per se, but they're so weak that it's even difficult to mouth words. You know what I mean? Um, so helping these patients, you know, some of the patients who maybe have a little bit better mobility are able to use letter [00:22:00] boards, um, or there's a couple of apps, like, um, I think it's passy muir has a type to text for patients who are, um, tricky, customized that can just kind of type and chat as they go that's really efficient. Um, but then there's, you know, the other medical aspects. So when patients are not just deconditioned, you know, they don't have the pulmonary drive to, to have their voice come out clearly and audibly, or they don't have the, um, the endurance and the stamina to produce, you know, output at the phrase or sentence level. Um, So you're giving the staff often tips on how to ask questions that that sort of maximize their communicative efficiency.  [00:22:38] Kate Grandbois: You've used the word deconditioning a few times. I've never heard that word before and chances are, if I've never heard it someone else hasn't heard it. So I'm going to ask you what. [00:22:47] Sara Penrod:  It's so funny, the things you take for granted, isn't it in what you do.  [00:22:49] Kate Grandbois:  Yeah. And then a few sentences ago you used the word deconditioning, which I sort of assumed was a strength related issue, but then you also talked about weakness. [00:23:00] So what is deconditioning?  [00:23:02] Sara Penrod:  So patients, there's all kinds of stats on this and I don't know them really off the top of my head, but so you know that as we age our muscles, um, just don't function the same way. Right. And they get weaker at a certain rate. Kate Grandbois:  I don't want to think about it. Sara Penrod:   Okay. I was just going to say, I think it starts at 40 and your muscle strength, and I don't want to hear it.  [00:23:20] Kate Grandbois:  I don't want to hear about that. I won't tell anyone my age, but  [00:23:25] Sara Penrod:  I think it doesn't start till age 70 or 80. So I think we're all good here. Kate Grandbois: Perfect. Perfect. Moving on.  Sara Penrod:  But patients who naturally lose a bit of strength and endurance every year to a certain degree, it's exacerbated when they're in the hospital. A because they're in bed and they're not moving around. And the muscles, their strength and functioning reduces precipitously when they're not using the muscle. So that like use it or lose it scenario is, it's precipitously worse for someone who's over 70. Add into that critical illness. Right? So, um, changes in their oxygenation, [00:24:00] changes in their, um, metabolism, the way they're processing food. Add to that there's probably potentially some degree of pre frailty or frailty. You know, the body's not processing nutrition the same way. There's probably oftentimes underlying medical conditions that are causing... They, these, all of these things that people can kind of function with can get quickly exacerbated, um, with a critical illness. So think about like a, a stroke or, um, a cardiac event. Um, You know, underlying, uh, like diabetes or underlying hypertension. These are all going to kind of put people at risk for more rapid deconditioning. Um, your question as to de-condition deconditioning versus strength is a really good one. And there's a lot of talk in that in our field right now, because can we talk about strength if we're not doing manometry right. Like if we're specifically talking about, um, you know, oral pharyngeal strength, can I say a person has weakness by looking at their swallowing? If I'm not doing manometry, there's kind of [00:25:00] this conversation. So manometry is when. Um, almost like an NG tube down someone's throat, a monomitor and have them swallow. And it basically has these sensors all the way down the monometer that actually says, okay, how strong is the pharyngeal squeeze? Or I think it started with esophageal manometry because there's all these issues with the esophagus. Right? How do we assess it? So the tube that goes all the way down the esophagus And then when there's esophageal peristalsis it monitors and you actually get this readout of where the muscles are working. Oh yeah. Oh, we could do a whole podcast on the esophagus [00:25:34] Kate Grandbois:  I know. I'm sorry I keep derailing with my very novice question. Um, okay. So you were talking about, um, helping patients who are, you know, having a hard time communicating for either communication disorder, reasons or medically other medical reasons and using additional external supports, like typing or an app. Help facilitate more [00:26:00] communication while they are in an ICU.  [00:26:02] Sara Penrod:  And a lot of times in the ICU, the patients are kind of dependent on their caregivers. And we see this a lot of times in institutions, unfortunately, but, um, so providing that education to the nursing staff, you know, um, And encourage the patient to give, um, you know, shorter responses to save endurance or asking yes, no questions to kind of maximize, to making sure you're both on the same page and that things are not getting lost. Um, yeah, we often get consults for communication boards. Um, I think this is true of anywhere that you get a consult for a communication board. There's just so much that compounds a patient's ability to use, uh, a communication board, you know, vision, obviously. Desire to use said communication board, you know, underlying, uh, receptive and expressive language. All of that is just made worse in the hospital. So, um, AAC is a great place to start. It's just, it's really tricky. The, a lot of these patients are just too sick, um, or they're only awake a certain amount during the day.[00:27:00]  So we do spend some time we've, we've been consulted a couple of times to do language assessments on patients who are intubated, um, when the team is trying to gauge whether or not the patient, um, is consistently answering questions, would you want a tracheostomy tube? Would you want a PEG. This person still has capacity, but we're sort of trying to get the idea. Um, are they consistently responding? So we've been asked to assess there a couple of times there's tons of resources for ICU, you know, letter boards and low-tech AAC. Um, it's just, you really, it is a unique patient who can consistently and effectively use it. We've found.  [00:27:38] Kate Grandbois:  Okay. That's really good to know. And I wonder if now is a good time to start talking about our second learning objective related to how, I mean, you've talked about all of this data that you're surrounded by all of this information that you're aggregating across different team members. And how can you efficiently, how do you efficiently do that in the ICU? [00:27:59] Sara Penrod:  [00:28:00] Yeah. So like I was saying it, you really do spend a ton of time on the chart. I mean, in the, in the chart reading and, and sort of synthesizing in your own way before I go see a patient in the ICU, I always do a chart review. I mean, that minute, not even in the morning before I make my lists, but before directly, before I go see the patient to, to check their labs, check their vitals, um, and then check in with the nurse, you know, try to get an idea of what the plan is for the day. So is the patient having a procedure? Are they, um, you know, on, you know, are their position positioning restrictions because of blood pressure issues or an entra-, extra ventricular drain that they can't be moved because, um, pressures in the head are being monitored, stuff like that. So really up to the minute, and then you're looking at what the team is planning for the day. So sometimes you'll see in the notes that the team is, you know, considering a long-term feeding tube placement, you're, you're involved in some of that decision making sometime. Um, what are the ventilator weaning, um, [00:29:00] plans for the day, you know, oh, person's going to come off of the vent today. Maybe it would be a good time to take a look at them off of the vent. Um, A lot of the medication changes, you know, are they lightening the sedation? Okay, they're going to turn off the sedation at 10. Maybe noon would be a good time to see this patient. So sort of hour by hour, things can be changing for these patients. So you're working with the teams overall plan for their medical stability and recovery, the nurses plan for the day, um, the patient family coming in to visit and, and family members having questions about what they can do, et cetera. So you, you know, it's a lot of back and forth. It's a lot of rescheduling on you. You know, a lot of times you make a plan in the morning and you do not stick to it even slightly because things are changing so rapidly.  [00:29:49] Kate Grandbois:  I wonder if you could talk a little bit about the role of counseling. You've mentioned communicating with caregivers and families, and I have to assume that these individuals are grieving. They're scared. Their loved [00:30:00] one is in the ICU for whatever reason. Are there component, do you find that there are a lot of counseling components involved in this job? I mean, I have to assume. Yes, but maybe you can tell us a little more about it. [00:30:11] Sara Penrod:  You know, it's we just, not long ago, reopened to family visitors. We had been closed in the ICU for a while for COVID reasons. And it's sort of like, whoa, I forgot what it's like to have family at the bedside. You know what I mean? Especially in critical care. Um, yeah, there's lots of counseling. Um, Kind of having a similar conversation with the family. Where do you think that their swallowing and communication is going to go? Um, I often talk to families about what they'll see in rehab, especially if patients don't seem to be progressing that quickly in the hospital. You know, I, I, I build up rehab, um, and talk about things that they'll work on in rehab to try to, you know, give families, um, Yeah. You know, have them hold onto hope and remind them that this is a very different loved one than you will see once they get to rehab them or once they even make [00:31:00] it to the medical floor and out of the ICU. Um, I talk a lot about, um, swallowing recovery and things that impact impaired swallowing. So a lot of times, like I said, for these ICU patients, they're super sick. It's not; It causes a secondary dysphasia. Yes. But it's not like, um, you know, sometimes you're suspecting or you're finding that the actual physiology is fine, but because this patient can't coordinate breathing and swallowing, or because they can't stay awake for five minutes or because they don't have the endurance to take more than a few sips, they do require either a modified diet or a feeding tube. So you're, you're sort of making sure that they understand that this is not a, you're not going to eat again. This is. A lot of this is made worse by your current medical or current pulmonary issues. Um, and I find patients and families, um, really appreciate hearing that kind of information, like, okay, it's yeah you're not allowed to eat, but it's because of these other reasons, not because you, can't not because you never will, again. [00:32:00] And same for communication, you know, um, a lot of times it's around the tracheostomy tube and the, and the ventilator we talk about when when the patients will be able to use the speaking valve and how they'll be able to communicate and other things that, um, you know, strategies for other types of communication. So we, we do more so now than, um, you know, even a few months ago, It's good to have families back in the room. You can see the difference in patient responses consistently.  [00:32:27] Kate Grandbois:  I bet. I'm also thinking about, you know, this, this concept of synthesizing information in an ICU, because this is a situation where a person's status is changing hour by hour, sometimes I assume. [00:32:37] Sara Penrod:  Oh yeah, definitely. Yeah. A lot of this, we, you and I talked about like the critical thinking aspect  [00:32:45] Kate Grandbois:  that was going to be my next question is this, how does that, how that relates to critical thinking? [00:32:48] Sara Penrod:  Yeah. So I always think of this concept in the ICU, what is causing what, you know what I mean? So a lot of times patients have aspiration and pneumonia and dysphasia, [00:33:00] um, but which caused which, you know what I mean? So sometimes patients are developing a pneumonia which can change mental status, which can cause aspiration. Um, then now that you've got this diagnosis of dysphasia, um, sometimes people are in with all kinds of GI stuff, abdominal stuff, you know, you've had nausea and vomiting. Now you've got, um, pneumonia and now you've got, you know, difficulty breathing. And now actually you really can't swallow because you actually can't breathe and your body can't tolerate, um, that, um, that swallow apnea. So. You know, that synthesizing the information again, you're looking at, okay. What, what are the events that were leading up to this, this pneumonia and, um, the research of John Ashford, he always talks about, um, pneumonia being an opportunistic secondary, secondary dysfunction. So these patients are critically ill and then this pneumonia kind of develops in this opportunistic way. So you're, so you're really, I think trying to get an idea of [00:34:00] the chicken and the egg, what is causing what for these patients, um, and that helps you prognosticate and it helps you talk to the team about what you're seeing. Um, cause you're able to give. The big so what, you know, like, yes, this person's on honey thick liquids, but, but, so what and why, and what does it mean to the team and what does it mean for the, for the patient's care? Ultimately. [00:34:24] Kate Grandbois:  that's, I, I love this concept. Critical thinking is such an important piece of what we do. And I'm not sure that we're explicitly taught how to prioritize information. I also heard this is my new favorite acronym. POEMS patient oriented evidence that matters. And it comes out of research from, I think, pharmacology about how to prioritize different, um, or no, it's not pharmacology it's it's medical data management. This is like a whole area of research that I randomly recently stumbled across. And it's related to what you're talking about in terms of exactly what you said. [00:35:00] So what, what matters? What, what is the information that you have that matters and in. There, it sounds like you're in a work setting where the data that's coming at you is just massive. That's way more data than I get about my pediatric kids, you know, my pediatric clients who are changing, but not hour to hour, you know, the hour to hour change and a pediatric client is, are you hungry and ready for snack? That's that's it. You know, I mean, not to say that there aren't medically complex, you know, pediatric kiddos out there, but this is a very different work setting that you're in constantly trying to aggregate information and prioritize it. [00:35:41] Sara Penrod:  Yeah. So you're starting in the day with a chart review, but to your point, I mean, sometimes you're literally going up to some of these units and you're walking around the unit to get to eyeball these patients because sometimes the chart, you know, you suspect, oh my gosh, this person has been through so much. They're going to look absolutely terrible. And you go in and [00:36:00] they're out of bed. They're in the chair. I mean, The lines and the drains and the alarms, and sometimes the IVs. I mean, you see a wall of 15 IVs running at one time, you know what I mean? So to a certain degree, it just takes getting used to it because you're like, you know, I could see a novice clinician being like, None of these people should eat. None of them should have speech, you know, but you do develop a certain, you know, desensitization to that kind of stuff, which I think is a good thing for the patients and comes with experiences. You're like, okay, well, let me get in there. Let me move some things around, see what I can do. But then sometimes you do a chart review and you're like, oh, it sounds like this person is going to be ready for a cheeseburger and you'll go see them. And it's. And they just look terrible. And that's that deconditioning and weakness that we're talking about. Um, you know, how frail is this person is hard to, it's hard to gauge just by chart review alone. A lot of times you'll go up and you'll say, okay, this person looks, look, it looks like they're ready for speech by chart review. I go off, they physically look like they're ready. I talked to the nurse. [00:37:00] Oh, we just had to, um, put them on a bunch of sedating medications because of X, Y, or Z. It's like, oh, oh, okay. I'm circling back. Try back at 2:00 PM. Um, or this person might go for a procedure, so they can't have anything. So. You know, you can see them a little bit, but it won't be a full assessment. And then you're kind of gauging like, oh, okay. Oh, this person's ready to eat, but you know, they're not allowed to sit up because they have to have their spinal x-rays and they have to be clear to sit up. Okay. Well, if we're going to feed them later, then we'll just come back later. So, um, I can't oppress upon your listeners, how intense it is to be up there in those units. And I say up there, cause ours is the sixth and seventh floor, but they can be on any floor. Um, but, um, just to even be walking around and, and you really get a sense of the gravity, um, you know, there’s multiple interprofessional teams everywhere. You know, the docs are constantly rounding. They're rounding with clinical dieticians, with clinical pharmacists. [00:38:00] Um, with the nurse. I mean, it's a huge team of anywhere from eight to 10 people. Um, sometimes you have to specialist, you know, um, pulmonary is rounding with the teams. It's, it's really intense. And to think that each of these team members has a, you know, we all have our priorities for these patients. We all have sort of these agendas. We want to push. I want my patients to talk and communicate and eat; pulmonology wants their lungs to be clear and their breathing to be at a certain level. So, um, it's intense. It's changing a lot. Um, but there's, there's so much room for speech, um, to advocate really advocacy and education, because like I said, you think that. I think this might've been before we were recording, but you, you expect physicians, these people are, are some of the brightest minds in the, in their fields. You expect them to understand the weeds of swallowing the way I do. I expect them to understand, oh, swallow apnea and, and the, the effects on pulmonary functioning. And it's really not the [00:39:00] case. I mean, we really are specialized in this area and I really do think about swallowing physiology in the impacts hours every day and the physicians have an understanding, but it's not the same as the critical thinking that we're expected to bring to it. So. It's it's wonderful. I obviously, I, I love that your podcast is under SLP nerd cast, cause I'm like to nerd out so hard.  [00:39:28] Kate Grandbois:  Well, and I'm learning as I'm talking to you that you are maybe in like nerd supreme, which is, uh, which is, uh, a title we have yet to dole out. So congratulate, you're just the, all this information. I mean, maybe it's because I don't work in this setting, but you, this is like an incredible amount of information that's being thrown at you. I mean, you met, you used the word intense and high into high energy, I think before describing this work setting and the way that you're, you're doing such a great job describing it in terms of how much data management you're [00:40:00] doing and how much critical thinking you're doing on a, I don't know, minute to minute, hour by hour on a, on a routine, um, repeated basis across your shift. And I have to assume that data management and technology are a huge component of this. Now that most of our hospitals have moved over. So when I started working, I was at an outpatient hospital. We use paper that's how not that I'm aging myself, but we did. And then they tried to make us, they tried to make us use an LMR or an EMR, and everybody was grumpy about it because we knew how to use our paper. And we didn't use dictation yet. But now that we have these data management systems and this chat feature that you talked about, I mean, I guess, cause I work in assistive technology. It's making me sort of interested in it, but that must be a critical component to be able to digest and analyze and prioritize this information since it's so fast paced and you're changing things are changing so quickly. [00:40:55] Sara Penrod:  Oh, absolutely. Yeah. The, I mean, we could go into good and bad [00:41:00] about, um, electronic medical records. Right. Um, but yeah, it's totally necessary. And there's a couple of features in the system that we use that help keep up to date with like labs and vitals and stuff like that minute by minute. Um, also I, the nurses in critical care are just, I mean, you think I have an understanding of medical aspects. I mean, these nurses are phenomenal, their understanding of meds and dosages and, um, they have such unique um, ability to synthesize this information differently because they spend so much time with the patients and they have to do so much functional care with them. You know what I mean? Um, so sometimes, you know, we're the communication specialists, but if, if I'm not getting something out of a patient. I'm definitely checking in with the, with the nurse. Like I'm not getting anything, like, are we concerned about a change in status here? Or am I not doing it right? Oh no, if you, oh, this patient, if you go to his right, because he has an old, you know, war injury and he can't hear out of his left ear. It's [00:42:00] like, these are the things that sometimes they're not in the medical chart that the nursing staff knows because they're doing all this problem solving and trial and error before you even get there for hours and hours and hours. And they are, the nurses are such a resource. Yeah. It's there. They're really wonderful. Actually, there, we have an SLP here who is now a critical care nurse and used to be an SLP, which I think is such an interesting transition. Yeah. Yeah.  [00:42:27] Kate Grandbois:  Wow. Good for that person. That's like a, that's a double threat right there. That's a lot of information [00:42:31] Sara Penrod: . Bedside swallow screen? I got it.  [00:42:35] Kate Grandbois:  Wow. That's really impressive. That's really, really impressive. Um, do you want to tell us a little bit about, um, the transition to the SLPs role in therapy or the diag, the SLP related diagnosis that happen? I'm just thinking about our third learning objective and I have a sneaking suspicion. You have another well of knowledge to share with us.[00:43:00]  [00:43:00] Sara Penrod:  Yeah. Um, so our third learning objective is, is sort of the factors. I was thinking things like confound the diagnoses. So this is kind of like what I was thinking is what we were talking about. Like what's causing what, right? Like all these things that can impact, um, your ability to do therapy and your ability to make diagnoses, right? So the nutritional lines that a patient has, for example, um, they may not have alternative nutrition in place. So once patients are extubated, oftentimes the oral feeding tube goes with it. And oftentimes the team wants speech to look at them before they decide, okay, are we going to put in an NG tube or are we going to put in, you know, a peg tube, a more permanent solution. Um, but there's a million reasons based on chart review that you don't want this person to eat. So a lot of times the medical status is confounding. You know, it's like, yeah, this person might be able to swallow, but their medical staff, I mean, they cannot [00:44:00] tolerate a drop of aspiration. So I don't even want to give them more than an ice chip or a drip of water or something like that. Um, you know, sometimes they're, they have lines that restrict their position, their positioning, like I said, the ventricular drains, um, if they're draining CSF, um, patients have to be clamped to be moved. They have what's called an arterial line, which is a line that goes, um, it's a catheter that goes directly into the artery that tracks the blood pressure closer to the source. And that mine has to be moved with the patients, almost like little chips with  [00:44:34] Kate Grandbois:  no one can see my face. My eyes are getting big. I'm like, oh my God, that's that, that is very serious stuff. That's very, very serious stuff. And I hate to simplify it into that, but this is. This is, you're talking about you're in that this is so redundant. You're in an ICU. This is life and death. I mean, this is critical medical stuff. I mean, I've known that the whole time, but when you start talking about arterial [00:45:00] lines and needing to get clamped, I just have to assume as an SLP, trying to aggregate, not only aggregate all this information, but prioritize it. Yes. You want your patient to communicate, but that might not be the top 10 things that the team 50 things that the team is worried about and trying to find your place in that that's a whole other skillset.  [00:45:23] Sara Penrod:  Yeah. Yeah. It really is. Yeah. The, so you're a lot of times what's confounding either your diagnosis or your ability to treat is just these complex medical situations. And that's kind of where you get into this critical thinking. Cause you're like, You know, based on chart review or based on how someone looks, it can be very easy to say, Nope, not appropriate, not safe. And I think you could make a case for no SLP in the ICU for that reason, but that doesn't help our patients and research is showing that. So, um, You know, learning how to work the equipment, learning which patients are [00:46:00] safe, learning how to move them or just completely deferring to the nursing staff is okay too. You know, a lot of times they're one-to-one nursing ratio or two to one, two patients for one nurse. So they're, they're a really good resource. They're there for you they have time. Most often when you go up to see a patient in critical care, the nurse is already in the room, um, they're always easy to find and easy to locate. So they're a huge resource. So you're, you're asking this patient, the nurse, I often will ask them. How do you think they'll do on swallowing or what communication needs do they have before I go see them? It often doesn't change whether I'm going to go see them or not. But I think it, it adds a piece to the picture, right? Like the nurses, like, oh, I think they're going to swallow fine, but they're on all this Dex. So they're totally sedated. So it's hard to catch them when they're awake. Dexamethazone is a sedating methods. [00:46:53] Sara Penrod:  Sorry. Yeah. Um, Right. All this common terminology. [00:47:00]  [00:47:01] Kate Grandbois:  It's fine. I mean, it's, it's one of those things where, you know, there are probably a lot of people listening who work in a hospital who knew exactly what that was, but I have to ask because I don't  [00:47:08] Sara Penrod:  love it. So, um, You know. Okay. So this patient is totally sedated. Um, but I think they swallow fine. And this is one of those compounding factors where it's like, okay, what do you do? You're talking to the team. How long are we thinking this person's going to need such significant sedation. Um, if we're thinking a really long time, then maybe a peg is the way to go. Um, If the person's alert and awake for maybe a half an hour a day, should we put them on a diet so that they have something to do to, to sort of reduce their restlessness, reduce their agitation, improve, you know, normalcy and routine and oral care and oral comfort. Um, even though you're not anticipating this is going to sustain their nutrition and a lot of days you're going to have to hold off because maybe the arousal isn't enough. Um, but the, the, the swallowing physiology supports eating. So what can we [00:48:00] do safely, um, in an environment despite all of these, these medical factors. Um,  [00:48:07] Kate Grandbois:  and I also have to assume that in terms of the SLPs role in the ICU, let's say you have a patient who is, you know, very complex, very sick, is very fragile. And through your data analysis and critical thinking, you've determined that working on your goals is really not a top priority. I have to assume that even if it never really becomes a top priority your presence and role on the team in terms of educating people or consulting sets that patient up better for rehab, is that an accurate statement? [00:48:45] Sara Penrod:  A hundred percent, I think. You know, being able to sort of predict what kind of a rehab candidate someone will be is one of our responsibilities, I mean, for PT, OT, and speech, right? Sometimes these patients are [00:49:00] critically ill. They're just being evaluated and the case managers are already like, are we talking long-term care or are we talking acute rehab? What are we thinking here? Um, and those things change really frequently, but the case managers have to be starting to set this plan into place. Um, some of what I specialize in is disorders of consciousness and low level cognition. So trying to determine which patients are appropriate for a disorders of consciousness program versus long-term care versus, you know, palliative interventions, um, you know, A lot of that plays a role too. And that's just, that just happens to be one of my specialties. Um, but the, the PTs and OTs in, in the ICU play a huge role with that too. And oftentimes we're sort of having these conversations together. It really depends to what the, what the patient's diagnoses are. I mean, a lot of times some of these like cardiac patients, for example, They look acutely terrible. Right? So they've had like a CABG times for, you know, [00:50:00] um, and then they had all these sort of subsequent issues. They had difficulty excavating after the procedure, and then they ended up with a tracheostomy tube. A lot of these patients get significantly de-conditioned because their, their heart hasn't been working right for however long, causing them to either have an acute event or to need this massive surgery. So there's sort of this precipitating course of weeks or months, and now they're like extra deconditioned. Um, it can keep them in like a cardiothoracic ICU for a longer time. And that's one of the units where I'm like, none of these people should be eating. They just are so weak. They all have this junky cough. They all just kind of look like they can't breathe. Um, so, you know, seeing them through their course of the hospitalization initially thinking like, oh my goodness, they're going to need, you know, inpatient rehab. And then a lot of times they end up in sort of like an intermediate level of care and then they end up on maybe the medical surgical floor. And then actually, you know, they're [00:51:00] tolerating their regular thin diet and they're working with PT and OT and they're walking. So sometimes your initial estimations of what someone will be able to do is totally wrong, but you're keeping that conversation fluid. And I have found it to be the cardiac patients that tend to surprise me, um, where I'm like, well, if I just don't know if that person will ever eat again and they ended up like, you know, tolerating a diet and looking so much better because so many, you know, think about they've had that, that cardiac procedure now. So many things are improving, you know, their, their blood flow to their body, their muscles are getting stronger and they're having all of this other medical improvement, which we know corresponds to improvement in, um, oral pharyngeal swallowing functioning based on the research. So  [00:51:41] Kate Grandbois:  I can't help, but feel like your knowledge base extends so far beyond what we learn in graduate school. Like in graduate school, I did not learn about, about heart and blood supply to the muscles. And how, and just think following the breadcrumbs about how [00:52:00] much that impacts your job as an SLP, is this something that you learn? I mean, I was going to make a bad joke and say through osmosis, but just like talking to nursing and I mean, how do you get this knowledge? I mean, it seems like this knowledge is critical to your job in an ICU.  [00:52:20] Sara Penrod:  Yeah, I guess, I guess just over time. I mean, I also have a specific interest. I sometimes think I should have been like an ENT PA or something like that. I, I have a very particular interest in the way um, the body works and the way I think Descartes, right. Descartes screwed us all up because it made it. So like now we're all specialized. We broke up the body into parts. It's like, no, you study this and you study this and you study this and we kind of forgot about the way the body works as a whole, right?  Yes, exactly.  I mean, if you have respiratory failure, what happens? Your kidneys help to start to compensate to perfuse your blood with oxygen. [00:53:00] That, that blows my mind. It's like, what do you mean? Somebody comes in with pneumonia and then they had a kidney injury. How does that work? Um, and why does it look like when patients are experiencing this problem? Their dysphagia is worse. Let me look into that more. It just comes back in from years of experience. We'll get better with some things, talking to doctors. And then, you know, CEUs I try to seek out the most medically in depth to use. I can find cause I find it fascinating  [00:53:23] Kate Grandbois:  Not onlythat, but I feel like what you're describing are the skills that you're demonstrating as we're talking are reflective of a transdisciplinary team, which is different than an inner disciplinary team or multidisciplinary team. Right. So the different members of the team working in silos, but working together. Right. So. Versus teaching each other versus yes, I'm an SLP, but I have my nursing bag of tricks where I have my tea bag of tricks that I can use within appropriated with, to have this launch because my team member taught these things to me. And I think at the pap trans disciplinary team is, is, is powerful. They're very redundant sentence. It's really important to be able to have this peer to peer education, particularly when you're working with people who are so clearly ill.  [00:53:58] Sara Penrod:  Oh, totally. Yeah. They're a big [00:54:00] theme. I think the next couple of years interprofessional team, and it is defined as the hoop and that key point that you mentioned that we understand that the depth breadth and other goals, you can set a whole career to learn. I mean, I'm asking for GI inservice because we want to more in depth, understand what can GI do if I'm saying, okay, everyone has a UBS and I'm recommending a GI consult. Well, what actual tools does GI have? If I better understand those, I'm better understanding when it's appropriate to give these consults and what might be the outcome there by cutting down on inappropriate consults, et cetera, et cetera, et cetera, you know, reducing, wasting, um, the patient, he gets the more accurate tasks. So, you know, the relationship we could go on and on just about the relationship between swallowing in the esophagus, because who's in charge of the relationship, I'm in charge of what they swallow. But once you get to the UES, I'm not charging more. If I don't understand what's happening. And the buck might stop with me or it might still course of assessment. That's not necessarily right. It's probably one of my favorite aspects. That'd be medical SLP.  [00:54:55] Kate Grandbois:  I mean, it's also sounds like it's a critical component to you being able to do your job successfully.  [00:54:59] Sara Penrod:  I think so. [00:55:00] Yeah.  [00:55:00] Kate Grandbois:  So in our last couple of minutes, is there anything else more you want to tell us about these, these confounding diagnoses and the relationships between these variables as a, as an SLP who was either interested in the ICU [00:55:09] Sara Penrod:  Yeah. One of the main assets is cognitive. I mean, condition is like this whole overarching concept, right? Um, you as LP, I think it's important that we know how to tease out medical related cognitive changes from a cognitive disorder. You know, you don't want patients unnecessarily carrying this diagnosis of a cognitive impairment when you suspect it's, you know, fluid related, kidney function, really oxygen related, um, you know, delirium related. So being very clear as to this is a presentation, but. You know, this is the ideology, or, you know, I suspect that when these things improve, this, these functional things will improve. Um, because cognition is sort of a term that gets thrown around, which has probably expanded rehab. Cause it's like, well, no cognition is a attention and problem solving. And what you're talking about is medication side effects or, you know, um, metabolic disarray causing X, Y, and Z. So. Specifically, I think it's important [00:56:00] not to be misdiagnosing people with things, but understand what's going on. And, um, communicating that to the team and monitoring that, you know, it seems so strange to pick someone up for cognitive treatment where you're kind of monitoring their cognitive improvement, but, you know, say somebody who's in with intractable seizures, they're getting all kinds of medications. It's like, you're not going to go in there. You might have orientation, but you're going to say, well, this person has taught me that in therapy. You're gonna say we're gonna have each of these meds, um, stabilize a little bit, and we're gonna do another look. And you know, we're going to make all the delirium recommendations, you know, try to maximize sleep during the day, all these of standard things. Um, I think it's important to be mindful of what you're diagnosing people with when, um, there's medic medical factors at play.  [00:56:38] Kate Grandbois:  I think that’s an incredible point, um, in, I wonder if, as our sort of parting thought, if there are. I don't know any advice, any words of wisdom, any additional information that you want to leave our listeners who might want a little more, who are interested in this, but aren't doing it yet, or maybe they are like you and they, you know, have digested some of this additional information. What other parting words of advice do you have for our [00:57:00] listeners?  [00:57:00] Sara Penrod:  So to SLPs friends in ICU, I would say check the labs. Trying to understand, find somebody who understands what the mutations and what the lobbying for what, seeing that you do change the way you frame, what you do as well, because there are reasons that they should be able to do what. The things that people in the ICU can do, and it is your responsibility to find those things. And then for people who are looking to get into the ICU, um, I would say, you know, start with a per diem job and, and make sure that if you get hired that you have really good training and mentorship, um, Cause a of this stuff makes sense, but if nobody tells you to do it, it's not necessarily obvious. So having a really good mentor, um, a mentor who thinks critically and who thinks that SLP in critical care is important. I think it's, it's hard to do something like this on your own. Um, I think [00:58:00] if you're in an ICU and you feel like you don't get good feedback, I would saytry reaching out to doctors just with, you know, on patient that kind of backups. And I put my hand up the resources I know is extremely competitive, but there's, there's a lot of stuff out there. And, um, you know, do your own personal research on what's the funding and how that impacts, um, functioning patients, all of those kind of follow up.  [00:58:25] Kate Grandbois:  Well, thank you so much for all of your wisdom. It's abundantly clear that, you know, a lot of things I now know because you've taught me more things. We're still grateful for your time. And so grateful for our, for sharing all your knowledge with us. Again, for anybody who maybe missed this earlier in the episode, Sarah has made a handout that is available for download for free. It's a lot of information. So if you're out and about, and you didn't write anything down, but you want a reference list or something to keep it, your doctor have you, um, it's available for download. There will be a link in the show notes. And thank you again for joining us [00:58:48] Sara Penrod:  before. Thank you so much. You want to really make kid super important and it's accessible and affordable. It's so necessary. So I really appreciate it.  [00:58:58] Kate Grandbois: Thanks that’s very nice of you to say.